¡¡Brief Summary:
On May 25,
2007, the patient Mrs. M from Indonesia, who suffered from ALS, was
hospitalized in our hospital. After about 70-day TCM treatment, she
achieved significant improvement, especially the gripping power of her hands
increased a lot. Before she left our hospital, her left hand could hold objects
of 21.6 kg, and her right hand could hold objects of 30.0 kg. It is considerably
ideal.
¡¡
Record of
Hospitalization
Name:
Mrs. M Sex: Female
Age:
42
Profession: Housewife
Nationality:
Indonesia
Marital Status: Married
Onset Season:
Summer Date of Admission: May 25,
2007
Complainer:
The patient
himself Reliability: Reliable
Major Complaint:
The
patient has suffered from weakness of the four limbs for 8 months, and the
condition has been aggravated for 2 months.
Present
Illness:
In September 2006, the patient began to feel pains of the right waist. At that
time, the patient applied ¡°Dampness Damage Plaster¡± for external use. Her pains
got some improvement. Three days later, the right lower limb started to be
suffered from weakness and sense of heaviness. She did no other treatment about
it. A month later, the upper limbs were suffered from weakness, and there
appeared involuntary beating in the limbs muscles. Therefore, she went to a
local hospital for EMG examination, and she was diagnosed with ¡°Motor Neuron
Disease¡± (MND). She was told that it is incurable, and then she got no
treatment. In Jan. 2007, the patient¡¯s hands were not able to hold any heavy
objects. From March to May 22, 2007, she ordered Chinese medicine
from a hospital in Hebei province. In recent two months, the weakness of the
lower limbs was aggravated, and she had difficulty in raising her upper limbs,
with frequent involuntary beating in the muscles of the limbs. She came to our
hospital for further treatment at 19:30 p.m. on May 25, 2007. Since
she got the disease, her spirit and appetite have been both normal with slightly
poor sleep. Her bowel movement and urination were both normal.
Disease History:
No history
of typhoid, tuberculosis, hepatitis, malaria
or other infectious diseases.
No allergic history of medicine or food. No operation or
trauma
history. No history of preventive vaccination provided.
Personal History:
She was born in Indonesia, living in a dry environment. No contact history of
schistosomiasis. No addiction to smoking, alcohol or special food. She was
even-tempered and open-minded.
Marital History:
She got married at 20. She has given birth to three sons and three daughters.
Her husband and children have been healthy all the time.
Menstrual History:
Her
menstrual onset was at the age of 15. Generally, her
menstrual period was six days every
28 or 29 days. Her last menstruation was on May 3,
2007.
Family History:
Her mother has suffered from ALS for 9 years. Her father is healthy. No family
history of other special diseases.
Physical Examination:
T 36.3¡æ£¬P
80 beats/minute,
R 20 times/minute, BP 100/70 mmHg.
She grew normally with common
nourishment. Her mind was clear. She had an expression of chronic illness and
languidness. Her body was in a positive posture and she was cooperative in
examination. Her skin was moist. No jaundice in the sclera. No superficial
lymph-node enlargement. Bilateral pupils were round, equal in size, and
sensitive to light. 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 80 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 pressing pains in renal region. Bowel
sound was normal. No spinal and pelvic deformity or tenderness. The upper limbs
were not able to hold any heavy objects and had difficulty in uplifting.
There was involuntarily frequent beating in the muscles of the limbs. When she
stooped down, there was involuntary beating in the back¡¯s muscles. There was
obvious weakness of the limbs. Her muscles strength was Grade
¢ó with normal muscle tension.
The brinell
levy was (+). Other
physiological reflex has not been elicited. Her tongue was slightly red with
white and thin tongue coating. Her pulse was thready and weak.
Diagnostic
examination: Not provided.
First diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification:
Deficiency of the liver and kidneys, the liver wind entering the network
channels.
Western medicine
diagnosis: 1.
Motor Neuron Disease (MND)
2.
Amyotrophic Lateral Sclerosis (ALS)
First Medical Record
May 25,
2007
Mrs. M, a 42-year-old
female, has suffered from weakness of the four limbs for 8 months, and the
condition has been aggravated for 2 months. She was picked up by our staff in
Zhijiang Airport, and arrived in Huaihua Red Cross Hospital for further
treatment at 19: 30 p.m. on May 25, 2007.
Essentials for
Diagnosis:
1. The patient has
suffered from weakness of the four limbs for 8 months, and the condition has
been aggravated for 2 months.
