Name: Manana                                                                                                       Sex: Female

Age: 59                                                                                                                  Marital Status: Married

Nationality: Georgia                                                                                               Date of Admission: Jan. 25, 2011

Companion: Alone

First Medical Record

Date: Jan. 26, 2011                               Time: 11:00 am

Manana, female, 59-year-old, had suffered from weakness in the region of neck, induced without any evident reasons since January, 2009. And later, the patient felt powerless in the two hands. In July, 2010, she began to feel weak on the part of the lower jaw. After examined in the hospital in Germany, the final report of his condition was ALS. The patient was hospitalized in our hospital for TCM treatment at 10:30 pm on January 25, 2011.

Essential for Diagnosis:

1. The patient had suffered from weakness on the neck for two years and from difficulty in chewing for half a year.

2. The patient had suffered from weakness in the region of neck induced without any evident reasons since January, 2009. And later, the patient felt powerless in the two hands. In July, 2010, she began to feel weak on the part of the lower jaw. After examined in the hospital in Germany, the final report of his condition was ALS. The patient did get good curative effect after taking the medicine of Rilutek, and the side effect was that he had bad appetite. Quitting using the Rilutek, he chosen herbal tea and acupuncture and massage for treatment in the locality. The strength of the two upper limbs was stronger than before.

3. When the patient hospitalized in our hospital, she had thin face, weak neck and lower jaw, and needed to hold her lower jaw often. She talked unclearly and the movement of opening and closing her mouth was not flexible. Chewing was difficult, and was not easy to eat hard food. No problem with swallow. There were sense of numbness and a little jumpings around the nose and the lips and the muscles on the lower jaw. She did not have much saliva, but had night salivation often. She did not feel dry in the mouth and liked to drink warm water. Urination was normal and 2 times night urination everyday. The strength of the upper limbs was not so bad, and the lower limbs were normal.

4. T: 36.3¡ãC   R: 20 times/minute    P: 80 times/minute   BP: 135/90mmHg

5. She had chronic facial complexion. The patient was thin and had clear mind and spirit. Sound of breathing in the lungs was clear, without any rhonchi. The heart rate was normal without any heart murmur.

6. The patient¡¯s cheek was thin and flesh-losing, with amyotrophy of the sternocleidomastoid on both sides of the neck. There was no amyostrophy on other part of the body.

7. The tongue was light red with thin and yellow tongue coating, and there was a little bit amyotrophy on the tongue. Pulse of the two hands was slippery.

Diagnostic Basis:

TCM: The patient had suffered from neck weakness and chewing problem, accompanied with muscle amyotrophy around the neck, which might be caused by spleen-qi deficiency. The spleen-qi deficiency led to no muscle-nourishing. The Yin-deficiency and endogenous heat led to light-red tongue, thin and yellow tongue-coating and emaciation. In addition, the patient had slippery pulse, numbness and jumping feeling on the facial muscles, which was caused by obstruction of channels due to wind-phlegm. So, the final diagnosis was atrophy disease, led by qi and yin deficiency and obstruction of channels due to wind-phlegm.

Western Medicine: The patient had suffered from neck weakness for 2 years, and chewing difficulty for half a year. Combined with the EMG check report done in Germany, the final diagnosis was ALS.

Diagnostic Differentiation:

TCM: The patient¡¯s disease should be differentiated from impediment pattern or Bi syndrome. To the atrophy disease, it is related to powerless of the muscles and bones, so that the patient feels no use of his limbs, anyhow, there is no joints pains and muscle pains. To the contrary, the impediment pattern is related with great joint pains. So they are not difficult to be distinguished.

Western Medicine diagnosis: The patient's condition should be differentiated from myasthenia gravis. Myasthenia gravis would be aggravated after exercise and it would be reduced after some rest. Almost no muscle atrophy and muscle jumpings and also no pseudo muscle hypertrophy. But ALS is caused by lesions of the central nervous system accompanied by muscular atrophy and muscle jumpings. Therefore, there was no difficulty to differentiate them.

First Diagnosis:

TCM: atrophy disease

Symptom identification: deficiency of qi and yin and obstruction of channels due to wind-phlegm.

Western medicine diagnosis: ALS

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢ò care.

