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Brief Summary:
On Sept. 13, 2007, Jose, from Portugal, who
suffered from weakness of the lower limbs along with
muscular atrophy, and disability of walking, was
hospitalized in our hospital. He has achieved
significant improvement after about three-month TCM
treatment here.
¡¡
Record of
Hospitalization
Name:
Jose
Sex: Male
Age:
57
Profession: Office
Clerk
Nationality:
Portugal
Marital Status: Married
Onset Season:
Summer
Date of Admission: Sept. 13, 2007
Complainer:
The patient
himself Reliability: Reliable
Major Complaint:
The
patient has suffered from weakness of the lower limbs along with muscular
atrophy for 3 years, and the condition has been aggravated by disability of
walking for one year.
Present Illness:
In June 2004, the patient began to feel weakness of the lower limbs without any
obvious causes. At that time, the patient paid no attention to it, and did no
treatment about it. Therefore, the disease was developing progressively. Three
months later, the patient began to suffer from muscular atrophy, but he still
took no treatment. In Aug. 2005, the patient went to a local hospital for a
diagnosis. After the EMG examination, he was diagnosed with
amyotrophic lateral
sclerosis
(ALS). The patient
was told that there may be some unpleasantness to happen in the future. In Oct.
2005, the patient began to take
Rilutek
up to now. From Mar. 2006 to Mar. 2007, the patient received the treatment of
acupuncture and massage for twice a week in a local hospital, but he got no
obvious improvement. In the second half of 2006, the patient¡¯s condition was
aggravated and even was not able to walk. Therefore, his movement had to be
supported by a wheelchair.
To seek for a further
comprehensive treatment, he was hospitalized in our hospital on Sept. 13,
2007. Since he got the disease, his spirit was poor, but his appetite was
normal. His sleep was sound. His urination was normal, and his bowel movement
was hard.
Disease History:
No history of typhoid, tuberculosis, hepatitis, malaria or other infectious
diseases. No allergic history of medicine or food. No history of blood
transfusion. No history of preventive vaccination provided. In 1975, he had a
trauma due to a car accident which resulted in his left tibia fracture, and then
he received the treatment of Compression Plate Fixation. In 1997, he received
the resection on his appendicitis in a local hospital, and now he recovered
completely.
Personal History:
He was born in Portugal. No contact history of schistosomiasis. No addiction to
smoking, alcohol or special food. He was mild-tempered and open-minded.
Marital History:
He got
married at the age of 27. Now he has three daughters. His wife and children have
been healthy all the time.
Family History:
His
parents were both healthy. No family history of special disease.
Physical Examination:
T 36.3¡æ£¬P
74 beats/minute, R 20 times/minute, BP 140/80 mmHg.
He grew normally with common
nourishment. His mind was clear. He had an expression of chronic illness and
languidness. His body was in a positive posture and he was cooperative in
examination. His skin was moist. No jaundice in the sclera. No superficial
lymph-node enlargement. Bilateral pupils were round and equal in size and
sensitive to light. No abnormity of skull and five organs. No enlargement of his
tonsils. With soft neck and
trachea placed in the middle. No enlargement
of the thyroid gland. No turgor jugular vein.
No thoracic deformity. Sound of
breath was bilaterally normal on auscultation. No respiratory rales or pleural
friction rubs. Heart border was normal. Heart beat was 74 times/minute. Cardiac
rhythm was regular. No pathological murmurs on
auscultation. Abdomen touched flat and soft without tenderness or
rebounding tenderness. The liver and spleen were not palpable. No percussion
pains in renal region. Bowel sound was normal. No spinal and pelvic deformity or
tenderness. His upper limbs were in free movement, but his lower limbs were
weak, accompanied with difficulty in movement and disability of walking.
Besides, both the
lower limbs¡¯ movement of flexion and extension completely paralyzed.
Both gastrocnemius
and soleus of his lower limbs were serious atrophic, and muscles of his feet
were also obviously atrophic.
The muscles of all over his body
beat uncontrollably and frequently. His lower limbs were Grade
¢ó
with lower muscle hypertonicity. The examinations of the anus and pudendum were
both normal. Other physiological reflex has not been elicited. His tongue was
red with slightly yellow tongue coating, and there were cracks in the middle
with teeth-marks at the edge of the tongue. His pulse was thready and weak.
