Brief Summary:
Mr. Joern, from Denmark, suffered from ALS
with the symptoms of weakness and amyotrophy of the left lower
limbs with lame walking. After the comprehensive treatment here,
his symptoms get much improvement.
Records of
Hospitalization
Name:
Joern Sex:
Male
Age:
60 years
Profession: Travel
Director
Nationality:
Denmark
Marital status:
Married
Onset Season:
Summer Date of Admission:
Jan. 6th, 2006
Complainer:
The patient himself
Reliability:
Reliable
Major complaint:
The patient has suffered from weakness and amyotrophy of the
left lower limbs for 2 years with six-month walking lamely
condition.
Present illness:
In January of 2006, the patient began to have weakness of the
left lower limbs without any obvious cause. At that time, the
patient didn¡¯t pay enough attention to nor do anything about it.
In June of 2006, he began to have muscular spasm and atrophy in
his left lower limbs, walking lamely; however, he had no
treatment for those symptoms. In Sep. 2006, he was diagnosed as
ALS by EMG and affection of Borelin by LP in the local hospital,
where he got three-month oral medication called Runterk which
was to be proved effectless. And in Dec. 2006 he took twenty-day
herbal tea posted to him from our hospital, after which he felt
certain symptomatic improved. So he came to our hospital for
further treatment. Since he had the disease, his spirit,
appetite and sleep had been good, and
his urination and defecation normal.
Past
history:
No history of typhoid, tuberculosis, malaria and hepatitis. No
allergic history of medicine or food. No operation history. No
history of preventive vaccination provided. In May of 2005 he
had plastic operation meniscus.
Personal history:
He was born in Denmark. No contact history of schistosomiasis.
No addiction to smoking, alcohol or special food. And he was
even-tempered and optimistic.
Marital history:
He was married at 25 and had
given birth to a son and a daughter. His wife and children have
been healthy all the time.
Family history:
Her parents were both healthy. No history of special disease.
Physical
examination
T 36.5¡æ£¬P
78 bpm, R 20bpm, BP 130/80mmHg, W 86kg
He is mid-nourished and normally developed. His mind is clear.
He has an expression of chronic illness and languidness. He is
in a positive position and cooperative in examination. His skin
is moist. No jaundice in the sclera. No superficial lymph-node
enlargement. Bilateral pupils are round and equal in size and
sensitive to light. No chest deformity. Sound of breath is
bilaterally normal on auscultation. No respiratory rales or
pleural friction rubs. Heart border is normal. Heart beat
78/min. Cardiac rhythm is regular. No pathological murmurs on
auscultation. Abdomen
touches flat and soft without tenderness or rebound tenderness.
Liver and spleen are not palpable. No percussion pain in renal
region. Bowel sound is normal. No spinal and pelvic deformity or
tenderness. No deformity or inflexibility of the right lower
extremity or upper ones. The condition of the left lower
extremity will be discussed in the next paragraph. The
development of his anus or pudendum is normal. His tongue body
is dull red with thin and white coating, and his pulse deep,
thread-like and loose.
Left lower limbs:
weakness and mild amyotrophy. The circumference of the right
thigh measured 12cm above the knee joint is 42cm, while that of
the left one is 44cm. Measured around 14cm below the knee joint,
the circumference of the left leg is 34cm, while that of the
right one is 36cm. Muscular strength is normal but muscular
tension is weakerl. There are obvious muscular jumps in his left
thigh and right leg.
Diagnostic
examination:
In Sep. 2006, he was diagnosed as ALS by EMG in a local
hospital.
First diagnosis:
TCM diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom diagnosis: liver and kidney deficiency; spleen and
stomach qi-asthenia.
WM diagnosis: ALS
First Medical
Record
Jan. 6th
2007
Joern, a 60-year male, the patient has suffered from weakness
and amyotrophy of left lower extremity for 2 years with
six-month condition of walking lamely. He came to the TCM Dep.
of Huaihua Red Cross Hospital on Jan. 6th 2007.
Essentials for
diagnosis:
1. Weakness and amyotrophy of the left lower extremity for two
years; walking lamely for half a year.
2. In Jan. 2006, the patient began to have weakness of left
lower extremity without any obvious cause. At that time, the
patient didn¡¯t pay enough attention to nor do anything about it.
In Jun. 2006, he began to have muscular spasm and atrophy in his
left lower limb, walking lamely; however, he had no treatment
for those symptoms. In Sep. 2006, he was diagnosed as ALS by EMG
and affection of Borelin by LP in a local hospital, where he got
three-month oral medication called Runterk which was of no
effect. And in Dec. 2006 he took twenty-day herbal tea posted by
our hospital, after which he felt certain symptomatic
improvement. So he came to our hospital for TCM treatment. Since
he had the disease, his spirit, appetite and sleep were good,
and his urination and defecation were normal.
3. T 36.5¡æ£¬P
78bpm, R 20bpm, BP 130/80mmHg, W 86kg
4. He is mid-nourished and normally developed. His mind is
clear. He has an expression of chronic illness and languidness.
