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Brief Summary: On Mar. 12, 2009, Aliasghar from Iran, who has suffered from ALS, accompanied with the symptoms of the weakness of the hands and muscular atrophy of the upper limbs, was hospitalized in our hospital. He has achieved significant improvement after 26 days TCM treatment here.

 

Record of Hospitalization

Name: Aliasghar                                                                                                   Birthplace: Iran

Sex: Male                                                                                                             Profession: Businessman

Age: 45                                                                                                                Date of Admission: Mar. 12, 2009

Nationality: Muslim                                                                                              Date of Record: Mar. 12, 2009

Marital Status: Married                                                                                       Onset Season: The Summer Solstice

Complainer: The patient himself

 

First Medical Record

Date: Mar. 12, 2009                                      Time: 24: 00 p. m.

Aliasghar, a 45-year-old male, has suffered from the symptoms of the weakness of the hands for 10 months and muscular atrophy of the upper limbs. He was hospitalized in our hospital for treatment at 24: 00 p. m. on Mar. 12, 2009.

Essentials for Diagnosis:

1. The patient has suffered from the weakness of the hands for 10 months.

2. Last May, the patient felt the weakness of the hands and flexibility declining of the fingers without obvious reasons. At that moment, he didn¡¯t pay much attention to this and had not taken any examination and treatment. Later his condition gradually became worse. So last September he went to a local hospital for EMG examination and was diagnosed with ALS. The doctor told him there was no treatment for ALS, so he contacted with our hospital and took 2 months herbal tea at home. He consciously felt there was some improvement, and then he came to our hospital for treatment at 24: 00 p. m. on Mar. 12, 2009. He had pale red tongue, thin white tongue coating and thready pulse.

3. T 36.2¡æ, P 80 times/minute, R 20 times/minute, BP 120/80mmHg.

4. He grew normally with common nutrition. His mind was clear. He had an expression of chronic illness and tiredness. His body was in a positive posture and he was cooperative with clear mind.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The patient felt the weakness of the hands, especially the left hand. There were the symptoms of obvious muscular atrophy of the upper limbs, flexibility declining of the finger and muscular jumping of the four limbs.

7. Accessory examination: EMG showed that he had ALS.

Diagnostic Basis:

TCM: The patient has suffered from the weakness of the hands for 10 months, especially the left hand. Meanwhile, there were the symptoms of obvious muscular atrophy of the upper limbs, flexibility declining of the fingers and muscular jumping of the four limbs. The patient was mainly characterized by disabled wilted limbs, so it was not difficult to be diagnosed as wilting pattern.

Western Medicine: The patient has suffered from the weakness of the hands for 10 months, especially the left hand. Meanwhile, there were the symptoms of obvious muscular atrophy of the upper limbs, flexibility declining of the fingers and muscular jumping of the four limbs. EMG showed that he had ALS.

Diagnostic Differentiation:

TCM: The patient¡¯s wilting pattern should be differentiated from impediment pattern. Wilting pattern is characterized by limp, weak, and emaciated limbs with the numbness of the muscles. But the patient usually has no joint pains. On the contrary, impediment pattern is generally characterized by joint pains. So they are not difficult to be distinguished.

Western Medicine: ALS should be differentiated from tumor of spinal cord, which is characterized by nerve root pains of the upper limbs, but without extensive trembling of the muscle bundles. Besides, there is disturbance of sensation and obstruction of the subarachnoid cavity. The disease can be diagnosed clearly by the examination of CT or MRI.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Wilting pattern

Symptom identification: Spleen qi vacuity, obstruction of the channels and network vessels.

Western Medicine: 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. Low-fat and high-protein diet.

5. TCM treatment strategy: fortify the spleen, boost qi, quick the blood circulation and free the channels and network vessels.

6. Herbal tea: one dosage a day and drink twice.

7. Acupuncture and massage: once a day

8. Have more medical examinations if necessary.

 

Date: Mar. 13, 2009                                      Time: 10: 30 a. m.