Diagnostic
examination: Not provided.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification: Liver-kidneys yin vacuity.
Western medicine
diagnosis:
Amyotrophic Lateral
Sclerosis
(ALS)
First Medical Record
July 18,
2007
Jose, a 57-year-old
male, has suffered from weakness of the lower limbs along with muscular atrophy
for 3 years, and the condition has been aggravated by disability of walking for
one year.
He was picked up by our staff in Zhijiang Airport and
arrived in Huaihua Red Cross Hospital for further treatment at 19: 00 p.m. on
Sept. 13, 2007.
Essentials for
Diagnosis:
1. The patient has
suffered from weakness of the lower limbs along with muscular atrophy for 3
years, and the condition has been aggravated by disability of walking for one
year.
2. In June 2004, the
patient began to feel weakness of the lower limbs without any obvious causes. At
that time, the patient paid no attention to it, and did no treatment about it.
Therefore, the disease was developing progressively. Three months later, the
patient began to suffer from muscular atrophy, but he still took no treatment.
In Aug. 2005, the patient went to a local hospital for a diagnosis. After the
EMG examination, he was diagnosed with
amyotrophic lateral sclerosis
(ALS). The patient
was told that there may be some unpleasantness to happen in the future. In Oct.
2005, the patient began to take
Rilutek
up to now. From Mar. 2006 to Mar. 2007, the patient received the treatment of
acupuncture and massage for twice a week in a local hospital, but he got no
obvious improvement. In the second half of 2006, the patient¡¯s condition was
aggravated and even was not able to walk. Therefore, his movement had to be
supported by a wheelchair.
To seek for a further
comprehensive treatment, he was hospitalized in our hospital on Sept. 13,
2007. Since he got the disease, his spirit was poor, but his appetite was
normal. His sleep was sound. His urination was normal, and his bowel movement
was hard.
3. T 36.3¡æ£¬P
74 beats/minute, R 20 times/minute, BP 140/80 mmHg.
4. He grew normally
with common nourishment. His mind was clear. He had an expression of chronic
illness and languidness. His body was in a positive posture and he was
cooperative in examination.
5.
His lower
limbs were weak, accompanied with difficulty in movement and disability of
walking. Both
gastrocnemius and soleus of his lower limbs were serious atrophic, and muscles
of his feet were also obviously atrophic. Both the lower limbs were completely
paralyzed. Below the ankle-joints, there were apparently swelling.
The muscles of all over his body
beat uncontrollably and frequently. His lower limbs were Grade
¢ó
with lower muscle hypertonicity.
6. No thoracic
deformity. Chest percussion noted resonance. Sound of breath is bilaterally
clear on auscultation. No sound of pleural friction.
7. Diagnostic
examination: Not provided
Diagnostic Basis:
TCM: The patient has
suffered from weakness of the lower limbs along with muscular atrophy for 3
years, and the condition has been aggravated by disability of walking for one
year. It belongs to vacuity
of the liver-kidneys and blood-essence, so it could not nourish the sinews and
vessels. Therefore, it gradually results in
flaccidity. With the
withered marrow and dry channels, the fat on his legs became thinner, and so he
kept a decadent spirit. The kidneys are in charge of bone-marrow. Due to lack of
the essence, his waist-ridge was wilting with difficulty in movement.
His tongue was red with slightly
yellow tongue coating, and there were cracks in the middle with teeth-marks at
the edge of the tongue. His pulse was thready and weak. All above symptoms
belong to the scope of the liver-kidneys Yin vacuity.
Western Medicine: The
patient has suffered from weakness of the lower limbs along with muscular
atrophy for 3 years, and the condition has been aggravated by disability of
walking for one year.
His lower
limbs were weak, accompanied with difficulty in movement and disability of
walking. He could neither raise nor sway his lower limbs, and also could not do
any flexible movement.
