Name: Daa                                                                                                            Sex: Female

Age: 47                                                                                                                 Marital Status: Married

Nationality: Slovene                                                                                              Date of Admission: April 9, 2011

Companion: Family

First Medical Record

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

This 47-year-old lady had suffered from weak and powerless limbs for two and half years, developing into difficult walking for 10 months. The patient was hospitalized in our hospital for TCM treatment at 19 pm on April 9, 2011.

Essential for Diagnosis:

1. The patient had been suffering from weak and powerless limbs for two and half years, developing into difficult walking for 10 months.

2. The patient complained of weakness and pains over her left upper limb without any evident causes on October, 2008. Fingers of her left hand were also weak, disabled to fix the fasteners on the clothes. She did not go to hospital for any examinations. In November, 2009, her left little finger was out of movement; left lower limb began to be weak; there were pains over her right wrist and muscle jumpings over her whole general body. In June, 2010, the above mentioned symptoms became severe, and the movement of dorsiflexion of her left foot was reduced. The report of EMG presented that she was attacked by motor neuron disease (MND), and according to the clinical symptoms of her condition, her condition was diagnosed as ALS. The hospital only gave her some medicine supplements for oral use, instead of any specific treatment.

3. When the patient hospitalized in our hospital, she felt weak and strength-less over her whole general body, particularly over her left-side body. There were muscle jumpings over her whole body. She also had shortness of breath, much phlegm and saliva, unclear speech, as well as pains over her shoulders and neck. She was easy to be fatigued. Spirit and sleep were good. She could sleep for around 8 hours every night. Urine was yellowish and stool was dry. Because of a fall 2 months ago, phalanx of her left food was broken; therefore, when walking, she suffered few pains. She could only walk for about 300 meters. Walking balance was not good.

4. T: 36.5¡ãC   R: 20 times/minute    P: 80 times/minute   BP: 120/70 mmHg

5. She had a natural facial expression. Her spirit activities were normal. She grew normally. The patient had walking problem. She showed active position. Grasping power: right hand, 9.5kg, left hand 6.1kg. Her tongue was pale with thin and white coating. Her pulse was weak and thready.

Diagnostic Basis:

TCM: The patient had been suffering from weak and powerless limbs for 2 and half years, developing into difficult walking problems for 10 months. The lungs dominate respiration and control qi throughout the body. Shortness of breath was due to deficiency of the lungs. The spleen governs the muscles and the four limbs. The deficiency of spleen and lungs led to improper transmitting of water and essence to the whole body, so muscle atrophy appeared. Yin deficiency of the liver and kidneys leads to loss of nourishment of the vessels and channels as well as muscles, therefore, muscle jumpings over her whole body and night sweating appeared. From the principle of TCM, deficiency of the lungs and spleen as well as yin deficiency of the liver and kidneys were the characters of atrophy disease.

Western Medicine: The patient suffered from weak and powerless limbs for two and half years, developing into difficult walking for 10 months, accompanied by muscle jumpings and muscle atrophy. Meanwhile, according to examination results of EMG and her clinical symptoms, she 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: deficiency of the lungs and spleen as well as yin deficiency of the liver and kidneys.

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: deficiency of the lungs and spleen as well as yin deficiency of the liver and kidneys.

6. TCM strategy: nourish the spleen and benefit the lungs, nourish the liver and kidneys as well as nourish blood and soften the tendons.

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: Apr. 11, 2011                                           Time: 10:30 am

Professor Yang, paid a visit to the patient. The patient felt weak and strength-less over her whole general body, particularly over her left-side body. There were muscle jumpings over her whole body. She also had shortness of breath, much phlegm and saliva, unclear speech, as well as pains over her shoulders and neck. She was easy to be fatigued. Spirit and sleep were good. Her stool was dry and urine yellowish. She complained of pains over the back of her feet when walking. She could only walk for around 300 meters, with bad balance. Physical check: The functions of her heart and lungs were normal. There was muscle atrophy over tucks muscles of her both hands, finger muscles and her left supraspinatus muscles. Grasping power: right hand, 9.5kg, left hand 6.1kg. Her tongue was pale with thin and white coating. Her pulse was weak and thready. Professor Yang thought from the TCM principle that the patient suffered from atrophy disease, which was due to deficiency of the lungs and spleen as well as yin deficiency of the liver and kidneys. The therapeutic methods for the atrophy disease are to nourish the spleen and benefit the lungs, nourish the liver and kidneys as well as nourish blood and soften the tendons.

Date: Apr. 12, 2011                                           Time: 10:30 am

Feedback of examinations: Blood routine, urine routine as well as the functions of the liver and kidneys were normal.

Date: Apr. 13, 2011                                           Time: 10:00 am

The patient said muscle jumpings over her whole general body were reduced. She was no longer that easy to be fatigued even after some exercise. Sleep was good.

Date: Apr. 17, 2011                                           Time: 10:00 am

The patient said symptoms of her whole body were changing better. Other conditions were good except of much saliva in her mouth.

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

There was no special improvement in the patient¡¯s conditions. Saliva was reduced somewhat. There was sweating over her chest. Urine was yellowish. Pains over her left foot back were reduced slightly when walking.

Date: Apr. 25, 2011                                           Time: 9:30 am

The patient felt sever pains over her left foot back, since they had a tour of mountain climbing. There was sweating over the front part of her chest. Strength over her whole body was increasing. Muscle jumpings were reduced evidently. Saliva was reduced.

Date: Apr. 30, 2011                                           Time: 9:15 am

The patient said strength of her four limbs was increasing some bit. Grasping power: right hand, 10.6 kg, left hand 6.4 kg. Now she could walk for around 400 meters. There were slight edema and pains over her left foot back. She had chest oppression, shortness of breath, sweating over her chest and occasional restless. Her tongue was red with thin tongue coating. Her pulse was wiry.   

Date: May 6, 2011                                            Time: 9:15 am

The patient¡¯s conditions were stable. She had good spirit and good sleep. Her appetite was normal. Bowel movement and urine were normal. Her tongue was red with thin coating. Her pulse was wiry.

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

After one month TCM treatment, the patient requested to leave hospital today. After treatment in our hospital, the patient¡¯s conditions were much better than before. Weakness and powerlessness of her four limbs were changing better. Chest oppression and shortness of breath were reduced. Muscle jumpings over her whole body and pains over her neck and shoulders were basically improved. Pains over her left foot back were reduced when walking. Sleep, appetite and sleep were good. She felt muscle-increasing on the tuck muscles of her left hand. Grasping power: right hand 10.8 kg, left hand 6.8 kg.

Doctor¡¯s advice after leaving hospital:

1. Maintain good moods and be careful with the cold.

2. Take herbal medicine back for continuing treatment.