Brief Summary:
On Aug. 11, 2007, an ALS patient
from Indonesia,
Vasal, who has suffered from hands
trembling with unsteady walking for years, was hospitalized in our
hospital. He has achieved significant improvement after about
three-month TCM treatment here. Now, he can no
longer use a wheelchair or crutches.
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Records of Hospitalization
Name: Vasal
Sex: Male
Age:
33 Profession: White-collar
Nationality:
Canada Marital status: Unmarried
Onset Season: Autumn
Date of Admission:
Aug. 11, 2007
Complainer: The
patient¡¯s himself Reliability: Reliable
Major Complaint: The
patient has suffered from hands trembling with unsteady
walking for 6 years, and the condition has been aggravated for 2 years.
Present
Illness:
In June 1999, the patient suddenly felt unable to get up on time for work,
accompanied by numbness of his head with slight pain. At the time, the patient
went to a hospital of Canada¡¯s capital for a MRI examination, and he was
diagnosed with MS. The hospital advised him to accept Lihua Intramuscular, and
he got some improvement. In Mar. 2001, he began to feel hands trembling with unsteadily walking, accompanied by muscular relaxation of his limbs and muscular
atrophy of his palms¡¯ hukou. He felt the trembling of his hands with weakness all
over his body. His sight declined progressively. Through the suggestions of the
Internet Professors of American and Canada, he was also given Lihua Intramuscular, but there was still
no obvious improvement. What¡¯s worse, his symptoms aggravated progressively.
The
present symptoms: He suffered from the trembling of his hands and
unsteadily walking, accompanied by muscular flab of his limbs and muscular
atrophy of his palms¡¯ hukou. He felt weakness all over the body with poor balance.
He could walk with the support of other people or a crutches. No symptoms of
dizziness, nausea, vomiting,
fever or fearing coldness. His spirit was normal, with small quality of diet
and sleep. He had once bowel movement every 3 to 5 days. His urination was frequent, three times at night. His tongue was red with white and thin tongue coating. His
pulse was weak and thready.
Disease History: he has
been healthy all the time. No history of typhoid, tuberculosis, hepatitis, or other
infectious diseases. No allergic history of medicine. No history of preventive
vaccination provided. There was a trauma on his right hand¡¯s rib before. No history of blood
transfusion.
Personal History: he was
born in Canada, living in a normal environment. No contact history of
schistosomiasis. With light diet. He had the hobby of drinking but now stopped.
Marital History: he was
unmarried.
Family History: His
parents were both healthy. No family history of inherited disease.
Physical Examination:
T 36.2¡æ,
P
84 bpm, R 18 bpm, BP 110/70mmHg
He
grew normally with common nourishment. His mind was clear. He had an expression
of chronic illness and languidness. His body was in a positive
posture and he was cooperative in examination. His skin was moist. No jaundice in the sclera.
He was with sparse hair and pale faces. No
superficial lymph-node enlargement. Bilateral pupils were round and equal in
size and sensitive to light. His nose has no any sinking or purulence.
There was no deformity of his ears or purulence. His mouth was dry. There was no
blood in his throat. There was no enlargement of his tonsils. Soft neck and wind
pipe located in the middle. There was no enlargement of hypothyroid. Sound of
breath was bilaterally normal on auscultation. No respiratory rales or pleural
friction rubs. Apex-beat is within 0.5cm of the central clavicle. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on
auscultation. Abdomen touched flat and soft
without tenderness or rebound tenderness. The liver and spleen were not palpable. No
percussion pain in renal region. Bowel sound was normal. No spinal and pelvic
deformity or tenderness. No deformity or inflexibility of his limbs. His
tongue was red with white and thin tongue coating. His pulse was weak and
thready.
The
specific condition: He was suffering from hands trembling, especially
worse in his left hand. He could not hold any pens to write. The experiment to his
hands was (+). His lower limbs were with poor balance. He was weak with the
support of crutches. The knees' joints were stiff.
The muscle strength was Grade
¢ó
with decreasing muscle tension.
Diagnostic examination: In June 1999, after the examination of MRI, he was
diagnosed with MS in a capital hospital of his own country.
First
diagnosis:
TCM
diagnosis: Tremor-syndrome
Symptom identification: Deficiency of the liver and kidneys, accompanied with
the liver-wind entering the channels.
Western medicine
diagnosis: Multiple sclerosis (MS)
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First
Medical Record
Aug. 11, 2007
Vasal,
a 33-year-old male, has suffered from hands trembling with
unsteadily walking for 6 years, and the condition has been aggravated for 2 years. He was picked up by our
staff at Zhijiang Airport and arrived in Huaihua Red Cross Hospital for further
treatment at 19: 40 p.m. Aug. 11, 2007.