He is in a positive position and cooperative in examination.
5. He has weakness and mild amyotrophy in left lower extremity.
The circumference of the right thigh measured 12cm above the
knee joint is 42cm, while that of the left one was 44cm.
Measured around 14cm below the knee joint, the circumference of
the left leg is 34cm, while that of the right one is 36cm.
Muscular strength is normal but muscular tension weaker than
normal. And there are obvious muscular jumps in his left thigh
and right leg. His hands are normal.
6. No thoracic deformity. Chest percussion noted resonance.
Sound of breath is bilaterally clear on auscultation. No sound
of pleural friction.
7. Diagnostic examination: In Sep. 2006, he was diagnosed as ALS
by EMG in a local hospital.
Diagnostic basis
TCM:
He has weakness and mild amyotrophy of left lower extremity for
two years with six-month condition of walking lamely. There
exists flaccidity of sinews and vessels in his left lower
extremity. And there are obvious muscular jumps in his left
thigh and right leg.
Western medicine:
He has weakness and mild amyotrophy in left lower extremity. The
circumference of the right thigh measured 12cm above the knee
joint is 42cm, while that of the left one was 44cm. Measured
around 14cm below the knee joint, the circumference of the left
leg is 34cm, while that of the right one is 36cm. Muscular
strength is normal but muscular tension weaker than normal. And
there are obvious muscular jumps in his left thigh and right
leg.
Diagnostic
differentiation
TCM: The patient¡¯s Wei-syndrome should be differentiated from
Bi-syndrome. Although they both fall into the category of limb
disease, they are different in pathogeny, pathogenesis and
clinical manifestations. Wei-syndrome is characterized as limp,
weak and emaciated limbs with shriveled muscles. A patient
suffering from Wei-syndrome may even become unable to hold an
object or to stand without support. Besides, the patient¡¯s lower
limbs are more often affected, though he or she usually has no
joint pain. On the contrary, Bi-syndrome is generally
characterized as aching pain, fixed heaviness and inflexibility
of sinews and bones, muscles and joints, with occasional
numbness or swelling, though, no paralytic manifestations. The
pathogenesis of Wei-syndrome is that the essence and blood in
five-fu organs is insufficient to travel through the whole body
leading to malnourish of the meridians and collaterals; while
that of Bi-syndrome is that the obstruction of meridians and
collaterals by pathogenic qi blocks the circulation of qi and
blood. They are not difficult to be distinguished in clinics.
WM: Wei-syndrome should be differentiated from myasthenia gravis
which can occur at any age and strikes typically between ages 10
and 35. Women are more often affected than men. The most obvious
characteristic of MG is rapid fatigability of the skeletal
muscles affected, improved with rest in various degrees. The
patient¡¯s condition fluctuates, relatively better in the morning
and worse at dusk. The onset is all of a sudden, often begun
with a group of muscles, and as time goes on, the disease
progressively affects other groups. It is most common that the
cranial innervate muscles are often the first group of muscles
to be affected evidenced by the fact that about 90 percent of
persons with MG have such initial symptoms as drooping eyelids
(ptosis) and double vision (diplopia). And the bulbar muscles
and girdle muscles are often the second group of muscles to be
affected. MG patients of different ages often have different
clinical manifestations and courses which are different from
those of Wei-syndrome paients.
First diagnosis:
TCM diagnosis: Weizheng (flaccidity syndrome)
Symptom diagnosis: liver and kidney deficiency; spleen and
stomach qi-asthenia.
WM diagnosis: ALS
Plan of treatment
strategy and nursing
1. On routine care of traditional Chinese internal medicine
2. On grade II care
3. Under care of a companion
4. High-protein diet
5. Herbal tea (to nourish liver and kidney and to invigorate
spleen and replenish qi): one dosage a day and drink by twice
Main herbs used in the herbal tea: Shudi (Cooked Rehmannia),
Baishen (White Ginseng), Tubie (Wingless cockroach), Zaopi
(Cornus), Niuxi (Achyranthes), Ruxiang (Frankincense), Moyao
(Myrrh), Suoyang (Cynomorium), Yimi (Coix), Zhimu (Anemarrhena),
Jixueteng (Millettia), Baizhu (Ovate Atractylodes).
6. Acupuncture and massage: once a day
7. Have more medical examinations if necessary
Date: 7th
of Jan. 2007
Time: 9:00 a.m.
In today¡¯s doctor¡¯s rounds, the patient told Dr. Yang that he
has weakness of left lower extremity and difficulty in walking.
Examinations: T 36.5¡æ£¬P
78bpm, R 20bpm, BP 130/80mmHg, W 86kg.
The patient has weakness in left lower extremity and difficulty
in walking. The circumference of his right thigh measured 12cm
above the knee joint is 42cm, while that of the left one was
44cm. Measured around 14cm below the knee joint, the
circumference of the left leg is 34cm, while that of the right
one is 36cm. Muscular strength is normal but muscular tension
weaker than normal. And there are obvious muscular jumps in his
left thigh and right leg. His tongue is dull red with thin and
white coating, and his pulse deep, threadlike and loose. In Sep.