Both of his lower
limbs were completely paralyzed. Both gastrocnemius and soleus of his lower
limbs were serious atrophic, and muscles of his feet were also obviously
atrophic. The muscles of all
over his body beat uncontrollably and frequently. His lower limbs were Grade
¢ó
with lower muscle hypertonicity. After the EMG examination in Aug. 2005,
he was diagnosed with
amyotrophic lateral
sclerosis
(ALS) in a local
hospital.
Diagnostic
Differentiation:
TCM: The patient¡¯s
wilting syndrome should be differentiated from impediment syndrome. In the late
period of impediment syndrome, the patient was not able to do any movement due
to the aching pains of the limb joints. With apraxic
limbs for a long
time, the muscles were limp and atrophic, which is similar to wilting syndrome,
but it is mainly characterized by aching pains on the limb joints. While wilting
syndrome is characterized by limp and weak, in general, there were no aching
pains on the limb joints. They are not difficult to be distinguished in clinics.
Western
Medicine: Wilting syndrome should be differentiated from grave myasthenia
gravis, which is an acquired autoimmune disease with the transferring obstacles
of nerve-muscles, and is caused by the autoimmune reaction resulting from the
acetylcholine receptor (AchR) of the striated muscle. It can occur at any age
and there are about 60 percent people stricken before 30 years old. Women are
more often affected than men are. The most obvious characteristic of MG in
clinics is rapid fatigability of the skeletal muscles affected, improved with
rest or medicines that inhibits the activity of cholinesterase.
They are not
difficult to be distinguished in clinics.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification: Liver-kidneys yin vacuity.
Western medicine
diagnosis:
Amyotrophic Lateral
Sclerosis
(ALS)
Plans for treatment
strategy and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade II care.
3. Under the care of
a companion.
4. High-protein diet.
5. Herbal tea (to
enrich yin and supplement the kidneys, soften the liver and extinguish the
wind): one dosage a day and drink twice.
Prescription: Varied
Decoction of the Supplementing-Kidneys and Softening-Liver.
Main herbs used in
the herbal tea: baishao (white peony), shudi (cooked rehmannia root), chuanwu
(aconite main tuber), etc.
6. Acupuncture and
massage: once a day.
7. Have more medical
examinations if necessary.
Date: Sept. 14,
2007 Time: 10:00 a.m.
The
patient complained that he has suffered from weakness
of the lower limbs along with muscular atrophy for 3 years, and the condition
has been aggravated by disability of walking for over one year. His lower limbs
were weak with seriously atrophic, so he could neither stand nor walk. His lower
limbs paralyzed completely, so he even could not do any flexible movement. There
were swellings below the ankle joints. His strength of his arms was lessened. He
felt languid and weak. There were muscles beating with feeling of tightening on
all over the body. He suffered from fuzzy eyes, wilt waist and distending
stomach duct. He kept a normal diet with dry month dying to drink. His bowel
movement was dry and hard. His tongue was red with light yellow tongue coating.
There were cracks in the middle of the tongue along with teeth marks at the edge
of the tongue. His pulse was thready, rapid and weak. TCM diagnosed it with
Flaccidity Syndrome because of the Liver-Stomach yin vacuity. Western medicine
diagnosed it with
Amyotrophic Lateral
Sclerosis
(ALS). The treatment
strategy is to enrich yin and supplement the kidneys, to soften the liver and
extinguish the wind.
Main herbs used in
the herbal tea: baishao (white Peony), shudi (cooked rehmannia root), chuanwu
(aconite main tuber), etc. three dosages in total. One dosage a day and drink
twice
Date: Sept. 16,
2007 Time: 9:00 a.m.
The patient¡¯s
examinations of ECG,
B-ultrasonic
examination and blood were
both normal. His urine examination was (+); the
Urea Ammonia was
9.61. Considering there were some errors. The patient would have more
examinations if necessary. The patient said that his muscles beating all over
the body was lessened.
Doctor¡¯s requirement is
to take four dosages of the herbal tea of the same prescription.
Date: Sept. 20,
2007 Time: 9:00 a.m.
The muscles beatings
all over the body almost disappeared. His lower limbs still could not do any
movement, and he had to sit all the time. His lower limbs drooped, so the blood
was difficult to flow back to the body, which resulted in swellings below the
knee joints. The
doctor advised him to lay his legs straight and do more exercise for his
suffering parts. He would continue to take five dosages of the herbal tea of the
same prescription.
