Record of
Hospitalization
Name: David T.
Anderson Sex: Male
Age:
45 Marital Status: Married
Nationality:
American Date of Admission:
Jan. 8, 2011
Companion:
Alone
First Medical
Record
Date: Jan. 8,
2011 Time: 14:00 pm
This 45-year-old man had suffer from unclear
speech for 11 months and muscle atrophy of the right upper limb
for 6 months, accompanied by weakness and muscle jumpings all
over the body. The patient was hospitalized in our hospital for
TCM treatment at 14 pm on January 8, 2011.
Essential for Diagnosis:
1. The patient had suffered from unclear
speech for 11 months and muscle atrophy of the right upper limb
for 6 months.
2. The patient had complained of speech
problem, weak wriggling of the facial and tongue muscles and
weak chewing without any obvious cause of disease in March,
2010. Then, he went to local hospital to take MRI examination
and EMG check. The report showed that Mr. David indeed had ALS.
He took the medicine of Rilutek and vitamins for the treatment
of ALS, but the therapeutic effects were not great. In August of
the same year, there was evident muscular atrophy of the right
upper limb, especially of the thumb web muscles and the muscles
of the thenar and hypothenar. He lost weight for 20 pounds,
accompanied by weakness and muscle jumpings over the whole body.
In November, 2011, he began to take the herbal medicines
delivered from our hospital for treatment, and his
above-mentioned conditions were reduced somewhat.
3. When the patient hospitalized in our
hospital, he had speech difficulty and swallowing problem and
sometimes he suffered from coughs. The right upper limb was
weak, accompanied by muscle atrophy. He was very easy to be
tired and was feeling weak all over the body. Besides, he had
muscle jumpings over the general body and occasionally had short
breath and chest tightness. The patient felt dry in the mouth
and liked hot drinking. Sometimes, he coughed with white and
sticky sputum. He felt cold limbs. His spirit was ok. Anyway, He
had good appetite and sleep. There was bowel movement one time a
day. Urine was of yellow color. The tongue was slightly red with
thin and yellow tongue-coating. In the middle of the tongue,
there were cracks, and along the tongue edge, there were tooth
marks. The surface of the tongue was a little uneven with weak
wriggling of the tongue. The pulse was slippery.
4. T: 36.3¡ãC R: 20 times/minute P: 60
times/minute BP: 104/70mmHg
5. He grows normally. The patient¡¯s daily
food was of medium nutrition. He had conscious mind and natural
facial expression, but the expression was exhausted. He could
walk by himself. He cooperated with doctors when did the
physical examination.
6. The formation and size of the thorax were
normal. The breathing sounds of the lungs were clear, with no
pathological murmurs. The heart rate was regular and it was 60
times per minute.
7. Examinations of MRI and EMG in March, 2010
in America showed the patient had been attacked by ALS.
Diagnostic Basis:
TCM: The
patient complained of speech problem for 11 months, accompanied
by weakness of the right upper limb and muscle atrophy for 6
months. Due to the long time of disease, the qi and blood of the
patient had been damaged and it also caused the deficiency of
intestines, spleen and qi, and therefore, speech problem,
chewing difficulty and weakness over the whole body occurred.
Nutrition could not be better digested due to the deficiency of
intestines and spleen. And because of that, he suffered from
muscle atrophy. Muscle jumpings over the general body were due
to insufficiency of the liver and kidney. From the principle of
TCM, deficiency of intestines, spleen and qi and liver-kidney
yin deficiency were the characters of atrophy disease.
Western Medicine:
According to the reports of electromyography and MRI and the
symptoms of speech problem and muscle spasms over the general
body, he should have suffered from ALS.
Diagnostic Differentiation:
TCM: Atrophy
diseases are usually differentiated with Bi syndrome or
impediment pattern. Atrophy diseases have such characteristics
as atrophy of the limbs¡¯ muscles, the weakness of the limbs and
the uselessness of the thin feet. The muscular atrophy and
muscle jumpings are the main symptoms of atrophy diseases. The
impediment patterns are reflected by the pains or tense pains on
the body joints. So it is easy to differentiate them.