2006, he was diagnosed as ALS by EMG in a local hospital.
Dr. Yang¡¯s analysis:
1. According to those manifestations, the patient¡¯s disease
falls into the category of
Wei-syndrome
(flaccidity syndrome)
which refers to the flaccidity and weakness of extremities
leading to inability to move freely. In clinics, amyotrophy and
weakness of lower extremities are eminent. The cause of the
disease can be external or internal. The external cause is the
long-term infiltration of splenic and gastric fluid by exogenous
pathologic factors such as warmth, heat, toxin, and damp heat.
While the internal causes are always impaired function of the
zang-fu organs due to factors such as irregular diet, chronic
illness, or overstrain, etc., leading to the asthenia of spleen
and stomach and consumption of liver and kidney. The condition
of chronic wei-syndrome patients will become critical if the
splenic and renal essence and qi are severely exhausted.
2. Symptom diagnosis: liver and kidney deficiency; spleen and
stomach qi-asthenia.
3. Principle of TCM treatment: to nourish liver and kidney and
to invigorate spleen and replenish qi. Main herbs used in the
herbal tea for six days: Shudi (Cooked Rehmannia), Baishen
(White Ginseng), Tubie (Wingless cockroach), Zaopi (Cornus),
Niuxi (Achyranthes), Ruxiang (Frankincense), Moyao (Myrrh),
Suoyang (Cynomorium), Yimi (Coix), Zhimu (Anemarrhena),
Jixueteng (Millettia), Baizhu (Ovate Atractylodes). A daily
dosage should be decocted twice.
4. Other treatments or examinations: daily acupuncture and
massage; have more medical examinations if necessary.
Date: 8th
of Jan. 2007 Time:
9:00 a.m.
Today the patient has no discomforts such as headache,
dizziness, nausea, vomit, fever or aversion to cold, except
weakness in left lower extremity and difficulty in walking. He
has no problem with spirit and appetite, and he has had a good
sleep. His bowel movement and urination are normal. His heart
and lungs are normal. His abdomen is flat and soft. The
condition of his left lower limb remains the same. His tongue is
dull red with thin and white coating. His pulse is deep,
threadlike and loose. Doctor¡¯s request: the herbal tea should
follow the original formulation.
Date: 9th
of Jan. 2007
Time: 9:00 a.m.
Today the patient has no discomforts such as headache,
dizziness, nausea, vomit, fever or aversion to cold, except
weakness in left lower extremity and difficulty in walking
manifested as walking lamely. He has no problem in spirit and
appetite, and he has had a good sleep. His bowel movement and
urination are normal. He has had routine blood, urine and stool
test, liver function test, hepatitis-B test, kidney function
tests, blood sugar test, blood fat test, of which the results
are all normal. He also has had ECG and X-ray of hip joints of
which the results are both normal. And he has had ultrasonic
examination of his spleen, kidney and gall bladder, of which the
results are all normal. However, he has liver enlargement. His
tongue is dull red with thin and white coating. His pulse is
deep, threadlike and loose. Doctor¡¯s request: the herbal tea
should follow the original formulation.
Date: 12th of Jan.
2007
Time: 9:00 a.m.
Today the patient has no discomforts such as headache,
dizziness, nausea, vomit, fever or aversion to cold, except
weakness in left lower extremity and difficulty in walking. He
has no problem with spirit and appetite, and he has had a good
sleep. His bowel movement and urination are normal. His heart
and lungs are normal. His abdomen is flat and soft. Unlike
before, his right toes are able to flex and extend again. His
tongue is dull red with thin and white coating. His pulse is
deep, threadlike and loose. Doctor¡¯s request: the patient should
have confidence in fight against the disease and be cooperate in
the treatment.
Date: 16th
of Jan. 2007
Time: 9:00 a.m.
Today the patient has no discomforts such as headache,
dizziness, nausea, vomit, fever or aversion to cold, except
weakness in left lower extremity and difficulty in walking
manifested as walking lamely. He has no problem in spirit and
appetite, and he has had a good sleep. His bowel movement and
urination are normal. His heart and lungs are normal. His
abdomen is flat. His tongue is dull red with thin and white
coating. His pulse is deep, threadlike and loose. Doctor¡¯s
request: the herbal tea should follow the original formulation.
Date: 19th
of Jan. 2007
Time: 9:00 a.m.
Today the patient has no
discomforts such as headache, dizziness, nausea, vomit, fever or
aversion to cold, except weakness in left lower extremity and
difficulty in walking manifested as walking lamely. He has no
problem in spirit and appetite, and he has had a good sleep. His
bowel movement and urination are normal. His heart and lungs are
normal. His abdomen is flat. His tongue is dull red with thin
and white coating. His pulse is deep, thread-like and loose.
Doctor¡¯s advice: the herbal tea should follow the original
formulation.
Based upon
our very successful help to many ALS patients, ALS is now one of
the significant focuses of our hospital.
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