2. In
September 2006, the patient began to feel pains of the right back. At that time,
the patient applied ¡°Dampness Damage Plaster¡± for external use. Her pains got
some improvement. Three days later, the right lower limb started to feel
weakness and sense of heaviness. She did no other treatment about it. A month
later, the upper limbs started to feel weakness, and there appeared involuntary
beating in the muscles of the limbs. Therefore, she went to a local hospital for
EMG examination, and she was diagnosed with ¡°Motor Neuron Disease¡± (MND). She
was told that it is incurable, and then she got no treatment. In Jan. 2007, the
patient¡¯s hands were not able to hold any heavy objects. From March to May 22,
2007, she ordered Chinese medicine from a hospital in Hebei province. In
recent two months, the weakness of the lower limbs was aggravated, and she had
difficulty in raising her upper limbs, with frequent involuntary beating in the
muscles of the limbs. She came to our hospital for further treatment at 19:30
p.m. on May 25, 2007. Since she got the disease, her spirit and
appetite have been both normal with slightly poor sleep. Her bowel movement and
urination were both normal.
3. T 36.3¡æ£¬P
80 beats/minute,
R 20 times/minute, BP 100/70 mmHg.
4. She grew normally
with common nourishment. Her mind was clear. She had an expression of chronic
illness and languidness. Her body was in a positive posture and she was
cooperative in examination.
5. She suffered from
weakness of
limbs. Both of her hands were not able to hold any heavy objects, with
difficulty in raising her upper limbs. Her muscle strength was Grade
¢ó
with normal muscle tension.
The brinell
levy was (+).
6. No thoracic
deformity. Chest percussion noted resonance. Sound of breath was 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 four limbs for 8 months, and the condition has
been aggravated for 2 months.
Due to
deficiency of the liver and kidneys, the essence-blood could not nourish the
muscles and vessel. Gradually it resulted in wilting syndrome. The loins are the
residence of the kidneys, and the kidneys are in charge of the bone. The
insufficiency of the essence-marrow makes limbs wilting and makes the lumbus and
knees weak. Her tongue was red and the pulse was thready and weak.
These are also the reflections of deficiency
of yin and blood, which belongs to the scope of wilting syndrome.
Western medicine: The
patient has suffered from weakness of the four limbs for 8 months, and the
condition has been aggravated for 2 months.
Both of her hands were not able to hold any objects, and
had difficulty in uplifting.
There was involuntarily frequent beating in the muscles of the limbs. When she
stooped down, there was involuntary beating in the back¡¯s muscles. There was
obvious weakness of the limbs. Her muscle strength was Grade
¢ó
with normal muscle tension.
The brinell
levy was (+). The
patient was diagnosed with ¡°Motor
Neuron Disease¡± (MND) by EMG examination in a hospital in her own country.
Diagnostic
Differentiation:
Western medicine:
Wilting syndrome should be differentiated from myasthenia gravis, which is a kind of acquired
autoimmune disease that there appear transmitting obstacles in the
sites of the neuromuscular junctions
owing to the reduced acetylcholine receptor. Myasthenia gravis
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 is rapid fatigability and weakness of the part
of the body¡¯s striated
muscles.
It will be improved with rest or medicines that
inhibit the activity of choline esterase.
It can also involve
cardiac muscles and
smooth muscles.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification:
Deficiency of the liver and kidneys, the liver wind entering the network
channels.
Western medicine
diagnosis: 1.
Motor Neuron Disease (MND)
2.
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. Regular diet.
5. Herbal tea (to
supplement the liver and to boost the kidneys,
to track down wind
and to free the network channels): Take three dosages of the herbal tea, one
dosage a day and drink twice.
Prescription: Varied
Decoction of the Kidneys-Supplementing Liver-Boosting.
Main herbs used in
the herbal tea: shudi (cooked rehmannia root), zaopi (cornus fruit), gouqi (lycium),
etc.
6. Acupuncture and
massage: once a day.
7. Have more medical
examinations if necessary.
Date: May 26,
2007 Time: 9:00 a.m.
Today the
patient complained to Dr. Yang that there was obvious weakness of the limbs,
with some difficulty in raising her upper limbs. The regular examination of the
urination was normal.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her heart and
lungs were normal, and her abdomen was soft and flat.
Dr. Yang¡¯s analysis:
1.
The patient
has suffered from weakness of the four limbs for 8 months, and the condition has
been aggravated for 2 months.
2.
She suffered
from weakness of limbs. Both of her hands were not able to hold any heavy
objects, with difficulty in raising her upper limbs. There was involuntarily
frequent beating in the muscles of the limbs. When she stooped down, there was
involuntary beating in the muscles of the back. Her muscle strength was Grade
¢ó
with normal muscle tension.
3. The patient was
diagnosed with ¡°Motor Neuron
Disease¡± (MND) by EMG examination in a national hospital.