Western Medicine diagnosis: ALS
should be differentiated with myasthenia gravis. Myasthenia
gravis would be aggravated after exercises and it would be
reduced after some rest. Almost no muscle atrophy and muscle
jumpings. But ALS is caused by lesions of the central nervous
system, accompanied by muscular atrophy and muscle jumpings.
Therefore, there is no difficulty to differentiate them.
First Diagnosis:
TCM: atrophy disease
Symptom identification:
liver-spleen qi vacuity and liver-kidney yin deficiency.
Western medicine diagnosis: ALS
Treatment strategy and nursing:
1. Routine care of traditional Chinese
internal medicine.
2. Grade
¢ò
care.
3. Companion.
4. Common diet.
5. Pathogenesis: dampness and heat staying in
the channels and joint points, qi vacuity and blood stasis, and
deficiency of the livers and lungs.
6. TCM strategy:
fortifying spleen, nourishing intestines and nourishing liver
and spleen.
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. 9,
2011 Time: 10:00 am
Professor Zhang, associate chief physician,
paid a visit to the patient. The patient complained of
disfluency in speech, occasional coughing, swallowing problem,
and weakness over the whole body and muscle jumpings. There was
evident muscle atrophy on the right upper limb, especially on
the thenar and hypothenar eminences and tucks muscles. He was
easy to be fatigue after doing some exercise. Occasionally, the
patient suffered from short breath and choking sensation in the
chest. He felt dry in the mouth and liked warm drinking. He
expectorated with white and viscous sputum. The patient always
felt cold in the four limbs. He had normal spirit and good
appetite and sleep. One time of bowel movement everyday. The
tongue was light red with thin and yellow tongue coating. There
were cracks in the middle of the tongue, teeth prints on the
edge of the tongue and slightly rough and uneven tongue surface.
The pulse was slippery. He had the medical history of asthma.
Professor Zhang thought from the TCM principle that the
patient¡¯s conditions were due to the deficiency of intestines,
spleen and qi and the deficiency of liver, spleen and yin. He
suffered from atrophy diseases. The TCM formula should have the
functions of invigorating intestines, fortifying spleen and
nourishing liver-kidney.
Date: Jan. 10,
2011 Time: 10:00 am
The patient said there was slightly reduce in
the dry taste in the mouth. No change on other conditions.
Date: Jan. 12,
2011 Time: 10:15 am
The patient complained of bad sleep
those days and no evident change on the muscle jumpings of the
upper limbs and muscles behind the legs of lower limbs.
Yesterday, the stool was watery but he did not sugger from
diarrhea. Urine was good. Thirst in the mouth was reduced and
the saliva was much. The tongue was slightly red with thin and
yellow tongue coating. There were cracks in the middle of the
tongue, teeth prints on the edge of the tongue and slightly
rough and uneyen tongue surface. No obvious change on the
creeping motion of the tongue body. The pulse was slippery.
Date: Jan. 16, 2011
Time: 10:30 am
The patient said muscle jumpings of the
muscles behind the legs were reduced, even though no evident
change on the muscles of the two upper limbs and back. There was
some improvement in speech problem, dry taste and the quantity
of saliva in the mouth. There was some increase of the tucks
muscles. The tongue was slightly red with thin tongue coating.
The pulse was slippery and weak. His spirit, appetite and sleep
were good.
Date: Jan. 20, 2011
Time: 10:00 am
The patient complained of bad sleep due to
the noise of the air conditioner in recent two days. He felt
obvious muscle jumpings during the night. The power of the two
hands was increasing. The patient felt slightly dry in the
mouth. The quantity of saliva was basically normal. The tongue
was slightly red with thin and yellow tongue coating. The pulse
was slippery but a little bit powerful.
Date: Jan. 24,
2011 Time: 10:00 am
The patient felt better those days. He did
not suffer from asthma since being hospitalized in our hospital.
Swallowing was good. He sometimes got coughing when drank water
too fast. Strength over the whole body was increasing. The power
of gripping: right hand, 13.1kg, left hand, 27.4kg. Muscle
jumpings were reduced. The patient did not feel too dry in the
mouth any more. And the quantity of saliva was basically normal.
