Brief Summary: General introduction of this report: Ms. Cidalia, from Portugal, has received our treatments for two months. After the doctors’ efforts, she got much improvement. Her treatment is successful.


 Medical Report of Huaihua Red Cross Hospital


Name: Cidalia                                                     Birth Place: Portugal

Sex: female                                                        Occupation: retired    

Age: 61                                                              Marital status: widow

Date of hospitalization: March 2nd, 2007       Date of record: March 3rd, 2007

Narrator: the patient herself.

The main complaint: atrophy and weakness in her left upper-limb for 8 months.

Present illness: two years ago, she started suffering weakness in her both hands in her upper-limbs; till June, 2006, she was processing worse, and she had the symptom of muscular atrophy in her arms. She was diagnosed with ALS by a local MRI examination. She took the medicine Rilutek for a short period. Two months ago, it was stopped because of its side-effect.

Anamnesis: she took the operation of appendectomy at the age of 36. When she was 48, she removed ovariotomy. Two years later, she got fracture in her femur. Seven years ago, she removed a carcinoid in her mandible. She doesn’t have the history of any infectious disease or medical and diet allergy. She had blood transfusion.

Personal history: she was born in Portugal. No habit of smoking or bibulosity, her temperament is gentle and open-minded.

Family history: no history of any special genetic diseases in his family.

Medical examination: T: 36.3℃ P: 64/min R: 21/min BP: 100/73mmHg

Normal growth of her body and common nutrition level. Clear consciousness and cooperative. No yellow stain of the skin sclera. No edema of the superficial lymph nodes. Normal growth of her head and five sense organs. Sensitive to the light reflection. Symmetrical size of the pupillae. Dry lips. No hyperaemia in the throat. No edema of the tonsil and thyroid gland. Her neck touches naturally soft. Thoracic cage is symmetrical. Normal vocal fremitus. Clear percussion sound. Normal breath sound in the lungs. Spirant of the pleura. The heart rate is 64 times per minute. Normal rhythm of the heart. The abdomen is flat and soft. A scar with the length of 5 cm is visible at her abdomen. No pressing pains and no rebound tenderness. No pressing pains in the region of kidneys. Normal intestinal gurgling sound. No malformation of spinal column and limbs. No pressing pains and no warm sense of the lower limbs.

There is clear atrophy in her left arm. The girth of her left arm up elbow joints 7cm is 2 cm smaller than that of her right arm. The myodynamia of her left hand is level 4; she can lift her left arm horizontally. Her shoulder joints can move about freely.

Accessory examination: it is shown ALS by her local electromyography and MRI examinations.

Primary diagnosis: TCM flaccidity syndrome.

Symptoms diagnosis: spleen vacuity, liver-kidney depletion.

Treatment strategy: fortify the spleen and boost qi; enrich liver and supplement kidney; settle tetany and extinguish wind. Acupuncture combined with massage one time a day.