Brief Summary:
On
March 20, 2010, the patient Juan from USA who has suffered from
ALS, accompanied by weakness in the four limbs, especially the
upper limbs almost paralyzed,
muscular dystrophy on the shoulders, weakness of lifting the
forearms
and
bad
walking with the lower limbs, muscular twitching all over the
body, slurred and nasal-sounding speech,
difficulty in chewing or swallowing, was hospitalized in our
hospital. After about 76 days comprehensive TCM treatment with
herbal tea, acupuncture and massage in our hospital, he achieved
significant improvement in his symptoms, especially in muscular
twitching, difficulty in chewing or swallowing, constipation.
His strength increased.
Record of Hospitalization
Name:
Juan Sex: Male
Age:
42 Profession: Policeman
Nationality:
USA Marital Status: Married
Onset
Season:
Vernal Equinox Date of Admission: March 20,
2010
Complainer:
The
patient himself Reliability: Reliable
First
Medical Record
Date:
March 20, 2010 Time: 8:30 p.m.
Juan,
who has suffered from
ALS, accompanied by weakness in the four limbs, especially the
upper limbs almost paralyzed,
muscular dystrophy on the shoulders, weakness of lifting the
forearms
and
bad
walking with the lower limbs, muscular twitching all over the
body, slurred and nasal-sounding speech,
difficulty in chewing or swallowing, was hospitalized in our
hospital.
Essentials for Diagnosis:
1.
The patient has suffered from weakness in his four limbs for 3
years, and the condition has worsened for about 8 months.
2.
In October 2007, the patient began to feel the weakness of his
right hand without obvious reasons. He went to a local hospital
and did a MRI examination and was diagnosed as ALS. He was
suggested to use Riluzole by the local doctor but with little
effect, followed by weakness in his left hand and then all over
the body. In August 2009, the patient could not walk with his
lower limbs,
accompanied by
difficulty in speaking, chewing and swallowing. There were also
hurried cough when drinking; blocking of throat by phlegm,
muscular twitching and cramping in the whole body. The test
results showed that atrophy had happened in both of the upper
limbs, shoulders. The arms could not raise or bend. The griping
power of his hands was 0.
3. T
36.3℃，P
80
beats/minute, R 20
times/minute, BP 120/80 mmHg.
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.
5. No thoracic
deformity. Sound of breath was short on auscultation.
No sound of
pleural friction. Cardiac rhythm was regular.
6.
The patient felt the weakness in his four limbs. Atrophy
appeared in supraspinatus, biceps brachii,
musculusdorsalisantibrachii, thenar, hypothenar, and
gastrocnemius. His hands were unable to hold things and the feet
were unable to walk. He needed to use wheelchair. Muscular
spasms appeared in the four limbs. The muscular strength of the
upper limbs was level = 1 \* ROMAN I and the strength of the
lower limbs was level = 2 \* ROMAN II. The patient had fever,
dry mouth, yellowish urine, dry stool and difficulty in
defection, slightly atrophic and reddish tongue body, thin and
yellowish tongue coating, fissured tongue body. There were teeth
marks on the edges of the tongue. The pulse was thin, weak and
rapid.
7.
Assistant examination:
Not
provided.
Diagnostic Basis:
TCM: The patient
has suffered from weakness of the four limbs for three years,
and the condition has been aggravated for 8 months. This is due
to depletion of liver and kidneys, lack of nourishment of liquid
blood to the sinews. The other symptoms are weakness of the
whole body, slightly atrophic and reddish tongue body, thin and
yellowish tongue coating, fissured body, teeth marks on the
edges of the tongue. The pulse was weak, thin and rapid. All the
signals of her tongue and pulse belong to the symptoms of qi
vacuity of the lungs and spleen, depletion of the liver and
kidneys. According to the above symptoms, he was diagnosed as
wilting pattern.
Western medicine: The patient has suffered from weakness of the
four limbs for three years, and the condition has been
aggravated for 8 months.
He did
MRI exam in 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: It should be differentiated from myasthenia
gravis, which will be worse after sports and work while it will
decrease after having a rest. But this situation is rare in ALS.
First Diagnosis:
TCM diagnosis: Wilting Pattern
Symptom identification: lung-spleen
qi vacuity, liver-kidney depletion
Treatment strategy: fortifying the spleen, boosting the lung,
enriching and supplementing the liver and kidneys.
