Brief
Summary:
On Feb. 9, 2009, Sarath from Sri Lanka, who has suffered from
ALS, accompanied with the symptom of the difficulties in
speaking and swallowing for one year, was hospitalized in our
hospital. He has achieved some improvement after 78 days TCM
treatment here.
Record of Hospitalization
Name:
Sarath Birthplace:
Sri Lanka
Sex:
Male Profession:
Civilian
Age:
60
Date of Admission:
Feb. 9, 2009
Religion:
Muslim
Date of Record:
Feb. 10, 2009
Marital Status:
Married
Onset Season:
Two days after Spring begins
Complainer:
The patient himself and the translator
First Medical Record
Date: Feb. 10, 2009 Time:
8: 00 a. m.
Sarath, a 60-year-old male, has suffered from
ALS, accompanied with the symptom of the difficulties in
speaking and swallowing for one year. He was hospitalized in our
hospital at 19: 00 p. m. on Feb. 9, 2009.
Essentials for Diagnosis:
1. The
patient has suffered from the symptom of the difficulties in
speaking and swallowing for one year.
2. Last
January, the patient began to feel the difficulties in speaking
and swallowing, but there were no itching and pains of the
throat. He could feel the difficulty in drinking in the early
stage, but later he could drink water without problem. He had no
ability to make his tongue curve upward, and the tongue could
not touch the lips. His pronunciation was not clear. There was
slight jumping of the muscles, but without the symptoms of the
pains and stiffness. He was given MRI examination in the local
hospital but with no clear diagnosis. Last April, he began to
take his traditional treatment in his country, but there was no
obvious improvement. Then he took western medicine treatment in
July, but there was still no much improvement. Last September,
he was given EMG examination in the local hospital and then was
diagnosed with ALS. Later he took our herbal tea treatment and
consciously felt the jumping of the muscles disappeared and the
tongue could touch the lips. So he went to our hospital for
further treatment. Since he suffered from the disease, there was
no obvious decline of the weight and
muscular strength. At present, the patient had the difficulty in
speaking and swallowing. He was fond of drinking warm water and
was easy to cough up when drinking. His breath and sleep were
normal. There was slight cough and he consciously felt the
phlegm in the throat. His appetite was generally good. There
were the symptoms of the sense of heavy head and vomiting if he
didn¡¯t take any food. But he felt comfortable after the meals.
His urine and bowel movement were normal.
3. He
had the history of
chronic rhinitis. No allergy to the food or
medicine.
4. T
36.2¡æ,
R 20 times/minute, P 84 times/minute, BP 120/78mmHg.
5. He grew normally with common nutrition. His mind was clear.
He had an expression of chronic illness and tiredness. His body
was in a positive posture. There was no
xanthochromia of the skin all
over the body and sclera. No enlargement of
superficial lymph nodes. No thoracic deformity. Sound of breath
was bilaterally normal on auscultation. Heart border was normal.
Heart beat was 80 times/minute. Cardiac rhythm was regular. No
pathological murmurs on auscultation. The abdomen was normal.
There were no tapping pains in the area of the kidneys. The
examination of nervous system was normal.
6. Accessory examination: None.
Diagnostic Basis:
TCM: The patient was characterized by the difficulties in
speaking and swallowing, so it was not difficult to be diagnosed
as wilting pattern. Due to insufficiency of ancestral qi, the
patient could not speak clearly. Spleen qi vacuity resulted in
improper nourishment of the tongue. Because of insufficiency of
lung qi and dynamia, his tongue could not curve upward. He had
the difficulty in swallowing and was easy to have dry cough, so
the phlegm was difficult to be coughed up. His tongue was thin
and white. His tongue coating was thick. These symptoms are the
manifestation of vacuity of the lungs and spleen, phlegm-damp
obstructing the channels and network vessels.
Western Medicine:
1. The
patient has suffered from the difficulties in speaking and
swallowing for one year.
2. He
was diagnosed with ALS in the local hospital.
Diagnostic Differentiation:
TCM: The patient¡¯s wilting pattern should be differentiated from
impediment pattern. Wilting pattern is characterized by limp,
weak, and emaciated limbs with the numbness of the muscles. But
the patient usually has no joint pains. On the contrary,
impediment pattern is generally characterized by joint pains. So
they are not difficult to be distinguished.