According to the
above information, TCM diagnosed as wilting syndrome, which is characterized as
retardation of
the limbs¡¯ muscles and vessel, weakness of the limbs, difficulty in movement,
accompanied by muscular atrophy. In clinical practice, this kind of disease
affects lower limbs more common, which is also called ¡°crippling wilt¡±. The
patients who suffer from it feel weakness of the spleen and stomach, lack of
sources of the qi and blood, which could not nourish the muscles and vessels,
and so it forms wilting limbs. The
kidneys are in charge of the bone. The insufficiency of the essence-marrow makes
the limbs wilting and makes the lumbus and knees weak.
Doctor¡¯s diagnosis:
Deficiency of the
liver and kidneys, the liver wind entering the network channels.
Doctor¡¯s strategy:
Supplementing the liver and boosting the kidneys, tracking down wind
and freeing the network channels.
Prescription: Varied
Decoction for Kidney-Supplementing Liver-Boosting.
Doctor¡¯s requirement
is to take three dosages of the herbal tea of the same formula. One dosage a day
and drink twice. Acupuncture and massage for once a day. The patient should have
more medical examinations if necessary.
Date: May 27,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still felt
her limbs
weak with difficulty in
raising the upper limbs. There
was involuntarily frequent beating in the muscles of the limbs.
The examinations of
the blood and the function of her liver and kidneys were all normal.
ECG examination was also normal.
After the B-ultrasonic
examination, her liver,
gallbladder, spleen and lungs were all normal.
Examination:
T 36.3¡æ£¬P
80 beats/minute,
R 20 times/minute, BP 100/70 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat. Her tongue was
slightly red with white and thin tongue coating. Her pulse was thready and weak.
Doctor¡¯s
requirement is that the herbal tea should follow the original formula.
Date: May 28,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still felt
her limbs
weak with difficulty in
raising the upper limbs. Both of her hands were not able to hold any heavy
objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her heart and
lungs were normal, and her abdomen was soft and flat. No aversion to coldness or
fever. No feeling of headache or dizziness. No nausea or vomit. Her spirit and
appetite were both normal, and her sleep was good. Her bowel movement and
urination were both normal. Her tongue was slightly red with white and thin
tongue coating. Her pulse was deep and thready. Doctor¡¯s requirement is that the
herbal tea should follow the original formula.
Date: June 1,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still felt
her limbs
weak with difficulty in
raising the upper limbs. Both of her hands were still not able to hold any heavy
objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat. No aversion to
coldness or heat. No feelings of headache or dizziness. No nausea or vomit. Her
spirit and appetite were both normal, and her sleep was good. Her bowel movement
and urination were both normal. Her tongue was slightly red with white and thin
tongue coating. Her pulse was deep and thready.
Doctor¡¯s requirement is to
take five dosages of the herbal tea of the same
prescription.
Date: June 6,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still felt
her limbs
weak with difficulty in
raising the upper limbs. Both of her hands were still not able to hold any heavy
objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her heart and
lungs were normal, and her abdomen was soft and flat. Her spirit and appetite
were both normal, and her sleep was good. Her bowel movement and urination were
both normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: June 11,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still felt
her limbs
weak with difficulty in
raising the upper limbs. Both of her hands were still not able to hold any heavy
objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her heart and
lungs were normal, and her abdomen was soft and flat. Her spirit and appetite
were both normal, and her sleep was good. Her bowel movement and urination were
both normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is to take five dosages of the
herbal tea of the same prescription.
Date: June 16,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort.
The
weakness of her limbs
was improving, and her upper limbs were getting better to uplift than before.
Her hands could rise by about
2cm. Both of her hands were still not able to hold any
heavy objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg. Her heart and lungs were
normal, and her abdomen was soft and flat. Her spirit and appetite were both
normal, and her sleep was good. Her bowel movement and urination were both
normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: June 21,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort.
The
weakness of her limbs
was improving, and her upper limbs were getting better to uplift than before.
She could raise her hands to
about 2cm. Both of her hands were still not able to
hold any heavy objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her heart and
lungs were normal, and her abdomen was soft and flat. Her spirit and appetite
were both normal, and her sleep was good. Her bowel movement and urination were
both normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is to take five dosages of the
herbal tea of the same prescription.
Date: June 25,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort. The
weakness of her limbs
was improving, and her upper limbs were getting better to uplift than before.
She could raise her hands to
about 2cm. Both of her hands were still not able to
hold any heavy objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her heart and
lungs were normal, and her abdomen was soft and flat. Her spirit and appetite
were both normal, and her sleep was good. Her bowel movement and urination were
both normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: June 29,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort. The
weakness of her limbs
was improving, and her upper limbs were getting better to uplift than before.