The tongue was slightly red with thin and yellow tongue coating.
The pulse was slippery.
Date: Jan. 28,
2011 Time: 9:00 am
The patient had nasal obstruction, dry
feeling in the throat and mouth and weak sensation over the
general body due to catching a cold recently. He did not cough.
Sleep was not so good. Speech was better. There was no evident
change on muscle jumpings.
Date: Jan. 31,
2011 Time: 9:00 am
The patient said he had recovered from cold.
Date: Feb. 5, 2011
Time: 10:00 am
The patient felt less muscle jumpings these
days, especially during the night. Other conditions were stable.
The tongue was a little bit red with white and thick tongue
coating. The pulse was slippery.
Date: Fed. 9,
2011 Time: 11:00 am
Muscle jumpings were reduced, but there were
still some jumpings on the muscles of the upper limbs, shoulders
and back. He did not feel dry in the mouth and throat any more.
Swallowing was good. The strength of the four limbs was
increasing and the motion of the two hands was better than
before. The tongue was a little bit red with white and thick
tongue coating. The pulse was slippery.
Date: Feb. 12, 2011
Time: 11:10 am
The patient¡¯s conditions were stable
recently. The mouth was a little dry. Appetite and sleep were
good.
Date: Feb. 16,
2011 Time: 9:30 am
The patient said the strength over the whole
body was increasing. It was easy for him to do some exercise.
The muscle jumpings over the general body were reduced to around
60%. There was a sense of sore pains on the region of the right
cheek bone, but it was much better than 3 days ago. Speech was
better. Swallowing was good. He felt dry in the mouth during the
night. When he lied on his side, he liked to breathe with his
mouth open. The motion of the tongue was more flexible than
before. There was some improvement in the uneven tongue surface.
The tongue was red with white and slightly yellow tongue
coating. The pulse was slippery.
Date: Feb. 21,
2011 Time: 9:00 am
Conditions of the patient were keeping
better. Appetite and sleep were good. He felt weak when spoke
with slow tempo.
Date: Feb. 25,
2011 Time: 9:00 am
The patient said his conditions were better.
Appetite, sleep and swallowing were good. He did not feel dry in
the mouth any more. Muscle jumpings on the right upper limb were
a little obvious. The weak sense of the speaking was turning
better. The tongue was red with thin tongue coating. The pulse
was thin and slippery.
Date: Feb. 28,
2011 Time: 10:00 am
The patient complained of no special change
on his conditions in recent 3 days. He felt dry in the mouth.
Sleep was not so good. The tongue was red with thin and yellow
tongue coating.
Date: Mar. 4,
2011 Time: 10:00 am
The patient said his conditions were turning
better. The strength over the whole body was increasing. Dry
taste in the mouth dispelled. He could sleep around 7 hours.
Except that muscle jumpings on the right upper limb were still
evident, muscle jumpings on other parts were reduced. The phlegm
in the throat was gone.
Date: Mar. 8s,
2011 Time: 10:00 am
The patient complained that the weak sense of
speaking sometimes was good but sometimes was bad. The tempo of
speech was slow. Other conditions were turning better and
better.
Date: Mar. 12,
2011 Time: 10:00 am
The conditions of the patient were stable
those days.
Date: Mar. 18, 2011
Time: 9:30 am
The patient said his conditions were better.
And he asked to leave the hospital tomorrow.
Date: Mar. 19,
2011 Time: 10:00 am
After more than 2 months TCM treatment, the
patient requested to leave hospital today. After treatment in
our hospital, the patient¡¯s conditions were much better than
before. He did not suffer from choking, swallowing problem, the
peristaltic facial muscles, dryness in the mouth, short
breathing, chest tightness and cold limbs any more. There were
some evident improvements on speech problem, chewing weakness,
weak sense of the general body and muscle jumpings. Since he was
hospitalized in our hospital, his asthma had been controlled
without any recurrence.
Doctor¡¯s advice after leaving hospital:
1. Maintain good moods.
2. Take 30 days herbal medicine back for
continuing treatment.
3. Avoid wind-cold and be careful with the
cold.