Brief
Summary:
On Sept. 13, 2007, Jose, from Portugal, who suffered
from weakness of the lower limbs along with muscular atrophy,
and disability of walking, was hospitalized in our hospital. He
has achieved significant improvement after about three-month TCM
treatment here.
¡¡
¡¡
Record of Hospitalization
Name:
Jose Sex:
Male
Age:
57 Profession: Office
Clerk
Nationality:
Portugal Marital Status:
Married
Onset
Season:
Summer Date of Admission:
Sept. 13, 2007
Complainer:
The
patient himself Reliability: Reliable
Major
Complaint:
The
patient has suffered from weakness of the lower limbs along with
muscular atrophy for 3 years, and the condition has been
aggravated by disability of walking for one year.
Present Illness:
In June 2004, the patient began to feel weakness of the lower
limbs without any obvious causes. At that time, the patient paid
no attention to it, and did no treatment about it. Therefore,
the disease was developing progressively. Three months later,
the patient began to suffer from muscular atrophy, but he still
took no treatment. In Aug. 2005, the patient went to a local
hospital for a diagnosis. After the EMG examination, he was
diagnosed with
amyotrophic lateral sclerosis
(ALS). The patient was told that there may be some
unpleasantness to happen in the future. In Oct. 2005, the
patient began to take
Rilutek
up to now. From Mar. 2006 to Mar. 2007, the patient received the
treatment of acupuncture and massage for twice a week in a local
hospital, but he got no obvious improvement. In the second half
of 2006, the patient¡¯s condition was aggravated and even was not
able to walk. Therefore, his movement had to be supported by a
wheelchair.
To
seek for a further comprehensive treatment, he was hospitalized
in our hospital on Sept. 13, 2007. Since he got the
disease, his spirit was poor, but his appetite was normal. His
sleep was sound. His urination was normal, and his bowel
movement was hard.
Disease History:
No history of typhoid, tuberculosis, hepatitis, malaria or other
infectious diseases. No allergic history of medicine or food. No
history of blood transfusion. No history of preventive
vaccination provided. In 1975, he had a trauma due to a car
accident which resulted in his left tibia fracture, and then he
received the treatment of Compression Plate Fixation. In 1997,
he received the resection on his appendicitis in a local
hospital, and now he recovered completely.
Personal History:
He was born in Portugal. No contact history of schistosomiasis.
No addiction to smoking, alcohol or special food. He was
mild-tempered and open-minded.
Marital History:
He
got married at the age of 27. Now he has three daughters. His
wife and children have been healthy all the time.
Family History:
His
parents were both healthy. No family history of special disease.
Physical Examination:
T 36.3¡æ£¬P
74 beats/minute, R 20 times/minute, BP 140/80 mmHg.
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. No superficial lymph-node
enlargement. Bilateral pupils were round and equal in size and
sensitive to light. No abnormity of skull and five organs. No
enlargement of his tonsils.
With soft neck and
trachea placed in the middle. No enlargement
of the thyroid gland. No turgor jugular vein.
No thoracic
deformity. Sound of breath was bilaterally normal on
auscultation. No respiratory rales or pleural friction rubs.
Heart border was normal. Heart beat was 74 times/minute. Cardiac
rhythm was regular. No pathological murmurs on
auscultation. Abdomen touched flat and soft without tenderness or
rebounding tenderness. The liver and spleen were not palpable.
No percussion pains in renal region. Bowel sound was normal. No
spinal and pelvic deformity or tenderness. His upper limbs were
in free movement, but his lower limbs were weak, accompanied
with difficulty in movement and disability of walking. Besides,
both
the lower limbs¡¯ movement of flexion and extension completely
paralyzed.
Both
gastrocnemius and soleus of his lower limbs were serious
atrophic, and muscles of his feet were also obviously atrophic.
The muscles
of all over his body beat uncontrollably and frequently. His
lower limbs were Grade
¢ó
with lower muscle hypertonicity. The examinations of the anus
and pudendum were both normal. Other physiological reflex has
not been elicited. His tongue was red with slightly yellow
tongue coating, and there were cracks in the middle with
teeth-marks at the edge of the tongue. His pulse was thready and
weak.