She could raise her hands to
about 2cm. Both of her hands were still not able to
hold any heavy objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg. Her heart and lungs were
normal, and her abdomen was soft and flat. Her spirit and appetite were both
normal, and her sleep was good. Her bowel movement and urination were both
normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is to take five dosages of the
herbal tea of the same prescription.
Date: July 3,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort. The
weakness of her limbs
was improving, and her upper limbs were getting better to uplift than before.
She could raise her hands to
about 2cm. Both of her hands were still not able to
hold any heavy objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her heart and
lungs were normal, and her abdomen was soft and flat. Her spirit and appetite
were both normal, and her sleep was good. Her bowel movement and urination were
both normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: July 7,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort.
The
weakness of her limbs
was improving, and her upper limbs were getting better to uplift than before.
She could raise her hands to
about 2 cm. Both of her hands were still not able to
hold any heavy objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg. Her heart and lungs were
normal, and her abdomen was soft and flat. Her spirit and appetite were both
normal, and her sleep was good. Her bowel movement and urination were both
normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is to take five dosages of the
herbal tea of the same prescription.
Date: July 11,
2007 Time: 9:30 a.m.
The patient did not
complain about any other special discomfort.
The
weakness of her limbs
was improving, and her upper limbs were getting better to uplift than before.
She could raise her hands to
about 4cm. Both of her hands were still not able to
hold any heavy objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her heart and
lungs were normal, and her abdomen was soft and flat. Her spirit and appetite
were both normal, and her sleep was good. Her bowel movement and urination were
both normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: July 15,
2007 Time: 9:30 a.m.
The patient did not
complain about any other special discomfort. The
weakness of her limbs was getting better, and her upper
limbs achieved obvious improvement to uplift.
She could raise her hands to about
4cm. Both of her hands were still not able to hold any
heavy objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her heart and
lungs were normal, and her abdomen was soft and flat. Her spirit and appetite
were both normal, and her sleep was good. Her bowel movement and urination were
both normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: July 19,
2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort. The
weakness of her limbs and her upper limbs both achieved
obvious improvement. She
could raise her hands to about 4cm. Both of her hands
were still not able to hold any heavy objects.
Examination:
T 36.3¡æ£¬P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
Her
heart and lungs were normal, and her abdomen was soft and flat. Her spirit and
appetite were both normal, and her sleep was good. Her bowel movement and
urination were both normal. Her tongue was slightly red with white and thin
tongue coating. Her pulse was deep and thready. Doctor¡¯s requirement is to take
five dosages of the herbal tea of the same prescription.
Date: July 23,
2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The weakness of her limbs
was getting much better, and her upper limbs achieved obvious improvement to
uplift. She could raise her hands to about 4cm. Both of her hands were still not
able to hold any heavy objects. Her heart and lungs were normal, and her abdomen
was soft and flat. Her spirit and appetite were both normal, and her sleep was
good. Her bowel movement and urination were both normal. Her tongue was slightly
red with white and thin tongue coating. Her pulse was deep and thready. Doctor¡¯s
requirement is that the herbal tea should follow the original formula.
Date: July 28,
2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The weakness of her limbs
was getting much better, and her upper limbs achieved obvious improvement to
uplift. She could raise her hands to about 4cm. Both of her hands were still not
able to hold any heavy objects, but she could write slowly. Her heart and lungs
were normal, and her abdomen was soft and flat. Her spirit and appetite were
both normal, and her sleep was good. Her bowel movement and urination were both
normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: August 2,
2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The weakness of her limbs
was improved significantly, and her upper limbs achieved obvious improvement to
uplift. She could raise her hands to about 4cm. Both of her hands were still not
able to hold any heavy objects, but she could write
slowly. Her heart and lungs were normal, and her abdomen was soft and
flat. Her spirit and appetite were both normal, and her sleep was good. Her
bowel movement and urination were both normal. Her tongue was slightly red with
white and thin tongue coating. Her pulse was deep and thready. Doctor¡¯s
requirement is that the herbal tea should follow the original formula.
Date: August 4,
2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The
weakness of her limbs was improved significantly, and her upper limbs
achieved obvious improvement to uplift. She could raise her hands to about 4cm.
the ripping power of her hands increased markedly. The left hand could hold
objects of 21.6 kg, and the right hand could hold objects of 30.0 kg. The
movements of her fingers were poor, but she could write slowly. Her heart and
lungs were normal, and her abdomen was soft and flat. Her spirit and appetite
were both normal, and her sleep was good. Her bowel movement and urination were
both normal. Her tongue was slightly red with white and thin tongue coating. Her
pulse was deep and thready. The patient would leave the hospital tomorrow.
¡¡