Western Medicine
diagnosis:
Amyotrophic Lateral Sclerosis (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. TCM treatment strategy: to fortify the spleen, boost the
lungs, enrich and supplement the liver and kidneys.
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: March 20, 2010.
Time: 08: 00 a. m.
The
patient had had weakness
in all the four
limbs for three years and had worsened for 8 months; especially
in the upper limbs which were almost paralyzed. He had short and
weak breath, difficulties in
speaking, chewing and swallowing; hurried cough when
drinking; blocking of throat by phlegm,
twitching and cramping of muscles
in the whole body. The test results showed that atrophy
had appeared in both of the upper
limbs, arms and shoulders. His limbs could not raise or bend.
He also had muscular dystrophy on the shoulders; weakness
in lifting his forearms and walking with lower limbs;
slight atrophy and reddish tongue body, thin and yellow tongue
coating; fissured tongue body. There were teeth marks on the
edges of the tongue. The pulse was weak, thin and rapid.
Date:
March 25,
2010.
Time: 10: 00 a. m.
The patient complained that he had shortness of breath and
difficulty in breathing when lying on the back or talking.
Stiffness of the lower limbs increased when walking. His tongue
was red-purple, shivering and fissured. His lips were of
red-purple. There were teeth marks on the edges of tongue. His
pulse is thin and rapid. The treatment strategy was the same as
before.
Date: March 30, 2010.
Time: 10: 00 a. m.
The patient complained that he had too much saliva and all the
four limbs couldn't move freely due to the weakness. There was
stiffness of ankle joints.
The times of twitching and cramping
of muscles in the whole body reduced a bit. Then
according to his latest condition, we changed his formula a
little. 6 dosages in total.
Date: April 5, 2010.
Time: 10: 00 a. m.
The patient's feedback was good. The strength of the upper limbs
increased; the toes could move up and down, the times of
twitching and cramping of the
muscles reduced. His sleep and
appetite were good.
According to his latest condition and progress, we adjusted his
formula a little again. 4 dosages in total.
Date:
April 15, 2010.
Time: 10: 00 a. m.
The patient's weakness in the four limbs and
difficulties in speaking
improved a lot. He complained that there was too much
saliva, and the mouth felt dry. He also had
hurried cough when drinking. His
sleep and appetite were good.
Then we adjusted his formula a little for the third time to let
him get further progress. 10 dosages in total.
Date:
April 25, 2010.
Time: 10: 00 a. m.
The
patient complained his burning sense in the eyes. So we added
two kinds of herbs to the formula and make it into herbal tea
for 6 days.
Date:
April 30, 2010.
Time: 10: 00 a. m.
The
patient's strength in fingers, lower limbs and neck increased.
The frequency of muscular jumping reduced. The difficulty in
breathing improved. The old pain in
hip joint reduced,
too. His eyes still felt a little sense of burning. With thick
and yellowish tongue coating, taut and thin pulse.
According to his feedback, we adjusted the formula again. 5
dosages in total.
Date:
May 5, 2010.
Time: 10: 00 a. m.
The
strength of the patient's lower limbs, neck and finger increased
continually. The times of muscular jumping in his right leg
reduced obviously. According to his feedback, we adjusted the
formula again. 6 dosages in total.
Date:
May 15, 2010.
Time: 10: 00 a. m.
The
patient got big improvement in the burning sense of the eyes.
The amount of
phlegm reduced. The
pain in his left hip joint was
alleviated too. The formula is the same as before.
Date:
May 30, 2010.
Time: 10: 00 a. m.
The
patient got obvious improvement of his weakness in the four
limbs, especially in the upper limbs and neck. The breath became
normal. The symptoms of difficulty in speaking and
inarticulateness improved a lot. The ability of swallowing was
fine. The function of the fingers improved too. He could go out
for a walk and play on the flat ground without using the wheel
chair today.
Date:
June 3, 2010.
Time: 10: 00 a. m.
Compared with before, the patient's conditions got obvious
improvement. After the 76 days of comprehensive treatment here
including herbal tea, massage and acupuncture, all his symptoms
improved a lot. His spirit, appetite and sleeping were very
good. The patient decided to leave the hospital tomorrow.
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