The patient has suffered from the weakness of the hands for 10 months. Last summer, the patient began to feel the weakness of the hands and flexibility declining of the fingers. Last September he went to a local hospital for EMG examination and was diagnosed with ALS. Then he contacted with our hospital and took 2 months herbal tea at home. He consciously felt there was some improvement. At present, he felt the weakness of the hands, especially the left hand. There were the symptoms of obvious muscular atrophy and flexibility declining of the fingers. He had the difficulty in drinking water and felt the joint pains of the fingers. Sometimes, there was muscular jumping of the arms, thenars and thighs. He felt heaviness of the body after tiredness. His sight was declining. He felt tired after walking a long period. His diet, speaking, bowel movement were normal. He had the difficulty in urination. There was scorching hot when he had urination, but there were no pains. His tongue was pale red. His tongue coating was thin and white. His pulse was thready. Professor Yang believed that he had suffered from wilting pattern due to spleen qi vacuity, obstruction of the channels and network vessels, so the treatment strategy was to fortify the spleen, boost qi, quick the blood circulation and free the channels and network vessels. The prescription was as follows: danggui (tangkuei), gancao (licorice root), huangqi (astragalus root), etc. 5 dosages in total.

 

Date: Mar. 14, 2009                                      Time: 10: 00 a. m.

According to the feedback, the routine examinations of the blood and urine were normal. The function of the liver and kidneys were also normal. The examination of B ultrasound showed that there was slight enlargement of the prostate.

 

Date: Mar. 17, 2009                                      Time: 10: 00 a. m.

His sleep was good. The urine and bowel movement both were normal. Compared with before, the strength of his upper limbs was stronger. He could use the remote controller better, but there was still weakness and heaviness of the upper limbs. His pulse was deep and thready. His tongue was pale. His tongue coating was thin and white. The prescription was made a little change. 4 dosages in total.

 

Date: Mar. 21, 2009                                      Time: 10: 00 a. m.

The patient said there was some improvement of the strength of the upper limbs. The flexibility of the fingers was better. The trembling of the muscles of his hands lessened, but he still felt the weakness of the upper limbs. Besides, there were pains of his left fingers. The other condition was normal. The former prescription was changed. 5 dosages in total.

 

Date: Mar. 26, 2009                                       Time: 9: 30 a. m.

His condition was further improved, but he still felt the weakness of the upper limbs. The flexibility of the fingers was not good. His pulse was deep and thready. His tongue was pale. His tongue coating was white. Continue to take the same prescription. 5 dosages in total.

 

Date: Mar. 28, 2009                                       Time: 9: 00 a. m.

He felt slight discomfort of the throat and cough due to having a cold. The prescription was changed a little.

 

Date: Mar. 31, 2009                                       Time: 9: 00 a. m.

The discomfort of the throat and cough basically disappeared. The flexibility of the fingers was obviously better than before. He felt slight pains of the left shoulder when sleeping. There was still weakness of the upper limbs, but there was no trembling of the muscles in the recent days. The other condition was normal. The prescription was as follows: baizhu (ovate atractylodes root), baishao (white peony root), chenpi (tangerine peel). 5 dosages in total.

 

Date: Apr. 6, 2009                                        Time: 9: 00 a. m.

The patient said there was some improvement of the strength of his upper limbs, but he still felt slight pains of the left shoulder. The former prescription was changed a little. 4 dosages in total.

 

Date: Apr. 7, 2009                                        Time: 9: 00 a. m.

The patient decided to leave the hospital tomorrow.

 

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It¡¯s not a long time that we have been here but during these 27 days, we have seen lots of little and important improvements in my father¡¯s condition. That is incredible that you can stop the process of this disease, we really appreciate your help. We are so happy with TCM treatment and we are so sad that we have to leave here soon but we will continue this treatment in our country for 4 months and will be in contact with Dr. Ming and others. We will really miss every one here.

Miasghar Nayier

Check the original handwriting here

 

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