Brief Summary:
On
November 19, 2009, Sherry from Canada, who has suffered from
ALS, was hospitalized in our hospital. She had weakness of the
right side body. And she had had difficulty in walking for 1
year. She has achieved obvious improvement after 83 days TCM
treatment here.
Record of Hospitalization
Name:
Sherry Birthplace: Canada
Sex:
Female
Profession: Pet cleaner
Age:
60 Date
of Admission:
November 19, 2009
Nationality:
Canada
Date of Record: November 19, 2009
Marital Status:
Married Onset Season:
Autumnal Equinox
Complainer:
The patient's herself
First Medical Record
Date: November 19, 2009
Time: 1: 00 a. m.
Sherry from Canada, who has suffered from ALS, was hospitalized
in our hospital on November 18, 2009. She had weakness of the
right side body. And she had had difficulty in walking for 1
year.
Essentials for Diagnosis:
1. The patient had weakness of the right side body. And she had
had difficulty in walking for 1 year.
2. The patient began to feel weakness one year ago. Besides, she
felt that her right leg had difficulty in walking. Then she had
muscular pains and spasms. She did not do any examination. One
weak ago, she went to a local hospital and she was diagnosed as
ALS. At last, she decided to come to our hospital to get the
comprehensive treatment.
3. T 36.2≧,
R 20 times/minute, P 81 times/minute, BP 140/80mmHg.
4. She grew
normally with medium nutrition. Her mind was clear. She had an
expression of chronic illness and tiredness. Her body was
cooperative with her mind.
5. No thoracic
deformity. Sound of breath was bilaterally normal on
auscultation. No sound of pleural friction. Heart border was
normal. Heart beat was 80 times/minute. Cardiac rhythm was
regular. No pathological murmurs on auscultation.
6. Her left hand's
grip strength was 28.9 kg and the right hand was 17.5 kg. Her
pulse was wiry.
7.
Accessory examination: None.
Diagnostic Basis:
TCM: The patient had suffered from weakness
of the body for 1 year. She had difficulty in walking. She had
muscular spasms and pains sometimes. Her sleeping was not good
and she was easy to wake up. The tongue body was pale. Her pulse
was weak and wiry. According to the symptoms of the tongue and
pulse, she was diagnosed as wilting pattern.
Western Medicine: She had weakness of the right side of the
body. And she had had difficulty in walking for 1 year. Her left
hand's grip strength was 28.9 kg and the right hand was 17.5 kg.
Her pulse was wiry. She was given MRI examination in the local
hospital and was diagnosed as ALS.
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: ALS should be differentiated from progressive
muscular dystrophy, which is characterized by obvious muscular
dystrophy in the legs. But there is no muscular trembling in the
fascicle. The disease can be diagnosed clearly by the
examination of MRI.
First Diagnosis:
TCM diagnosis: Wilting pattern
Symptom identification: vacuity of the spleen and the kidneys,
obstruction of channels and network vessels.
Western Medicine
diagnosis: ALS (amyotrophic lateral sclerosis)
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. TCM treatment
strategy: fortify the spleen, boost qi and the kidneys, quicken
the blood and free the network vessels.
6. Herbal tea: one
dosage a day and drink twice.
7. Acupuncture and
massage: once a day.
8. Have more
medical examinations if necessary.
Date: November 19, 2009
Time: 10: 00 a. m.
The patient began to feel weakness one year ago. Besides, she
felt that her right leg had difficulty in walking. Then she had
muscular pains and spasms. She did not do any examination. One
weak ago, she went to a local hospital and she was diagnosed as
ALS. Her tongue body was pale. Her condition is due to vacuity
of the spleen and the kidneys, obstruction of channels and
network vessels. So our treatment strategy is to fortify the
spleen, boost qi and the kidneys, quicken the blood and free the
network vessels. Then we prepared a special formula for her.
Date:
November 22, 2009
Time: 10: 00 a. m.
The patient's weakness and walking had no obvious progress. But
her sleeping was good. There were no spasms. Then she still used
the same formula to see the effect.
Date: November 25, 2009
Time: 10: 00 a. m.
The patient said that her walking had improved a little. Then
she was told to use the same formula.
Date: November 30, 2009
Time: 10: 00 a. m.
The patient said that her walking had got much improvement. Her
sleeping was good and she did not have uncomfortable feeling.
Date: December 5, 2009
Time: 10: 00 a. m.
The patient said that she felt well. We changed the above
formula a little for the first time.
Date: December 10, 2009
Time: 10: 00 a. m.
The patient said that weakness of the lower limbs had got
obvious improvement. She could walk to a longer distance than
before. Then we added another kind of herb to her formula for
the second time.
Date: December 15, 2009
Time: 10: 00 a. m.
The patient said that everything was good. Her condition
continued to become better. So she continued to use the above
formula.
Date: December 20, 2009
Time: 10: 00 a. m.
Her condition continued to become better. Then she still used
the same formula.
Date: December 25, 2009
Time: 10: 00 a. m.
The patient said that she felt well and everything was good. So
she continued to use the same formula.
Date: December 31, 2009
Time: 10: 00 a. m.
The patient had
diarrhoea and constipation. So we changed her formula a little
for the third time.
Date: January 5, 2010
Time: 10: 00 a. m.
The patient had no uncomfortable feeling. She did exercise every
day. Then she still used the same formula.
Date: January 10, 2010
Time: 10: 00 a. m.
The patient said that her condition was stable. She could feel
the muscular jumpings sometimes. Then we did not change her
formula.
Date: January 15, 2010
Time: 10: 00 a. m.
The patient's condition was stable. So she was told to use the
same formula to consolidate the result.
Date: January 20, 2010
Time: 10: 00 a. m.
The patient said that she was good. Her tongue body was red and
her pulse was wiry. Then we change the formula a little.
Date: January 25, 2010
Time: 10: 00 a. m.
The patient's condition was stable. So she was told to use the
same formula to consolidate the result.
Date: January 30, 2010
Time: 10: 00 a. m.
The patient said that she had cough sometimes. Then we prepared
another formula according her condition.
Date: February 9, 2010
Time: 10: 00 a. m.
Compared with before, her condition got obvious improvement.
After the 83 days of comprehensive treatment here including
herbal tea, massage and acupuncture, the symptoms improved a
lot. Her condition was stable. The patient decided to leave the
hospital tomorrow.