2014, Saleh Abd, came from Saudi Arabia, who suffered from ALS
On June. 01, 2014, Saleh Abd, came from Saudi Arabia, who suffered from ALS. He had muscles atrophy over his upper limbs and muscles jumpings for one and a half years. He was hospitalized in our hospital. He got great improvement after 25 days TCM treatment. He could walk 200 meters after the treatment, while he could only walk 70 meters with a stick when arrived here.
Record of Hospitalization Name: Saleh Abd Sex: Male Age: 48 Marital Status: Married Nationality: Saudi Arabia Date of Admission: Jun. 01, 2014 Companion: his brother First Medical Record Date: June 01, 2014 Time: 10:00 a.m. Saleh Abd, male, 48 years old, had suffered from muscle atrophy over his upper limbs and muscles jumpings for one and a half years. The patient was hospitalized in our hospital with ALS for TCM treatment at 21:30 p.m. on May 31, 2014. Essential for Diagnosis:
1. The patient had suffered from muscle atrophy over his upper limbs and muscle jumpings for one and a half years. There were no medicine and food for him to get allergy response.
2. The power of his right hand was getting weak in the beginning of February of 2013, especially when he opened the door and the bottle cover. And after 4 months, the patient’s situation was getting worse. His legs were also getting weak. He had no history of trauma. The problem was numbness and sphincter jumping at the beginning. And then he felt tired. There was no power with his upper limbs. And he could not raise his hands. And he also had muscle jumpings. And there was no power for standing. He had short breath. He had paroxysmal spasms and muscle jumpings all over his body. The temperature of his four limbs was low. While his body temperature increased, the spasms would be obviously relieved. His appetite was poor as well as his sleep. There was hot sensation in his palms and soles. The color of his urine was yellow.
3. T: 36.3°C R: 20 times/minute P: 88 times/minute BP: 120/80mmHg
The patient had normal growth, physique and spiritual activity, while with chronic disease face. There was no hyperaemia in his throat. He had difficult swallowing, without saliva. His chest was symmetrical. But there were obvious muscle jumpings in his chest and his arms. Sound of breathing was slightly heavy, and in the bottom of his lungs there were obvious dull sounds. Rhythm of his heart was 88 times per minute. Heart rate was irregular. His abdomen was soft without pressing pains and rebound tenderness. The temperature of his four limbs was low, especially his lower limbs. He often had spasms over his lower limbs. The result of meningeal irritation syndrome was negative. But the Babinski sign and Ober’s sign were positive. The tongue coating was thin. The pulse was deep and wiry.
4. Examination: No
Diagnostic Basis: TCM: Atrophy syndrome Western Medicine: ALS Treatment strategy and nursing:
1. Routine care of traditional Chinese internal medicine.
2. Grade Ⅱ care, companion, and nutritional diet.
3. To apply for the three routine inspection, ESR examination, rheumatoid factors, anti-O, the function of kidneys and liver, electrocardiogram (ECG), etc.
4. Herbal tea: one dosage a day and drink twice
5. Acupuncture and massage: once a day 6. Relax mind, regulate emotion and take nutritional diet. Date: Jun. 1, 2014 Time: 10:00 a.m. Dr. Ming, doctor-in-charge, paid a visit to the patient. The power of his upper limbs was weak. He had muscle atrophy and muscle jumpings. He could not raise his hands. He had short breath. And he had paroxysmal spasms and muscle jumpings all over his body. The temperature of his four limbs was low. While his body temperature increased, the spasms would be obviously relieved. His appetite was poor as well as his sleep. There was hot sensation in his palms and soles. The color of his urine was yellow. The pulse was deep, wiry and rapid. Date: Jun. 02, 2014 Time: 10:00 a.m. The patient felt that his sleep was good. We got the results of examination: Alanine amino transfer 55 u/t; AST 43 u/t; A/G 4.0; CK 419; 2- hydroxbutyric acid 22, the other electrolyte were fine. Date: Jun. 03, 2014 Time: 10:00 a.m. The patient said the muscle jumpings were relieved. And the muscle spasms improved. And his body temperature increased. The other symptoms were the same. Date: Jun. 4, 2014 Time: 10:00 a.m. The patient said his appetite was better. And his urination and bowel movement were normal. The muscle jumpings were the same as the yesterday. His sleep was good. Date: Jun. 08, 2014 Time: 10:00 a.m. The patient said he felt the hot sensation of his soles and his sleeping was not good in last two days. But his breath and blood pressure were normal. The muscle jumpings had no obviously improved. His bowel movement was normal without constipation. The color of urine was clear. So the doctor adjusted the formula and dosage. He could walk 120 meters without using the stick. Date: Jun. 10, 2014 Time: 10:00 a.m. The patient said his sleep was not good. He had insomnia. But his appetite was good. And he had hot sensation in his soles when he slept. His pulse was floating. Date: Jun. 16, 2014 Time: 10:00 a.m. The patient felt the hot sensation in his soles had disappeared yesterday. And his sleep was getting better. The pulse was wiry and rapid. The dry mouth was not obvious. Date: Jun. 19, 2014 Time: 10:00 a.m. The patient said his sleep was still not good. And he felt that there was phlegm in his throat. The phlegm caused his poor sleeping. So the doctor adjusted the formula. He could walk 200 meters without using the stick. Date: Jun. 20, 2014 Time: 10:00 a.m. The phlegm decreased. But the patient had sweating, short breath and insomnia. He still had the hot sensation in his palms and soles. Date: Jun. 21, 2014 Time: 10:00 a.m. In latest days the spasms of his body had been great improved. But he still had short breath. The pulse was weak and floating. Date: Jun. 25, 2014 Time: 10:00 a.m. The patient decided to leave our hospital. He took the herbal tea for 2 months to consolidate the effect. Doctor’s advice after leaving hospital: