Brief Summary:
On Jan. 24, 2008, Tor, from Norway, who suffered from
difficulties in swallowing and speaking, along with weakness of
his limbs, was hospitalized in our hospital. After about
two-month TCM treatment here, his difficulties in swallowing and
speaking, as well as his unclear and influent speech, all have
been improved significantly.
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Record of
Hospitalization
Name:
Tor
Sex:
Male
Age:
43
Profession: Businessman
Nationality:
Norway
Marital Status:
Married
Onset Season:
Winter
Date of Admission:
Jan. 24, 2008
Complainer:
The patient
himself
Reliability: Reliable
Major Complaint:
The
patient has suffered from difficulties in swallowing and
speaking, accompanied with weakness of his limbs for 4 months.
Present Illness:
In Sept. 2007, without any obvious causes, the patient began to
have the symptoms of difficulties in swallowing and speaking,
accompanied with the weakness of his limbs. At that time, the
patient paid no attention to it, and did no treatment about it.
Therefore, the disease was aggravated progressively. In Dec.
2007, the patient went to a local hospital for a diagnosis.
After the EMG examination, the patient was diagnosed with
amyotrophic lateral sclerosis
(ALS).
The doctor prescribed him Rilutek for
oral taking without any other treatment. To his
disappointment, there was no obvious improvement.
To seek for a
further comprehensive treatment, he was hospitalized in our
hospital on Jan. 24, 2008. Since he got the disease,
he has kept normal spirit, appetite and sleep. His bowel
movement and urination were both normal.
Disease History:
No history of typhoid, tuberculosis, hepatitis, malaria or other
infectious diseases. No allergic history of medicine or food. No
history of trauma or operation. No history of blood transfusion.
History of preventive vaccination not provided.
Personal History:
He was born in Norway, living in a dry environment. 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 36. So far, he has two sons. His wife and
sons have been healthy all the time.
Family History:
His
parents are both healthy. No family history of special disease.
Physical
Examination:
T 36.6¡æ£¬P
81beats/minute, R 22 times/minute, BP 110/70 mmHg, W 80 kg.
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 deformity of
skull and the five sense organs.
No congestion
in throat. No swollen tonsil. The soft neck and trachea placed
in the middle. No enlargement
of the thyroid gland. No congestion of the 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 81 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. He has suffered from
weakness of the upper limbs. In the experiment, the
gripping power of his left hand was 22.6 kg, and that of the
right hand was 33.9 kg. The muscular strength of his upper limbs
was Grade
¢ó
with normal muscle hypertonicity. His lower limbs were also
weak, and the muscular strength of them was also Grade
¢ó
with normal muscle hypertonicity. He had the difficulties in
swallowing and speaking, and his speech was neither clear nor
fluent. The examinations for the anus and pudendum were both
normal. His physiological reflex exists. Other pathological
symptoms have not been elicited. His tongue was dark red with
thin and white tongue coating. His pulse was slippery and weak.
Diagnostic
examination: Not provided.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification: Insufficiency of the liver and kidneys,
accompanied with deficiency of the lungs- spleen and qi.
Western medicine
diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
First Medical
Record
Date: Jan. 24,
2008
Time: 22:00
Tor, a 43-year-old
male, has suffered from difficulties in swallowing and speaking,
accompanied with weakness of his limbs for 4 months. He was
picked up by our staff in Zhijiang Airport and arrived in
Huaihua Red Cross Hospital for further treatment at 21: 30 p.m.
on Jan. 24, 2008.
Essentials for
Diagnosis:
1. The patient has
suffered from difficulties in swallowing and speaking,
accompanied with weakness of his limbs for 4 months.
2. In Sept. 2007,
without any obvious causes, the patient began to have the
symptoms of difficulties in swallowing and speaking, accompanied
with the weakness of his limbs. At that time, the patient paid
no attention to it, and did no treatment about it. Therefore,
the disease was aggravated progressively. In Dec. 2007, the
patient went to a local hospital for a diagnosis. After the EMG
examination, the patient was diagnosed with
amyotrophic lateral sclerosis
(ALS).
The doctor prescribed him Rilutek for
oral taking without any other treatment. To his
disappointment, there was no obvious improvement.
To seek for a
further comprehensive treatment, he was hospitalized in our
hospital on Jan. 24, 2008. Since he got the disease,
he has kept normal spirit, appetite and sleep. His bowel
movement and urination were both normal.
3. T 36.6¡æ£¬P
81beats/minute, R 22 times/minute, BP 110/70 mmHg, W 80 kg.
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. He had the
difficulties in swallowing and speaking, and his speech was
neither clear nor fluent. He has suffered from weakness of all
the limbs. The muscular strength of his upper limbs was Grade
¢ó
with normal muscle hypertonicity. In the experiment, the
gripping power of his left hand was 22.6 kg, and that of the
right hand was 33.9 kg. The muscular strength of them was also
Grade
¢ó
with normal 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 difficulties in swallowing and speaking,
accompanied with weakness of his limbs for 4 months. Because of
deficiency of the liver and kidneys, his essence-blood could not
nourish his sinews and vessels, and gradually it resulted in
flaccidity. He has suffered from weakness of all the limbs, with
an expression of chronic illness and languidness. He also had
difficulty in speaking. Due to insufficiency of the liquids,
abnormality of the qi and blood, and the lungs heat scoring the
lobes, his limbs lose the nourishment. With the weakness of the
spleen and stomach, the essence-blood could not nourish his
muscles. All the symptoms belong to the scope of flaccidity. His
tongue was dark red with thin and white tongue coating. His
pulse was small, slippery and weak.
Western Medicine:
The patient has suffered from difficulties in swallowing and
speaking, accompanied with weakness of his limbs for 4 months.
His speech was neither clear nor fluent. He has suffered from
weakness of all the limbs. The muscular strength of his upper
limbs was Grade
¢ó
with normal muscle hypertonicity. In the experiment, the
gripping power of his left hand was 22.6 kg, and that of the
right hand was 33.9 kg. The muscular strength of the lower limbs
was also Grade
¢ó
with normal muscle hypertonicity. In Dec. 2007, after EMG
examination in a local hospital, he was diagnosed with
amyotrophic lateral sclerosis
(ALS).
Diagnostic
differentiation
TCM: The patient¡¯s
wilting syndrome should be differentiated from impediment
syndrome. Wilting syndrome is characterized by the limp, weak,
and emaciated limbs with muscular atrophy. A patient who has
suffered from wilting syndrome may even become unable to hold an
object or to stand without any support. Besides, the patient¡¯s
lower limbs are more often affected, though he or she usually
has no joint pains. On the contrary, impediment syndrome is
generally characterized by aching pains, fixed heaviness and
inflexibility of sinews and bones, muscles and joints, with
occasional numbness or swelling, though, no paralytic
manifestations. They are not difficult to be distinguished in
clinical practice.
Western Medicine: Wilting syndrome should be differentiated from
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 is rapid fatigability of the
skeletal muscles affected, improved with rest or medicines that
inhibits the activity of cholinesterase. They are different from
those of wilting syndrome patients.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification: Insufficiency of the liver and kidneys,
accompanied with deficiency of the lungs-spleen and qi
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. Regular diet.
5. Herbal tea (to
enrich and supplement the liver and kidneys, supplement the
spleen and boost the lungs): One dosage a day and drink twice.
Main herbs used in
the herbal tea: baisheng (white ginseng), baishu (ovate
atractylodes root), shanyao (dioscorea), etc.
6. Acupuncture and
massage: once a day.
7. Have more
medical examinations if necessary.
Date: Jan. 25,
2008 Time: 9:00 a.m.
Today the patient
said to Dr. Yang that he had suffered from difficulties in
swallowing and speaking, along with the weakness of all his
limbs. His speech was neither clear nor fluent.
Examination:
T 36.6¡æ£¬P
81beats/minute, R 22 times/minute, BP 110/70 mmHg, W 81 kg.
His heart and lungs
were normal, and his abdomen was soft and flat.
Dr. Yang¡¯s
analysis:
1. The patient has
suffered from difficulties in swallowing and speaking,
accompanied with weakness of his limbs for 4 months.
2. He has suffered
from weakness of the upper limbs. In the experiment, the
gripping power of his left hand was 22.6 kg, and that of the
right hand was 33.9 kg. The muscular strength of his upper limbs
was Grade
¢ó
with normal muscle hypertonicity. He has also suffered from
weakness of the lower limbs, and the muscular strength of them
was also Grade
¢ó
with normal muscle hypertonicity. He had difficulties both in
swallowing and speaking, and his speech was neither clear nor
fluent.
3. National
examination: In Dec. 2007, after EMG examination, he was
diagnosed with
amyotrophic lateral sclerosis
(ALS) in a local
hospital.