Western Medicine: The patient¡¯s ALS should be differentiated
from apoplexy
sequelae, which also has the difficulties in speaking and
swallowing. Besides, the patient suffering from apoplexy
sequelae has the symptom of
paralysis
of one side of the body. The disease can be diagnosed
definitely by CT examination.
First Diagnosis:
TCM (Traditional Chinese Medicine) diagnosis: Wilting pattern
Symptom identification: vacuity of the lungs and spleen,
phlegm-damp obstructing the channels and network vessels.
Western Medicine diagnosis: 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. Low-fat
and high-protein diet.
5. Acupuncture and massage: once a day.
6. Herbal
tea: one dosage a day and drink twice.
Main herbs used in the herbal tea: chenpi (tangerine
peel), shanyao (dioscorea root), sharen (amomum fruit), etc.
Date: Feb. 13, 2009 Time:
11: 00 a. m.
The patient said he could feel slight improvement of his
swallowing. There was the symptom of reflux in the past when he
was drinking, but now he could drink the water completely and
there was no reflux. Besides, there was phlegm in the throat. He
could not speak clearly. Continue to take the same prescription.
4 dosages in total. (From Apr. 14 to Apr. 17)
Date: Feb. 17, 2009 Time:
11: 00 a. m.
The patient said the function of drinking water was better in
the recent two days and there was no reflux. The flexibility and
atrophy of the tongue were improved. His pronunciation was
better than before. Since he had slight cold yesterday
afternoon, there was the symptom of running nose. But now he had
no cough. Occasionally, he could feel two times of transient
muscular jumping of the right shoulder within a day, but there
were no pains of the joints and muscles.
Date: Feb. 22, 2009 Time:
11: 00 a. m.
The function of swallowing and drinking water was basically
normal. His pronunciation was further improved.
Saliva
secreted by glands in the mouth lessened 50%. His diet and sleep
were normal. The prescription was as follows: fuling (Poria),
huangqi (astragalus root), sharen (amomum fruit), etc. 5 dosages
in total. (From Apr. 23 to Apr. 27)
Date: Feb. 27, 2009 Time:
11: 00 a. m.
The function of swallowing was further improved.
Saliva
secreted by glands in the mouth lessened. The flexibility of the
tongue was better, but there was no much improvement of his
speaking in the recent days. His sleep and diet were normal.
Date: Mar. 2, 2009 Time:
11: 00 a. m.
His speaking and swallowing were further improved.
Secretion in the mouth lessened. His spirit and sleep were good.
Yesterday there were slight pains of his left abdomen. The
prescription was changed as follows: sharen (amomum fruit),
shegan (belamcandae root), chuanxiong (ligusticum root), etc. 5
dosages in total. (From Mar. 5 to Mar. 9)
Date: Mar. 9, 2009 Time:
11: 00 a. m.
His condition was basically good. His diet and sleep were
normal. There were no pains of the waist. The function of
speaking was no obvious improvement in the recent days. The
prescription was changed as follows: taizishen (pseudostellaria
root), xuanshen (scrophularia root), digupi (lycium root bark),
etc. 5 dosages in total. (From Mar. 10 to Mar. 14)
Date: Mar. 14, 2009 Time:
11: 00 a. m.
The flexibility of the tongue was better than before. Secretion
in the mouth lessened. There were stasis macules on the tongue.
He had slimy yellow tongue. So the treatment strategy was to
quicken the blood circulation and transform stasis.
Date: Mar. 19, 2009 Time:
11: 00 a. m.
He consciously felt obvious improvement of the
pronunciation in the recent days. His drinking, diet and sleep
were good. There was slight muscular jumping of the right eye
socket. The prescription was changed as follows: chenpi (tangerine
peel), danggui (tangkuei), baizhu (ovate atractylodes root),
etc. 5 dosages in total. (From Mar. 20 to Mar. 24)
Date: Mar. 24, 2009 Time:
11: 00 a. m.
His
pronunciation was further improved. He felt the function of
swallowing and drinking water was basically good. His sleep was
normal. The amount of secretion in
the mouth was nearly the same as the normal condition, but there
was slightly increasing of the secretion after tiredness. There
was no jumping of the muscles. His mood was comparatively good,
with no grief. The atrophy of the tongue was further improved.
The stasis macules on the tongue obviously lessened. The
prescription was changed as follows: digupi (lycium
root bark), honghua (carthamus flower), dangshen (codonopsis
root), etc. 5 dosages in total. (From Mar. 25 to Mar. 29)
Date: Mar. 28, 2009 Time:
15: 00 p. m.