Diagnostic examination: Not provided.
First
Diagnosis:
TCM
diagnosis: Wilting syndrome
Symptom identification: Liver-kidneys yin vacuity.
Western medicine diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
First
Medical Record
July
18, 2007
Jose,
a 57-year-old male, has suffered from weakness of the lower
limbs along with muscular atrophy for 3 years, and the condition
has been aggravated by disability of walking for one year.
He was picked up by our staff in
Zhijiang Airport and arrived in Huaihua Red Cross Hospital for
further treatment at 19: 00 p.m. on Sept. 13, 2007.
Essentials for Diagnosis:
1.
The patient has suffered from weakness of the lower limbs along
with muscular atrophy for 3 years, and the condition has been
aggravated by disability of walking for one year.
2. In
June 2004, the patient began to feel weakness of the lower limbs
without any obvious causes. At that time, the patient paid no
attention to it, and did no treatment about it. Therefore, the
disease was developing progressively. Three months later, the
patient began to suffer from muscular atrophy, but he still took
no treatment. In Aug. 2005, the patient went to a local hospital
for a diagnosis. After the EMG examination, he was diagnosed
with
amyotrophic lateral sclerosis
(ALS). The patient was told that there may be some
unpleasantness to happen in the future. In Oct. 2005, the
patient began to take
Rilutek
up to now. From Mar. 2006 to Mar. 2007, the patient received the
treatment of acupuncture and massage for twice a week in a local
hospital, but he got no obvious improvement. In the second half
of 2006, the patient¡¯s condition was aggravated and even was not
able to walk. Therefore, his movement had to be supported by a
wheelchair.
To
seek for a further comprehensive treatment, he was hospitalized
in our hospital on Sept. 13, 2007. Since he got the
disease, his spirit was poor, but his appetite was normal. His
sleep was sound. His urination was normal, and his bowel
movement was hard.
3. T 36.3¡æ£¬P
74 beats/minute, R 20 times/minute, BP 140/80 mmHg.
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.
His lower limbs were weak, accompanied with difficulty in
movement and disability of walking.
Both
gastrocnemius and soleus of his lower limbs were serious
atrophic, and muscles of his feet were also obviously atrophic.
Both the lower limbs were completely paralyzed. Below the
ankle-joints, there were apparently swelling.
The muscles of all
over his body beat uncontrollably and frequently. His lower
limbs were Grade
¢ó
with lower muscle hypertonicity.
6. No
thoracic deformity. Chest percussion noted resonance. Sound of
breath is bilaterally clear on auscultation. No sound of pleural
friction.
7.
Diagnostic examination: Not provided
Diagnostic Basis:
TCM:
The patient has suffered from weakness of the lower limbs along
with muscular atrophy for 3 years, and the condition has been
aggravated by disability of walking for one year.
It belongs to
vacuity of the liver-kidneys and blood-essence, so it could not
nourish the sinews and vessels. Therefore, it gradually results
in flaccidity.
With the withered
marrow and dry channels, the fat on his legs became thinner, and
so he kept a decadent spirit. The kidneys are in charge of
bone-marrow. Due to lack of the essence, his waist-ridge was
wilting with difficulty in movement.
His tongue was red
with slightly yellow tongue coating, and there were cracks in
the middle with teeth-marks at the edge of the tongue. His pulse
was thready and weak. All above symptoms belong to the scope of
the liver-kidneys Yin vacuity.
Western Medicine: The patient has suffered from weakness of the
lower limbs along with muscular atrophy for 3 years, and the
condition has been aggravated by disability of walking for one
year.
His lower limbs were weak, accompanied with difficulty in
movement and disability of walking. He could neither raise nor
sway his lower limbs, and also could not do any flexible
movement.
Both
of his lower limbs were completely paralyzed. Both gastrocnemius
and soleus of his lower limbs were serious atrophic, and muscles
of his feet were also obviously atrophic.
The muscles of all
over his body beat uncontrollably and frequently. His lower
limbs were Grade
¢ó
with lower muscle hypertonicity. After the EMG examination in
Aug. 2005, he was diagnosed with
amyotrophic lateral sclerosis
(ALS)
in a local hospital.