According to the
above information, TCM considered it as wilting syndrome
(flaccidity syndrome). Wilting syndrome is characterized by the
limp, weak, and emaciated limbs with muscular atrophy. Because
of the insufficiency of the liquids and abnormality of the qi
and blood, his limbs lose the nourishment. With the deficiency
of spleen and stomach, and lungs heat scoring the lobes, the
essence-blood could not nourish his sinews and vessels. Then it
leads to the malnutrition of the muscles, and gradually it
resulted in flaccidity. Dr. Yang¡¯s analyzed it was Insufficiency
of the liver and kidneys, accompanied with deficiency of the
lungs- spleen and qi.
Principle of TCM
treatment: Enriching and supplementing the liver and kidneys,
supplementing the spleen and boosting the lungs. Herbal tea
prescribed for four days including baisheng (white ginseng),
baishu (ovate atractylodes root), shanyao (dioscorea), etc. One
dosage a day and drink twice.
Doctor¡¯s
requirement is to take four dosages of the herbal tea of the
same prescription. Acupuncture and massage for once a day. The
patient will have more medical examinations if necessary.
Date: Jan. 26,
2008 Time: 9:00 a.m.
The patient said
that he had difficulties in swallowing and speaking, and that
his speech was neither clear nor fluent. Besides, He suffered
from weakness of all the limbs.
His heart and lungs
were normal, and his abdomen was soft and flat. The physical
examination was the same as before. He has been keeping normal
spirit, appetite and sleep. His bowel movement and urination
were both normal. His tongue was red with thin and white tongue
coating, his pulse was slippery. Since the weather has turned
out to be terrible these days, especially freezing weather, the
doctor advised him to wear more clothes to avoid catching a
cold.
Date: Jan. 27,
2008 Time: 9:00 a.m.
The patient said
that he had difficulties in swallowing and speaking, and that
his speech was neither clear nor fluent. Besides, He suffered
from weakness of all the limbs.
His heart and lungs
were normal, and his abdomen was soft and flat. The physical
examination was the same as before. He has been keeping normal
spirit, appetite and sleep. His bowel movement and urination
were both normal. His tongue was red with thin and white tongue
coating, his pulse was slippery.
The herbal tea is
followed by the former prescription.
Date: Feb 1,
2008 Time: 9:00 a.m.
The patient said
that he had difficulties in swallowing and speaking, and that
his speech was neither clear nor fluent. Besides, He suffered
from weakness of all the limbs.
His heart and lungs
were normal, and his abdomen was soft and flat. The physical
examination was the same as before. He has been keeping normal
spirit, appetite and sleep. His bowel movement and urination
were both normal. His tongue was red with thin and white tongue
coating, his pulse was slippery.
The herbal tea is
followed by the former prescription.
Date: Feb 6,
2008 Time: 9:00 a.m.
The patient said
that he had difficulties in swallowing and speaking, and that
his speech was neither clear nor fluent. Besides, He suffered
from weakness of all the limbs.
His heart and lungs
were normal, and his abdomen was soft and flat. The physical
examination was the same as before. He has been keeping normal
spirit, appetite and sleep. His bowel movement and urination
were both normal. His tongue was red with thin and white tongue
coating, his pulse was slippery.
The herbal tea is
followed by the former prescription.
Date: Feb 11,
2008 Time: 9:00 a.m.
The patient said
that he had difficulties in swallowing and speaking, and that
his speech was neither clear nor fluent. Besides, He suffered
from weakness of all the limbs.
His heart and lungs
were normal, and his abdomen was soft and flat. The physical
examination was the same as before. He has been keeping normal
spirit, appetite and sleep. His bowel movement and urination
were both normal. His tongue was red with thin and white tongue
coating, his pulse was slippery.
The herbal tea is
followed by the former prescription.
Date: Feb 16,
2008 Time: 9:00 a.m.
Today the patient
said that his difficulties in swallowing and speaking, along
with his unclear and influent speech all have become better, so
has the weakness of all his limbs.
His heart and lungs
were normal, and his abdomen was soft and flat. The physical
examination was the same as before. He has been keeping normal
spirit, appetite and sleep. His bowel movement and urination
were both normal. His tongue was red with thin and white tongue
coating, and his pulse was slippery and weak.
The herbal tea is
followed by the former prescription.
Date: Feb 21,
2008 Time: 9:00 a.m.
His difficulties in
swallowing and speaking, along with his unclear and influent
speech all have got some improvement, so has the weakness of all
his limbs.
His heart and lungs were normal, and his abdomen was soft and
flat. The physical examination was the same as before. He has
been keeping normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was red with
thin and white tongue coating, and his pulse was slippery and
weak. The
herbal tea is followed by the former prescription.