Essentials for diagnosis:
1. The
patient has suffered from hands trembling with unsteadily walking for 6
years and the condition has been aggravated for 2 years.
2. In June 1999, the patient
suddenly felt unable to get up on time to work, accompanied by numbness of his
head with slight pain. At the time, the patient went to a hospital of Canada¡¯s
capital for a MRI examination, and he was diagnosed with MS. The hospital
advised him to accept Lihua
Intramuscular, and he got some improvement. In Mar. 2001, he began to feel
trembling of his hands and unsteadily walking, accompanied by muscular
relaxation of his limbs and muscular atrophy of his palms¡¯ hukou. He felt the
trembling of his hands and weakness all over his body. His sight declined
progressively. Through the suggestions of the Internet Professors of American
and Canada, he was also given Intramuscular, but there was still
no obvious improvement. What¡¯s worse, his symptoms aggravated progressively. The
present symptoms: he was suffering from the trembling of his hands and
unsteadily walking, accompanied by muscular relaxation of his limbs and muscular
atrophy of his palms¡¯ hukou. He felt weak all over the body with poor balance.
He could walk with the support of other people or a crutches. No symptoms of
dizziness, nausea, vomiting,
fever or fearing coldness. His spirit was normal, with small quality of diet
and sleep. He is constipated. He had once bowel movement every 3 to 5 days. His
urination was frequent, three times a night. His
tongue was red with white and thin tongue coating. His pulse was weak and
thready.
3. T
36.2¡æ£¬P
84 beats/minute, R 18 times/minute, BP 110/70mmHg
4. He
grew normally with common nourishment His mind was clear. He had an expression
of chronic illness and languidness. His body was in a
positive posture and he was cooperative in examination.
5. No deformity of his spine and
limbs. The jumping of his knees was (+). The babinski levy also was (+). The
knees' joints were slightly stiff.
6. No
thoracic deformity. Chest percussion noted resonance. Sound of breath is
bilaterally clear on auscultation. No sound of pleural friction.
7.
Diagnostic examination: In June 1999, after the examination of MRI, he was
diagnosed with MS in a capital hospital of his own country.
Diagnostic basis
TCM:
The patient has suffered from hands trembling with unsteadily walking for
6 years. It belongs to vacuity of the liver-kidneys and blood-essence, so it could
not nourish the sinews and vessels. The qi-blood runs sluggishly, which leads to
the muscles trembling. The liver is in charge of sinews, which is the viscus of
wind and wood. The liver-wind enters the channels, so the sinews and vessels could
not be in charge. Since the deficiency of the liver and kidneys, he suffered from
frequent urination. Chronic disease could hurt the qi-blood, which leads to
the weakness all over the body. His tongue was red with white and thin tongue
coating. His pulse was weak and thready.
Western Medicine:
The
patient has suffered from hands trembling with unsteady walking for 6
years, accompanied by weakness all over his body.
His legs could raise 40 degrees. The reflection of knees was
of
hypertonicity. The Babinski levy
also was (+). The keens¡¯ joints were stiff. In June1999, after the examination of MRI, he was diagnosed with MS. His muscular tension decreased
with Grade
¢ó
muscle strength. The experiment to his
hands was (+).
Diagnostic differentiation:
TCM:
The patient¡¯s
tremor syndrome should be differentiated from spasm. Spasm is particularly
prevalent in the attacking period of acute fever or chronic disease. Spasm is
more often persistent, sometimes intermittent. The movement of his hands
and feet was not very flexible. Some patients have the symptoms of fever,
showing the white parts of the eyes, and loss of consciousness. While tremor syndrome is a kind of
chronic disease, with the main symptoms of uncontrollable trembling in the parts
of head, neck, hands and feet. The range of trembling is slight, and the
frequency is very fast. It is not difficult to be distinguished with the
symptoms of muscular spasms, fever and loss of consciousness.
Western Medicine:
Tremor syndrome should be differentiated from sequelae of cerebral hemorrhage.
Sequelae of cerebral hemorrhage are particularly prevalent in the elderly, often
leading to part of the body dysfunction. The lesion part is the brain vascular.
While multiple sclerosis is a nervous system of chronic disease that impacts the
central nervous system (like the brain, nerve and spinal cord), which causes visual
impairment completely, ataxia, unclear speech, tremor, limb numbness, weakness,
or even hemiplegia. They are not difficult to be distinguished with the
pathogeneses and conditions of disease.
First diagnosis:
TCM
diagnosis: Tremor Syndrome
Symptom identification:
Deficiency of the liver and kidneys, accompanied with the liver-wind entering
the channels.
Western
medicine diagnosis: MS
Plans
for treatment strategy and nursing
1. Routine care of traditional Chinese internal medicine.
2. Grade II care.
3.