Diagnostic Differentiation:
TCM:
The patient¡¯s wilting syndrome should be differentiated from
impediment syndrome. In the late period of impediment syndrome,
the patient was not able to do any movement due to the aching
pains of the limb joints. With apraxic
limbs
for a long time, the muscles were limp and atrophic, which is
similar to wilting syndrome, but it is mainly characterized by
aching pains on the limb joints. While wilting syndrome is
characterized by limp and weak, in general, there were no aching
pains on the limb joints. They are not difficult to be
distinguished in clinics.
Western Medicine:
Wilting syndrome should be differentiated from grave myasthenia
gravis, which is an acquired autoimmune disease with the
transferring obstacles of nerve-muscles, and is caused by the
autoimmune reaction resulting from the acetylcholine receptor
(AchR) of the striated muscle. It can occur at any age and there
are about 60 percent people stricken before 30 years old. Women
are more often affected than men are. The most obvious
characteristic of MG in clinics is rapid fatigability of the
skeletal muscles affected, improved with rest or medicines that
inhibits the activity of cholinesterase.
They
are not difficult to be distinguished in clinics.
First
Diagnosis:
TCM
diagnosis: Wilting syndrome
Symptom identification: Liver-kidneys yin vacuity.
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.
High-protein diet.
5.
Herbal tea (to enrich yin and supplement the kidneys, soften the
liver and extinguish the wind): one dosage a day and drink
twice.
Prescription: Varied Decoction of the Supplementing-Kidneys and
Softening-Liver.
Main
herbs used in the herbal tea: baishao (white peony), shudi
(cooked rehmannia root), chuanwu (aconite main tuber), etc.
6.
Acupuncture and massage: once a day.
7.
Have more medical examinations if necessary.
Date:
Sept. 14, 2007 Time:
10:00 a.m.
The patient
complained that he has suffered from
weakness of the lower limbs along with muscular atrophy for 3
years, and the condition has been aggravated by disability of
walking for over one year. His lower limbs were weak with
seriously atrophic, so he could neither stand nor walk. His
lower limbs paralyzed completely, so he even could not do any
flexible movement. There were swellings below the ankle joints.
His strength of his arms was lessened. He felt languid and weak.
There were muscles beating with feeling of tightening on all
over the body. He suffered from fuzzy eyes, wilt waist and
distending stomach duct. He kept a normal diet with dry month
dying to drink. His bowel movement was dry and hard. His tongue
was red with light yellow tongue coating. There were cracks in
the middle of the tongue along with teeth marks at the edge of
the tongue. His pulse was thready, rapid and weak. TCM diagnosed
it with Flaccidity Syndrome because of the Liver-Stomach yin
vacuity. Western medicine diagnosed it with
Amyotrophic Lateral Sclerosis
(ALS). The treatment strategy is to enrich yin and supplement
the kidneys, to soften the liver and extinguish the wind.
Main
herbs used in the herbal tea: baishao (white Peony), shudi
(cooked rehmannia root), chuanwu (aconite main tuber), etc.
three dosages in total. One dosage a day and drink twice
Date:
Sept. 16, 2007 Time:
9:00 a.m.
The
patient¡¯s examinations of ECG,
B-ultrasonic
examination
and blood were both normal. His urine examination was (+); the
Urea
Ammonia was 9.61. Considering there were some errors. The
patient would have more examinations if necessary. The patient
said that his muscles beating all over the body was lessened.
Doctor¡¯s requirement is to take four dosages of the herbal tea
of the same prescription.
Date:
Sept. 20, 2007 Time:
9:00 a.m.
The
muscles beatings all over the body almost disappeared. His lower
limbs still could not do any movement, and he had to sit all the
time. His lower limbs drooped, so the blood was difficult to
flow back to the body, which resulted in swellings below the
knee joints.
The
doctor advised him to lay his legs straight and do more exercise
for his suffering parts. He would continue to take five dosages
of the herbal tea of the same prescription.
Date:
Sept. 25, 2007 Time:
9:00 a.m.
The
muscles beatings all over the body were improved significantly.
