Brief Summary: On November 18, 2013, Grebenikova, from Russia, who had suffered from difficult swallowing for one year, developing into weight losing and muscle jumping for 6 months, was hospitalized in our hospital. Her condition was diagnosed as ALS. She achieved some great improvement after 86 days TCM treatment.

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Record of Hospitalization

Name: Grebenikova                              Sex: Female

Age: 69                                                 Marital Status: Married

Nationality: Russian                             Date of Admission: November 18, 2013

Companion: Her Granddaughter 

First Medical Record

Date: Nov. 19, 2013                                Time: 09:30 a.m.

This 69-year-old lady had suffered from difficulty swallowing and talk for one year, developing into weight losing and muscle jumping for 6 months. The patient was hospitalized in our hospital for TCM treatment at 12:30 p.m. on November 18, 2013.

Essential for Diagnosis:

1. The patient had been suffering from difficulty swallowing and talk for one year, developing into weight losing and muscle jumping for 6 months. She had no allergy history of any food or medicine.

2. When the patient hospitalized in our hospital, she felt difficulty in swallowing and speaking. She felt dryness in her mouth. She drank much water. In recent 6 months, her voice became lower and then she suffered speaking problem. Appetite was poorer than before. The sense of hunger was not that stronger than before. No night sweat or night heat over the body. She suffered frequent night urination, sometimes 2 times, while sometimes 3-4 times. The night urination problem had been lasted for ten years. She also suffered headache for many years. She felt dizziness in recent 4 months. The color of urine was yellowish. The stool was hard. She lost weight in recent months, but no change over her power, right hand: 19.6 kilos; left hand 15.2 kilos. Sometimes she suffered muscle jumpings and muscle spasms. Shortness of breath was not obvious. Her pulse was slippery and rapid. Her tongue was red with yellowish coating.

3. T: 36.4C   R: 20 times/minute    P: 80 times/minute   BP: 170/90 mmHg

5. She had a chronic sick facial expression. Her spirit activities were normal. She grew normally. There was no yellow skin or yellow sclera over her whole body. Rhythm of her heart was 80 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. Her abdomen was soft with no pressing pains and rebound tenderness. There were few muscle jumpings over her four limbs, but there was no obvious muscle atrophy over them.

Diagnostic Base:

TCM:

   The patient was old. Her kidneys were in a deficient state. The deficiency of kidney-yang led to the deficiency of liver-yang. Wind-yang attacked upwards the mind, which caused change of emotion. Liver stagnation led to qi stagnation. The patient suffered painful menstruation often when she was young. Floating yang got up, which caused dizziness and headache. The stomach meridian goes through the neck. Over heat caused dryness in the mouth. Wind-yang disturbed inside, which caused muscle jumping. Therefore, her condition should be deficiency of the kidneys and liver-yang hyperactivity as well as wind-fire attacking upwards the mind. The treatment should be nourishing the kidneys and tonifying the spleen.

Western Medicine diagnosis:

   1. Chronic ill occurrence.

   2. Symptoms: Swallowing and speaking difficulty, muscle jumpings

   3. Lab examination report.