During the recent two days, the patient could feel mouth dry at
3: 00 o¡¯clock in the morning. Besides, there was the symptom of
headache when he got up. The difficulty of speaking became
worse. His tongue was moist and slippery. His tongue coating was
slimy and yellow. The prescription was changed as follows:
baizhu (ovate atractylodes root), honghua (carthamus flower),
danggui (tangkuei), etc. 3 dosages in total. (From Mar. 29 to
Mar. 31)
Date: Mar. 31, 2009 Time:
15: 00 p. m.
The dryness of the mouth basically disappeared. He felt his
throat was comfortable. The secretion in the mouth was in
moderate amount. There was no
difficulty in swallowing. The former prescription was changed a
little. 4 dosages in total. (From Apr. 1 to Apr. 4)
Date: Apr. 4, 2009 Time:
15: 00 p. m.
The function of his swallowing was good. He didn¡¯t feel mouth
dry. He felt his throat was comfortable. The secretion in the
mouth was in
moderate amount. The atrophy of the
tongue was further improved. His pronunciation
was sonorous. Slimy yellow
tongue coating became thin. It was a good change. Continue to
take the same prescription. 3 dosages in total. (From Apr. 5 to
Apr. 7)
Date: Apr. 7, 2009 Time:
12: 00 a. m.
The patient felt his throat was comfortable. There was slightly
increasing of the secretion in the mouth. The atrophy of the
tongue was further improved. His tongue coating was thin and
yellow. The prescription was changed as follows: danggui
(tangkuei), baizhu (ovate atractylodes root), chuanxiong
(ligusticum root), etc. 3 dosages in total. (From Apr. 8 to Apr.
10)
Date: Apr. 11, 2009 Time:
16: 00 p. m.
His condition was stable. The secretion in the mouth was in
moderate amount. He didn¡¯t feel mouth
dry. His diet and sleep were good. But he felt the chewing
strength lessened in the recent week and there was slight
muscular jumping of the eye sockets. The prescription was
changed as follows: danggui (tangkuei),
chenpi (tangerine peel), ciwujia (manyprickle acathopanax root),
etc. 3 dosages in total. (From Apr. 12 to Apr. 14)
Date: Apr. 14, 2009 Time:
16: 00 p. m.
His condition was stable. There was no improvement of his
speaking. He felt slight headache for one day. There was still
slight muscular jumping of the
eye sockets. The prescription was changed as follows: danggui (tangkuei),
chenpi (tangerine peel), dangshen (codonopsis root), etc. 3
dosages in total. (From Apr. 15 to Apr. 17)
Date: Apr. 17, 2009 Time:
12: 00 a. m.
His condition was generally good. There was no difficulty in
swallowing. His pronunciation was better than before. He didn¡¯t
feel headache and slight muscular jumping of the eye sockets.
The prescription was changed as follows: pangdahai (sterculia),
chenpi (tangerine peel), baizhu (ovate atractylodes root), etc.
3 dosages in total. (From Apr. 18 to Apr. 20)
Date: Apr. 20, 2009 Time:
17: 00 p. m.
His condition was generally good. There was no difficulty in
swallowing. Compared with before, his
pronunciation was better. There was
slight muscular jumping of the eye sockets.
The secretion in the mouth was
increasing. He felt his throat was sticky. The prescription was
changed as follows: danggui (tangkuei), tianma (gastrodia),
pangdahai (sterculia), etc. 1 dosage in total. (Apr. 21)
Date: Apr. 21, 2009 Time:
9: 00 a. m.
The patient had the difficulty in speaking. He could speak
simple words and the
pronunciation was not clear. Besides, there was slight
difficulty in swallowing. He was easy to cough up when drinking.
His spirit was not good. He had the problem of the flexibility
of the tongue. His tongue was tender with cracks in the middle
of the tongue. He had rough and
trembling tongue. His tongue coating was pale yellow and
slightly slimy. His pulse was thready and weak. So the treatment
strategy was to boost qi, enrich yin, dispel phlegm and
extinguish wind. The prescription was changed as follows: faxia
(pro formula pinellia), gouqi (lycium berry), danshen (salvia
root), etc. 5 dosages in total. (From Apr. 22 to Apr. 26)
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