Summary stage
Date: Feb. 25, 2008
Time: 9:30 a.m.
Tor, a 43-year-old
male, has suffered from difficulties in swallowing and speaking,
accompanied with weakness of his limbs for 4 months. He was
hospitalized in Huaihua Red Cross Hospital for TCM treatment at
21: 30 p.m. on Jan. 24, 2008. So far, he has been
hospitalized for 30 days.
Admission
Condition:
T 36.6¡æ£¬P
81beats/minute, R 22 times/minute, BP 110/70 mmHg, W 81 kg.
His
heart and lungs were normal, and his abdomen was soft and flat.
He had
difficulties both in swallowing and speaking, and
his speech was
neither clear nor fluent. He has also suffered from weakness of
all the limbs. The muscular strength of his upper limbs was
Grade
¢ó
with normal muscle hypertonicity. In the experiment, the
gripping power of his left hand was 22.6 kg, and that of the
right hand was 33.9 kg. He has been keeping a normal spirit,
appetite and sleep. His bowel movement and urination were both
normal.
Admission
Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification: Insufficiency of the liver and kidneys,
accompanied with deficiency of the lungs- spleen and qi.
WM diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
The
Course of Diagnosis:
Since
the patient was hospitalized here, he has been prescribed herbal
tea to enrich and supplement the liver and kidneys, supplement
the spleen and boost the lungs.
One
dosage a day and drink twice. 100 ml each time, accompanied with
acupuncture and massage once a day for a comprehensive
treatment. The patient has got some improvement.
The
Current Condition:
T 36.6¡æ£¬P
81beats/minute, R 22 times/minute, BP 110/70 mmHg, W 81 kg.
His
heart and lungs are normal, and his abdomen is soft and flat.
The difficulties both in swallowing and speaking has improved
obviously, so has
his unclear and
influent speech. The weakness of all his limbs has also got much
better. He has been keeping normal spirit, appetite and sleep.
His bowel movement and urination were both normal. His tongue
was red with thin and white tongue coating. His pulse was
slippery and weak.
The
Current Diagnosis:
TCM
diagnosis: Wilting syndrome
Symptom
identification: Insufficiency of the liver and kidneys,
accompanied with deficiency of the lungs- spleen and qi.
Western medicine
diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
Plans
for treatment strategy:
1.
Continue to take the herbal tea.
2.
Acupuncture and massage for once a day.
3.
Keep a pleasant mood and open-minded spirit.
Date: Feb 26,
2008 Time: 9:00 a.m.
His difficulties in
swallowing and speaking, along with his unclear and influent
speech all have got some improvement, so has the weakness of all
his limbs.
His heart and lungs were normal, and his abdomen was soft and
flat. The physical examination was the same as before. He has
been keeping normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was red with
thin and white tongue coating, and his pulse was slippery and
weak. The
herbal tea is followed by the former prescription.
Date: Mar. 1,
2008 Time: 9:00 a.m.
His difficulties in
swallowing and speaking, along with his unclear and influent
speech all have got much better, so has the weakness of all his
limbs. His
heart and lungs were normal, and his abdomen was soft and flat.
He has been keeping normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was red with
thin and white tongue coating, and his pulse was slippery and
weak. The
herbal tea is followed by the former prescription.
Date: Mar. 6,
2008 Time: 9:00 a.m.
His difficulties in
swallowing and speaking, along with his unclear and influent
speech all have been improved a lot, so has the weakness of all
his limbs.
His heart and lungs were normal, and his abdomen was soft and
flat. The physical examination was the same as before. He has
been keeping normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was red with
thin and white tongue coating, and his pulse was slippery and
weak. The
herbal tea is followed by the former prescription.
Date: Mar. 11,
2008 Time: 9:00 a.m.
His difficulties in
swallowing and speaking, along with his unclear and influent
speech all have been improved a lot, so has the weakness of all
his limbs. He
has been keeping a stable condition. His tongue was red with
thin and white tongue coating, and his pulse was slippery and
weak. The
herbal tea is followed by the former prescription.
Date: Mar. 13,
2008 Time: 9:00 a.m.
The patient has
been keeping a stable condition. His difficulties in swallowing
and speaking, along with his unclear and influent speech all
have been improved significantly, so has the weakness of all his
limbs. In the physical examination,
his heart and lungs
were normal, and his abdomen was soft and flat. He has been
keeping normal spirit, appetite and sleep. His bowel movement
and urination were both normal.
The patient
demanded to leave the hospital today.
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