3. Companion.

4. High protein food and soft food.

5. Pathogenesis: deficiency of qi and yin and obstruction of channels due to wind-phlegm.

6. TCM strategy: tonifying qi and nourishing yin, extinguishing wind and resolving phlegm so as to smooth the channels.

7. Herbal tea: one dosage a day and drink twice

8. Acupuncture and massage: once a day

9. Have more medical examination if necessary.

Date: Jan. 27, 2011                                         Time: 10:00 am

The patient had suffered from neck weakness for 2 years and chewing difficulty for half a year. In 2010, she went to Germany for EMG examination, and the diagnosis was ALS. At present, the patient was flesh-loosing on the face, weak on the part of neck and lower jaw, and the lower jaw needed to be held often. He couldn¡¯t speak clearly, and was not flexible to open and close the mouth. Due to the chewing difficulty, he could not eat hard foods, but with no problem in swallowing. No respiration stress. There were numbness around the nose, the lips and lower jaw muscles, accompanied with slight jumpings. Less saliva in the mouth, but slavering during the sleep. She did not feel dry in the mouth, and liked drinking warm water. Appetite was normal. Sleep was good. Night urination 2 times per night. There was amyotrophy of the facial biting muscle and of the sternocleidomastoid on both sides of the neck. There was no amyotrophy on other part of the body. The tongue was light red with thin and yellow tongue coating. The tongue was a little bit atrophic. Professor Yang thought the patient has suffered from atrophy disease, which was caused by the deficiency of qi and yin and obstruction of channels due to wind-phlegm. Therefore, herbs of tonifying qi and nourishing yin, extinguishing wind and resolving phlegm so as to smooth channels would be selected for the treatment, such herbs as dangshen (gensing), caihu (bupleuri), tianma (gastrodia), etc..

Date: Jan. 29, 2011                                         Time: 10:00 am

The patient said she needed less time to hold the lower jaw now. The tongue was still light red but the tongue coating was thin and white. The pulse was slippery.

Date: Feb. 1, 2011                                          Time: 10:00 am

The patient said there was less numb feeling on the part of the nose and the nearby of lips. Less slavering during the night sleep. And the saliva had become clear and thin from thickness and could be spit out. Some improvement of the chewing function.

Date: Feb. 9, 2011                                           Time: 10:00 am

There was almost no numbness on the nose. And the time to hold the lower jaw was reducing. The chewing functions maintained progress. Appetite was better than before. The patient gained weight of 1 kg.

Date: Feb.11, 2011                                           Time: 10:00 am

The patient felt better than before. She used to be spasmous when the hands were holding things too long, but at present, no spasms any more.

Date: Feb. 16, 2011                                          Time: 10:00 am

The patient felt better and was in good mood. Good appetite and sleep. There was distinct alleviation about the stiffness. Some improvement on the flexibility of the tongue.

Date: Feb. 26, 2011                                          Time: 10:00 am

The patient gained another 1kg weight. Nights sleep was good. Some improvement of the lower jaw movement. The tongue was a little red with thin and yellow tongue-coating.  

Date: Mar.1, 2011                                          Time: 10:00 am

The patient complained too much saliva in the mouth, especially after meals, which might be easy to cause choking. He still felt neck weakness.

Date: Mar. 6, 2011                                          Time: 10:00 am

The patient said there was less phlegm in the mouth. When using the right hand with power, it would sometimes tremble. His spirit was good.

Date: Mar. 11, 2011                                          Time: 10:00 am

The condition of the patient was stable. There was distinct improvement on his muscle movement of the face and mouth. The chewing function was improved also. The sternocleidomastoid on both sides of the neck was a little bit thicker than before.

Date: Mar. 16, 2011                                          Time: 10:00 am

The patient had good spirit these days. Great improvement had been achieved on the lower jaw movement, with much less time to hold it. The chewing function also changed better. The tongue was a little dark with thin and white tongue-coating.

Date: Mar. 21, 2011                                           Time: 10:00 am

Good night sleep these days with less night-waking. One time urination per night. The tongue was a little dark with thin and white tongue-coating. The pulse was mild but a little weak.

Date: Mar. 26, 2011                                            Time: 10:00 am

Recently, the patient felt feeble on the two upper limbs. The tongue was a little dark with thin and white tongue-coating. The pulse was mild but a little weak.

Date: Apr. 1, 2011                                            Time: 10:00 am

The patient complained of weakness of the upper limbs and heaviness. It was a little hard for him to raise them. Sleep was good. The tongue was a little dark and red but better than before.

Date: Apr. 7, 2011                                            Time: 10:00 am

The patient spoke much clearly than before. In addition, chewing and raising the head were more powerful than before. The sternocleidomastoid on both sides of the neck and the left facial bite muscle were much more than the day coming to the hospital. But, the neck was weak, and when she was laying down on the bed, and wanted to get up, she needed someone or herself to hold her head. The tongue coating was thin and yellow. The pulse was a little bit weak.

Date: Apr. 14, 2011                                            Time: 10:00 am

The condition of the patient was stale, continuing the treatment with the same formula.

Date: Apr. 21, 2011                                            Time: 10:00 am

Today the patient had been hospitalized in the hospital for 86 days. After nearly 3 months comprehensive treatment of herbal tea, acupuncture and massage, she achieved significant improvement as to her conditions. She could speak more clearly than before and the volume of the phlegm in the mouth was almost normal. Head-raising and chewing were of power. The  sternocleidomastoid on both sides of the neck and the left facial biting muscle were much more than the day coming to the hospital, even though she still felt weak on the neck and when she was laying down on the bed, and wanted to get up, she needed someone or herself to hold her head. The strength of the four limbs was increasing, even though there was a sense of feebleness of the two upper limbs. The patient now was in high spirit with good sleep and appetite. She had gained 2.5 kg weight after coming to our hospital.

Doctor¡¯s advice after leaving hospital:

1. Take care of the diet, maintain good moods, and avoid wind-cold.

2. Take 60 days herbal medicine back for continuing treatment.