Date: Sept. 25,
2007 Time: 9:00 a.m.
The muscles beatings
all over the body were improved significantly. He still suffered from abdominal
distention with dry and hard bowel movement. His ankle joints were stiff and
unable to do any flexible movement. There were swellings below the ankle joints.
The treatment is to enrich the liver and supplement kidneys, quicken the blood
and soften the hardness.
He would continue to
take five dosages of the herbal tea of the same prescription.
Date: Sept. 29,
2007 Time: 9:00 a.m.
After taking the
treatment of herbal tea and massage, the muscles beating all over the body was
lessened day by day. It has been three days since the muscles beating stopped.
The stiff ankle joints and swellings were improved obviously.
He would continue to take herbal tea of the same
prescription.
Date: Oct. 5,
2007 Time: 9:00 a.m.
The stiffness of the
ankle joints was improved apparently, and his toe-joints could do some slightly
flexible movement. There were contracted movements among the muscles of his
legs. The patient was glad to receive such great improvement, so he kept a
pleasant mood.
Doctor¡¯s requirement is to take herbal tea of the same prescription.
Date: Oct. 10,
2007 Time: 9:00 a.m.
In recent days, the
patient has suffered from vomiting, poor intake and loose bowel movement for
twice a day. No stomachache. The treatment strategy is to warm the center and
dissipate cold, to fortify the spleen and transform food.
Doctor¡¯s requirement is to take three dosages of the herbal tea as
following: baishu (ovate atratylodes root), fulin (poria), dangshen (codonopsis
root), etc.
Date: Oct. 13,
2007 Time: 9:00 a.m.
The patient said that
his food intake was normal without any vomiting. He still suffered from
abdominal distention
with once loose bowel movement a day.
Doctor¡¯s requirement is to take herbal tea of the former
prescription without lycium. In recent days, the patient felt that there were
muscular contracted movements among his legs and calves. He was told he was
recovering in a good condition.
Date: Oct. 18,
2007 Time: 10:00 a.m.
The patient
complained about his uncomfortable throat. In the examination, there were
swellings and congestion on the throat. He was considered to have caught a cold.
The doctor added 6g Sichuan Coptis root, etc. to his herbal tea. The patient had
the symptoms of dry bowel movement and
abdominal distention.
There were muscular contracted movements among his
legs and calves. His left knee joints can do flexible movement, and the symptoms
of swellings and livor below his ankle joints was lessened, which showed that
his condition was improving. There was stiffness on his ankle joints, especially
serious on his left one. The patient told the doctor that he had had the history
of trauma 30 years before.
Date: Oct. 20,
2007 Time: 10:00 a.m.
The
patient¡¯s angina due to a cold has almost recovered. He was in poor spirit with
abdominal distention and dry
bowel movement. There were symptoms of swelling below the ankle joints of his
lower limbs, so the doctor advised him to eat more fruit and vegetables, and he
could not only take high-protein food. The main herbs in the prescription as
following: baishu (ovate atratylodes root), huangqi (astragalus
root), dangshen (codonopsis root), etc.
Date: Oct. 23,
2007 Time: 10:00 a.m.
In recent days, the patient has
caught a cold along with dieting outside, so he was considered that his diarrhea
resulted from the hurt on his stomach. He suffered from loose bowel movement for
twice a day, accompanied with
abdominal distention, poor intake and weakness. He was prescribed by
1000ml energy mixture with potassium chloride. He orally took self-prepared
medicine for his diarrhea. The TCM treatment strategy is to boost qi and fortify
the spleen. The main herbs in the three dosages of the herbal tea as following:
baishen (white ginseng), huangqi (astragalus root),
caihu (bupelurum root), etc.
Date: Oct. 24,
2007 Time: 9:00 a.m.
The
patient said that his spirit got better. No abdominal distention or diarrhea.
The doctor advised him that he¡¯d rather go on a light diet than a greasy or
high-protein diet. He should avoid the spicy or cold food.
Date: Oct. 26,
2007 Time: 9:00 a.m.
The
patient¡¯s condition was normal. He did not feel any
other special discomfort. His diet increased. He had slight abdominal
distention. No diarrhea. He kept a normal spirit. The main herbs in another
three dosages of the herbal tea:
baishen (white ginseng),
huangqi (astragalus root), caihu (bupelurum root), etc.