He still suffered from abdominal distention with dry and hard
bowel movement. His ankle joints were stiff and unable to do any
flexible movement. There were swellings below the ankle joints.
The treatment is to enrich the liver and supplement kidneys,
quicken the blood and soften the hardness.
He would
continue to take five dosages of the herbal tea of the same
prescription.
Date:
Sept. 29, 2007 Time:
9:00 a.m.
After
taking the treatment of herbal tea and massage, the muscles
beating all over the body was lessened day by day. It has been
three days since the muscles beating stopped. The stiff ankle
joints and swellings were improved obviously.
He would continue to take herbal tea of the same
prescription.
Date:
Oct. 5, 2007 Time: 9:00
a.m.
The
stiffness of the ankle joints was improved apparently, and his
toe-joints could do some slightly flexible movement. There were
contracted movements among the muscles of his legs. The patient
was glad to receive such great improvement, so he kept a
pleasant mood.
Doctor¡¯s
requirement is to take herbal tea of the same prescription.
Date:
Oct. 10, 2007 Time:
9:00 a.m.
In
recent days, the patient has suffered from vomiting, poor intake
and loose bowel movement for twice a day. No stomachache. The
treatment strategy is to warm the center and dissipate cold, to
fortify the spleen and transform food.
Doctor¡¯s requirement is to take three dosages of the herbal tea as
following: baishu (ovate atratylodes root), fulin (poria),
dangshen (codonopsis root), etc.
Date:
Oct. 13, 2007 Time:
9:00 a.m.
The
patient said that his food intake was normal without any
vomiting. He still suffered from
abdominal distention
with once loose bowel movement a day.
Doctor¡¯s requirement is to take herbal tea of the former
prescription without lycium. In recent days, the patient felt
that there were muscular contracted movements among his legs and
calves. He was told he was recovering in a good condition.
Date:
Oct. 18, 2007 Time:
10:00 a.m.
The
patient complained about his uncomfortable throat. In the
examination, there were swellings and congestion on the throat.
He was considered to have caught a cold. The doctor added 6g
Sichuan Coptis root, etc. to his herbal tea. The patient had the
symptoms of dry bowel movement and
abdominal
distention. There were muscular
contracted movements among his legs and calves. His left knee
joints can do flexible movement, and the symptoms of swellings
and livor below his ankle joints was lessened, which showed that
his condition was improving. There was stiffness on his ankle
joints, especially serious on his left one. The patient told the
doctor that he had had the history of trauma 30 years before.
Date:
Oct. 20, 2007 Time:
10:00 a.m.
The patient¡¯s
angina due to a cold has almost recovered. He was in poor spirit
with
abdominal distention and dry bowel movement. There were symptoms
of swelling below the ankle joints of his lower limbs, so the
doctor advised him to eat more fruit and vegetables, and he
could not only take high-protein food. The main herbs in the
prescription as following: baishu
(ovate atratylodes root), huangqi (astragalus root), dangshen
(codonopsis root), etc.
Date:
Oct. 23, 2007 Time:
10:00 a.m.
In recent days, the
patient has caught a cold along with dieting outside, so he was
considered that his diarrhea resulted from the hurt on his
stomach. He suffered from loose bowel movement for twice a day,
accompanied with
abdominal distention, poor intake and weakness. He was prescribed by
1000ml energy mixture with potassium chloride. He orally took
self-prepared medicine for his diarrhea. The TCM treatment
strategy is to boost qi and fortify the spleen. The main herbs
in the three dosages of the herbal tea as following:
baishen (white ginseng), huangqi
(astragalus root), caihu (bupelurum root), etc.
Date:
Oct. 24, 2007 Time:
9:00 a.m.
The patient said
that his spirit got better. No abdominal distention or diarrhea.
The doctor advised him that he¡¯d rather go on a light diet than
a greasy or high-protein diet. He should avoid the spicy or cold
food.
Date:
Oct. 26, 2007 Time:
9:00 a.m.
The patient¡¯s
condition was normal. He did not feel any
other special discomfort. His diet
increased. He had slight abdominal distention. No diarrhea. He
kept a normal spirit. The main herbs in another three dosages of
the herbal tea:
baishen
(white ginseng), huangqi (astragalus root), caihu (bupelurum
root), etc.