Regular diet.
4.
Herbal tea (to enrich and nourish the liver and kidneys, to extinguish wind and
check tetany): one dosage a day and drink twice.
Main
herbs in five dosages of the herbal tea: baishu (ovate atractylodes root), shengqi
(fresh astragalus root), fuling (poria), etc.
6.
Acupuncture and massage: once a day.
7.
Take 20-minute exercise every day for the function of his limbs.
8.
Have more medical examinations if necessary.
Date:
Aug. 12, 2007 Time: 10:30 a.m.
Today
the patient complained to Dr. Yan that he suffered from his hands¡¯
trembling and unsteady walking. The examination of the blood, bowel movement and
urination were all normal. The examination of the function of his liver and
kidneys were both normal. The electrolyte examination was also normal.
Examination: T 36.2¡æ£¬P
84 beats/minute, R 18 times/minute, BP 110/70mmHg.
His heart and lung were normal, and his abdomen was soft and flat.
Doctor Yan¡¯s analysis:
1. The
patient has suffered from hands trembling with unsteady walking for 6
years, and the condition has been aggravated for 2 years.
2.
He suffered from hands trembling, especially worse in his left hand. He could not hold
any pens to write. The experiment on his hands was (+). His lower limbs were with poor balance. He had
difficulty in walking and could walk slowly about 10 to 15 meters with the
support of crutches. His lower limbs were weak and limp with stiff knees¡¯ joints.
The muscle strength of his limbs was Grade
¢ó with decreasing muscle tension.
3. In June 1999, after the
examination of MRI, he was diagnosed with MS in a local hospital.
According to the above information,
TCM considered it as Tremor syndrome. Dr. Yan's analyzed it was
owing to deficiency of the liver and kidneys, accompanied with the liver-wind
entering the channels.
Principle of TCM treatment:
Fortifying the spleen and boosting qi, enriching the liver and supplementing the kidneys, extinguishing wind and
checking tetany. Herbal tea prescribed for five days including baishu (ovate
atractylodes root), shengqi (fresh astragalus root), fuling (poria), etc. One
dosage a day and drink twice.
Prescription: VariedDecoction of the Extinguishing-Wind and Checking-Etany. Doctor¡¯s requirement
is to take five dosages of herbal tea in the same prescription.
Acupuncture and massage for once a day. The patient will have more medical
examinations if necessary.
Date:
Aug. 13, 2007 Time: 9:30 a.m.
The
patient did not complain about any other special discomfort and still felt his
hands¡¯ trembling with unsteady walking. The ECG examination was normal, and
the B-ultrasonic examination of the liver, kidneys, ureter, bladder and
prostate was also normal.
His heart and lungs were normal, and his abdomen was soft and flat. His spirit
and appetite were normal, and his sleep was good. His bowel movement and
urination were both normal.
His tongue was red with white and thin tongue coating. His pulse was weak and
thready. Doctor¡¯s requirement is that the patient should follow the original
formula.
Date:
Aug. 14, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was getting better than before. His unsteady walking was also
improving. His heart
and lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement: is that the patient should follow the original formula.
Date:
Aug. 18, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was improving, and his unsteady walking also improved. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Aug. 22, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling was improving, and his unsteady walking improved
significantly. His heart and
lung were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Aug. 26, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling got better than before. His unsteadily walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is to take five dosages of the herbal tea of the herbal tea in the former prescription.
Date:
Aug. 30, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling got better than before, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Sep. 4, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Sep. 9, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is to take five dosages herbal tea of the former prescription.
Date:
Sep. 14, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. He could walk about 100m to 200m alone. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Sep. 20, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling got better than before, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Sep. 25, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Sep. 30, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was food. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is to take five dosages of the herbal tea of the former prescription.
Date:
Oct. 5, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and fine. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Oct. 10, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Oct. 15, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
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Date:
Oct. 20, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is to take five dosages of the herbal tea of the former prescription.
Date:
Oct. 25, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Oct. 30, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved
significantly. His heart and
lungs were normal, and his abdomen was soft and flat. His spirit and appetite
were normal, and his sleep was good. His bowel movement and urination were both
normal. His tongue was red
with white and thin tongue coating. His pulse was weak and thready. Doctor¡¯s
requirement is that the patient should follow the original formula.
Date:
Nov. 2, 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort and felt his hands¡¯
trembling lessened obviously, and his unsteady walking improved significantly
than before. His heart and lungs were normal, and his abdomen was soft and flat.
His spirit and appetite were normal, and his sleep was good. His bowel movement
and urination were both normal. His tongue was red with white and thin tongue
coating. His pulse was weak and thready. The patient demanded to leave the hospital
today.
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