Brief Summary:
On March
27, 2010, Charles, who has suffered from ALS, accompanied by the
symptoms of weakness in the right part of his body; failure in
walking without a crutch; loss of balance; obvious atrophy in
the muscles of the forearm, hypothenar and greater thenar;
pitting edema in his lower limbs, was hospitalized in our
hospital. After 84 days comprehensive TCM treatment here, he
got big improvements in weakness in the right part of his body,
failure in walking without a crutch, loss of balance. The
symptoms of muscular twitching, pitting edema in his lower limbs
have disappeared. He could walk without the crutch or any help
when leaving the hospital.
Record of Hospitalization
Name:
Charles Birthplace:
the United States
Sex:
Male Profession:
Electrician
Age:
60 Date of Admission:
March 27, 2010
Nationality:
USA Date of Record:
March 27, 2010
Marital Status:
Married Onset Season:
Vernal equinox
Complainer:
The patient himself
First Medical Record
Date:
March 27, 2010
Time: 10: 00 a. m.
Charles, who has suffered from ALS, accompanied by the symptoms
of weakness in the right part of his body for about 1 year and
worsened for about half a year; failure in walking without a
crutch; loss of balance; obvious atrophy in the muscles of the
forearm, hypothenar and greater thenar; pitting edema in his
lower limbs, was hospitalized in our hospital. Diarrhea
occasionally occurred. Muscular spasms all over his body,
especially in his legs and back. He lost 8 pounds of weight. He
liked to drink a lot of water because of his dry mouth. His
tongue body was reddish with white coating. His lips were
red. The pulse was slippery and fast.
Essentials for Diagnosis:
1. The patient had had weakness in the right part of his body
for about 1 year and became worse for about half a year.
2. A year ago, the patient had weakness in the right part of his
body without obvious reasons. He didn't pay much attention to
this. In September 2009, the muscles of his right side of the
body began to wither and he started to lose weight. So he came
to a local hospital to take an EMG test. He was diagnosis as ALS
with the EMG results. Still he didn't take any treatment but
stayed at home for a rest. When he came to our hospital, he had
the symptoms of weakness in the right part of his body, failure
in walking without a crutch, loss of balance, obvious atrophy in
the muscles of the forearm, hypothenar and greater thenar,
muscular spasms all over his body, pitting edema in his lower
limbs, diarrhea, especially in his leg and back, dry mouth,
night sweat. His tongue body was
reddish with white coating. There were teeth marks on the edges
of the tongue. His lips were red. The pulse was slippery
and rapid. The gripping strength
of the left hand was 25.7 kg. The gripping strength of the right
hand was 1.6 kg.
3. T 36.5≧,
R 20 times/minute, P 82 times/minute, BP 130/85mmHg.
4. He grew normally with medium nutrition. His mind was clear.
He had an expression of chronic illness and tiredness. His body
was cooperative with his mind. His walking was lame.
5. No thoracic deformity. Sound of breath was bilaterally normal
on auscultation. No sound of pleural friction. No pathological
murmurs on auscultation.
6. The patient had weakness in the right part of his body,
obvious atrophy in the muscles of the forearm, hypothenar and
greater thenar, muscular spasms all over his body, pitting edema
in his lower limbs, diarrhea, especially in his leg and back,
dry mouth, night sweat. His tongue
body was reddish with white coating. His lips were red.
The pulse was slippery and rapid. The
level of muscular strength was grade
‰.
The muscle tension was decreased.
7. Accessory examination: None.
Diagnostic Basis:
TCM: The patient had weakness
in the right part of his body for about 1 year and worsened for
about half a year. Insufficiency of essence-blood, sinews and
vessels deprived of nourishment, liver-kidney depletion,
liquid-blood could not provide enough nutrition to the sinews.
Western Medicine: The patient had had weakness in the right part
of his body for a year and became worsened for half a year.
There was atrophy in the muscles of the forearm, hypothenar and
greater thenar; muscular spasms all over his body especially in
his leg and back, pitting edema in his lower limbs, diarrhea. He
needed a crutch to walk and his walking was gimpy and lamely.
The level of muscular strength was
‰.
The muscle tension was decreased.
The results of EMG and MRI in his local hospital showed that he
had ALS.
Diagnostic Differentiation:
TCM: The patient's wilting pattern should be differentiated from
impediment pattern. Wilting pattern is mainly characterized by
emaciated sinews and bones, weakness of the muscles, thin. When
it improves to a serious stage, the patient would unable to hold
thing or walk. However, impediment pattern is generally
characterized by joint pains. So they can be distinguished from
each other.
Western Medicine: The patient's ALS should be differentiated
from myasthenia gravis. The symptoms
of myasthenia gravis always increase after exercise and work and
reduce after rest.
First Diagnosis:
TCM (Traditional Chinese Medicine) diagnosis: Wilting pattern.
Symptom identification: depletion and vacuity of spleen qi,
depletion of kidneys and liver, stagnant water-damp.
Western Medicine: 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. Treatment strategy: boost qi, fortify spleen, enrich and
nourish the liver and the kidneys, disinhibit water, transform
dampness.
6. Herbal tea: one dosage a day and drink twice. 180 ml every
time.