Date: Oct. 29,
2007 Time: 14:00 p.m.
In
recent days, the patient has eaten some fruits, which resulted in diarrhea,
accompanied with rectal tenesmus. He suffered with poor intake and weakness. The
patient took self-prepared medicine for his diarrhea, and he was prescribed by
1000ml + gentamicin 240,000 U and energy mixture. The patent felt no special
discomfort. The patient continued to take two dosages of the herbal tea of the
former formula.
Date: Oct. 31st
2007 Time: 10:00 a.m.
The
patient diarrhea recovered completely. His bowel movement was dry with blood in
it. Today the invited professor Yu of surgery examined him, and found that there
were several hemorrhoids among some hard and dry bowel movement of his anal
canal. There was no other abnormality. It was considered that the patient had
taken too much self-prepared medicine for diarrhea. Therefore, he was prescribed
by glycerine
enema for
external use. The doctor advised him to eat more fruit and take the herbal tea
for further examination. The TCM treatment strategy is to fortify the spleen and
supplement the kidneys. The main herbs in the three dosages of the herbal tea as
following:
baishen (white ginseng), huangqi (astragalus root), caihu (bupelurum root), etc.
Date: Nov. 3,
2007 Time: 9:00 a.m.
The
patient¡¯s bowel movement was hard and dry. After the
Glycerine Enema (Kaisailu)
for external use twice, he
excluded a lot of bowel movement. His diet got better significantly, and he kept
a normal spirit with good mood. The patient continued to take the herbal tea to
fortify the spleen and supplement the kidneys. Doctor¡¯s requirement is to take
four dosages of the herbal tea of the same formula.
Date: Nov. 7,
2007 Time: 9:00 a.m.
In
recent days, the patient has had slightly muscular beatings. His other condition
was normal. Doctor¡¯s requirement is to take five dosages of the herbal tea of
the following formula:
baishen (white ginseng),
huangqi (astragalus root), baishu (ovate atratylodes root), etc.
Date: Nov. 12,
2007 Time: 9:00 a.m.
The
patient¡¯s muscular beatings disappeared. The swellings below his ankle joints of
his lower limbs were lessened. The contracted strength of his lower limbs¡¯
muscles increased. His bowel movement and urination were both normal. He kept a
normal diet and steady mood. There was no other abnormality. The doctor added
Tangkuei to another five dosages of the herbal tea.
Date: Nov. 17,
2007 Time: 9:00 a.m.
The
stiffness of his lower limbs¡¯ ankle joints was lessened significantly. His skin
was in purple. There was blood block due to his tiredness after travel. Another
three dosages of the herbal tea was invariable as following:
baishen (white Ginseng),
huangqi (astragalus root), baishu (ovate atratylodes root), etc.
Date: Nov. 20,
2007 Time: 9:00 a.m.
The
stiffness of his lower limbs¡¯ ankle joints was lessened significantly. Doctor¡¯s
requirement is to take four dosages of the herbal tea of the foremer formula.
Date: Nov. 25,
2007 Time: 9:00 a.m.
The
swellings of his lower limbs¡¯ ankle joints were lessened further. There were
slight swelling on his feet and back. His skin was in purple and dark. He kept a
normal diet and sleep. His bowel movement and urination were both normal.
Doctor¡¯s requirement is to take four dosages of the herbal tea of the same
formula. Doctor¡¯s requirement is to take six dosages of the herbal tea of the
former formula.
Date: Nov. 30,
2007 Time: 9:00 a.m.
The
patient kept a steady condition. Doctor¡¯s requirement is to take four dosages of
the herbal tea of the former formula.
Date: Dec. 4,
2007 Time: 9:00
a.m.
The
muscular beatings all over his body disappeared completely. The swellings on his
lower limbs almost recovered. The stiffness on his ankle joints was improved
significantly. The blood circulation of his lower limbs was improved. He kept a
normal diet, sleep and digestion. The patient took 30 dosages of the herbal tea
for the former formula and demanded to leave the hospital. |
