Brief Summary: On April 14, 2014, Alsalahi, from Yemen, who had suffered from movement limitation over his left leg, accompanied by slight muscle atrophy over his left leg, was hospitalized in our hospital. His condition were ALS and diabetes. He achieved significant improvement after 55 days TCM treatment.

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Record of Hospitalization

Name: Alsalahi                                                 Sex: Male

Age: 59                                                            Marital Status: Married

Nationality: Yemen                                          Date of Admission: Apr. 15, 2014

Companion: his son

First Medical Record

Date: Apr. 15, 2014                                Time: 10:00 am

This 59-year-old man had suffered from movement limitation over his left leg for eight months, accompanied by slight muscle atrophy over his left leg. The patient was hospitalized in our hospital for TCM treatment at 19 pm on April 14, 2014.

Essential for Diagnosis:

1. The patient had been suffering from movement limitation over his left leg for eight months, accompanied by slight muscle atrophy over his left leg. He was diagnosed as Type  diabetes in 2009. No allergy history to any food or any medicine.

2. When the patient hospitalized in our hospital, he suffered movement limitation over his left foot. He walks with the help of walking stick. Muscles over his left thigh was slightly atrophic. There were pains over his left thigh sometimes. He felt tired and heavy over his whole body, especially his left leg. Movement over his upper limbs were very slow. Muscle jumpings were seen over his four limbs. He did not feel any headache or dizziness. There were no tinnitus or deafness problems. He did not have difficulty in swallowing or speaking. He suffered night sweating. Sleep was not good. He had night urination for 4-5 times per night. Appetite was good. Lower limbs were afraid of cold.

3. T: 36.4C   R: 20 times/minute    P: 74 times/minute   BP: 125/70 mmHg

4. His spirit activities were normal. There was no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. His neck was soft with no resistance. His chest was symmetrical. Rhythm of his heart was 74 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. His abdomen was soft with no pressing pains and rebound tenderness. There was muscle atrophy over the muscles of his left thigh. His tongue was red with slightly thick and yellowish tongue coating. His pulse was deep and thready.

First Diagnosis:

TCM: atrophy disease

Western medicine diagnosis: ALS and Type  diabetes.

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade  care.

3. Companion.

4. Diet with low fat and high protein.

5. Herbal tea: one dosage a day and drink twice

6. Acupuncture and massage: once a day

7. Have more medical examination if necessary.