7. Acupuncture and massage: once a day.
8. Have more medical examination if necessary.
Date: March 27, 2010 Time:
9: 00 a. m.
The patient had had weakness in the right part of his body for a
year and became worse for half a year. A year ago, the patient
had weakness in the right part of his body without obvious
reasons. He didn't pay much attention to this. In September
2009, the muscles of his right body began to wither and he began
to lose weight. So he came to a local hospital to take an EMG
test. He was diagnosed as ALS with the EMG results. The patient
had weakness in the right part of his body for a year and became
worse for half a year, atrophy in the muscles of the forearm,
hypothenar and greater thenar, muscular spasms all over his body
especially in his leg and back, pitting edema in his lower
limbs, diarrhea, and night sweat. His appetite and sleep were
good. His urination was normal. His
tongue body was reddish with white coating. There were teeth
marks on the edges of the tongue.
The gripping strength of the left hand was 25.7kg. The
gripping strength of the right hand was 1.6kg.
According to his overall problems, professor Zhang prescribed
the first formula for him. 5 dosages in total.
Date: March 28, 2010 Time:
15: 00 p. m.
Yesterday's test results:
Routine blood test: normal
Electrolyte test: Ca 1.8mnol/l
Urine test: normal
Function of liver: normal
Function of kidneys: normal
According to the test result, we suggested the patient to supply
more calcium.
Date: March 28, 2010 Time:
15: 00 p. m.
According to the feedback, there was no abnormality of the
examination of urine R. Besides, his functions of the liver and
kidneys were all in normal condition. His RF and ESR were a
little higher than normal level.
Date: March 29, 2010 Time:
10: 00 a. m.
The patient's health condition was stable. There was no specific
change. So the treatment strategy stayed the same. We suggested
him to do some exercise to strengthen the function of his four
limbs.
Date: April 6, 2010 Time:
10: 00 a. m.
The patient said that the strength of his limbs had been
increasing. He got improvement in walking, as he could walk
about 50 meters without a crutch. The pitting edema in his lower
limbs had disappeared. There were muscle spasms in the
guadriceps femoris and gastrocnemius. Both his appetite and
sleep were good. His urination and stool were normal. According
to his progress and feedback, we changed the formula to see
further improvement.
Date: April 15, 2010 Time:
10: 00 a. m.
The patient complained that there were pains on the joint of his
left knee especially after doing some activities. Muscular
spasms still appeared. Both his
appetite and sleep were good. His urination and stool were
normal. Two herbs were added into the formula, 5 dosages.
Date: April 20, 2010 Time:
10: 00 a. m.
The
patient said that there were pains on the joint of his left knee
especially after doing some activities. The strength of his
lower limbs increased. His right fingers were more flexible than
before. The balance became better, too. He got big improvement
in walking. He can walk for 20 minutes with a crutch everyday.
According
his latest feedback, we adjusted the formula once again. 4
dosages.
Date: April 24, 2010 Time:
10: 00 a. m.
The patient told us he had had an operation in the joint of his
left knee. This part still felt painful. The pain increased when
the patient take some activities. According to this matter, we
changed the formula to take care of this new problem. 6 dosages
in all.
Date: April 30, 2010 Time:
10: 00 a. m.
The pains in the joint of the patient's left knee reduced a lot.
The strength of his right upper limb and lower limb increased a
lot. When the patient was standing or walking, the color of his
lower limbs¨ skin changed to cyanotic and the lower limbs became
swelling. We analyzed that it was because of
the obstacle of blood reflux. So we
changed the formula a little to deal with this problem. 6
dosages.
Date: May 5, 2010 Time: 9:
00 a. m.
The patient complained that the pains in the joint of the knee
had reduced a lot. There was no obvious change in the strength
of the whole body. His legs were cyanotic due to the long time
walk. The part bellow the ankle was a bit edema. And he felt
heavy sense of his legs. Slightly cough. We adjusted the formula
again.
Date: May 14, 2010 Time:
10: 00 a. m.
The patient's balance had changed a lot, the edema improved too.
He could walk a longer time than before. But he still felt weak.
The color of his leg was change to normal. The cough had
disappeared. The new formula mainly focused on the enrichment of
liver and kidneys.
Date: May 20, 2010 Time:
10: 00 a. m.
The patient had diarrhea again. It is because he didn't pay
attention to his diet. He drank some cold beverage. Other
healthy conditions were still the same. The formula was the same
as before.
Date: May 31, 2010 Time:
10: 00 a. m.
The patient complained that he had gotten a bad cough which made
him vomit twice and diarrhea four times. His stools were watery.
We prescribed two herbal products to him. After taking them, the
symptoms of vomitting and diarrhea disappeared. Also, we changed
the formula again.
Date: June 15, 2010 Time:
10: 00 a. m.
The patient said that his weakness, difficulty in walking and
imbalance all had gotten obvious improvement. He could walk
without a crutch at all. Symptoms as followed became much
better: muscle spasms all over his body especially in his leg
and back, pitting edema in his lower limbs, diarrhea, and night
sweat. Both his appetite and
sleep were good. The formula was the same as before.
Date: June 20, 2010 Time:
10: 00 a. m.
The patient said
all his symptoms were much better, so he wanted to leave the
hospital tomorrow morning. He took three months' herbal tea back
home to continue and stabilize the treatment.
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