Date:
Oct. 29, 2007 Time:
14:00 p.m.
In recent days, the
patient has eaten some fruits, which resulted in diarrhea,
accompanied with rectal tenesmus. He suffered with poor intake
and weakness. The patient took self-prepared medicine for his
diarrhea, and he was prescribed by 1000ml +
gentamicin 240,000 U and energy mixture. The patent felt no special
discomfort. The patient continued to take two dosages of the
herbal tea of the former formula.
Date:
Oct. 31st 2007 Time:
10:00 a.m.
The patient
diarrhea recovered completely. His bowel movement was dry with
blood in it. Today the invited professor Yu of surgery examined
him, and found that there were several hemorrhoids among some
hard and dry bowel movement of his anal canal. There was no
other abnormality. It was considered that the patient had taken
too much self-prepared medicine for diarrhea. Therefore, he was
prescribed by
glycerine enema
for
external use. The doctor advised him to eat more fruit and take
the herbal tea for further examination. The TCM treatment
strategy is to fortify the spleen and supplement the kidneys.
The main herbs in the three dosages of the herbal tea as
following:
baishen
(white ginseng), huangqi (astragalus root), caihu (bupelurum
root), etc.
Date:
Nov. 3, 2007 Time: 9:00
a.m.
The patient¡¯s bowel
movement was hard and dry. After the
Glycerine Enema (Kaisailu)
for external use
twice, he excluded a lot of bowel movement. His diet got better
significantly, and he kept a normal spirit with good mood. The
patient continued to take the herbal tea to fortify the spleen
and supplement the kidneys. Doctor¡¯s requirement is to take four
dosages of the herbal tea of the same formula.
Date:
Nov. 7, 2007 Time: 9:00
a.m.
In recent days, the
patient has had slightly muscular beatings. His other condition
was normal. Doctor¡¯s requirement is to take five dosages of the
herbal tea of the following formula:
baishen
(white ginseng), huangqi (astragalus root), baishu (ovate
atratylodes root), etc.
Date:
Nov. 12, 2007 Time:
9:00 a.m.
The patient¡¯s
muscular beatings disappeared. The swellings below his ankle
joints of his lower limbs were lessened. The contracted strength
of his lower limbs¡¯ muscles increased. His bowel movement and
urination were both normal. He kept a normal diet and steady
mood. There was no other abnormality. The doctor added Tangkuei
to another five dosages of the herbal tea.
Date:
Nov. 17, 2007 Time:
9:00 a.m.
The stiffness of
his lower limbs¡¯ ankle joints was lessened significantly. His
skin was in purple. There was blood block due to his tiredness
after travel. Another three dosages of the herbal tea was
invariable as following:
baishen
(white Ginseng), huangqi (astragalus root), baishu (ovate
atratylodes root), etc.
Date:
Nov. 20, 2007 Time:
9:00 a.m.
The stiffness of
his lower limbs¡¯ ankle joints was lessened significantly.
Doctor¡¯s requirement is to take four dosages of the herbal tea
of the foremer formula.
Date:
Nov. 25, 2007 Time:
9:00 a.m.
The swellings of
his lower limbs¡¯ ankle joints were lessened further. There were
slight swelling on his feet and back. His skin was in purple and
dark. He kept a normal diet and sleep. His bowel movement and
urination were both normal. Doctor¡¯s requirement is to take four
dosages of the herbal tea of the same formula. Doctor¡¯s
requirement is to take six dosages of the herbal tea of the
former formula.
Date:
Nov. 30, 2007 Time:
9:00 a.m.
The patient kept a
steady condition. Doctor¡¯s requirement is to take four dosages
of the herbal tea of the former formula.
Date:
Dec. 4, 2007 Time:
9:00 a.m.
The muscular beatings all over his body disappeared completely.
The swellings on his lower limbs almost recovered. The stiffness
on his ankle joints was improved significantly. The blood
circulation of his lower limbs was improved. He kept a normal
diet, sleep and digestion. The patient took 30 dosages of the
herbal tea for the former formula and demanded to leave the
hospital.
¡¡
