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Brief Summary: On Feb. 9, 2009, Sarath from Sri Lanka, who has suffered from ALS, accompanied with the symptom of the difficulties in speaking and swallowing for one year, was hospitalized in our hospital. He has achieved some improvement after 78 days TCM treatment here.

 

Record of Hospitalization

Name: Sarath                                                                                                     Birthplace: Sri Lanka

Sex: Male                                                                                                           Profession: Civilian

Age: 60                                                                                                               Date of Admission: Feb. 9, 2009

Religion: Muslim                                                                                                 Date of Record: Feb. 10, 2009

Marital Status: Married                                                                                      Onset Season: Two days after Spring begins

Complainer: The patient himself and the translator

 

First Medical Record

Date: Feb. 10, 2009                                       Time: 8: 00 a. m.

Sarath, a 60-year-old male, has suffered from ALS, accompanied with the symptom of the difficulties in speaking and swallowing for one year. He was hospitalized in our hospital at 19: 00 p. m. on Feb. 9, 2009.

Essentials for Diagnosis:

1. The patient has suffered from the symptom of the difficulties in speaking and swallowing for one year.

2. Last January, the patient began to feel the difficulties in speaking and swallowing, but there were no itching and pains of the throat. He could feel the difficulty in drinking in the early stage, but later he could drink water without problem. He had no ability to make his tongue curve upward, and the tongue could not touch the lips. His pronunciation was not clear. There was slight jumping of the muscles, but without the symptoms of the pains and stiffness. He was given MRI examination in the local hospital but with no clear diagnosis. Last April, he began to take his traditional treatment in his country, but there was no obvious improvement. Then he took western medicine treatment in July, but there was still no much improvement. Last September, he was given EMG examination in the local hospital and then was diagnosed with ALS. Later he took our herbal tea treatment and consciously felt the jumping of the muscles disappeared and the tongue could touch the lips. So he went to our hospital for further treatment. Since he suffered from the disease, there was no obvious decline of the weight and muscular strength. At present, the patient had the difficulty in speaking and swallowing. He was fond of drinking warm water and was easy to cough up when drinking. His breath and sleep were normal. There was slight cough and he consciously felt the phlegm in the throat. His appetite was generally good. There were the symptoms of the sense of heavy head and vomiting if he didn¡¯t take any food. But he felt comfortable after the meals. His urine and bowel movement were normal.

3. He had the history of chronic rhinitis. No allergy to the food or medicine.

4. T 36.2¡æ, R 20 times/minute, P 84 times/minute, BP 120/78mmHg.

5. 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. There was no xanthochromia of the skin all over the body and sclera. No enlargement of superficial lymph nodes. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation. The abdomen was normal. There were no tapping pains in the area of the kidneys. The examination of nervous system was normal.

6. Accessory examination: None.

Diagnostic Basis:

TCM: The patient was characterized by the difficulties in speaking and swallowing, so it was not difficult to be diagnosed as wilting pattern. Due to insufficiency of ancestral qi, the patient could not speak clearly. Spleen qi vacuity resulted in improper nourishment of the tongue. Because of insufficiency of lung qi and dynamia, his tongue could not curve upward. He had the difficulty in swallowing and was easy to have dry cough, so the phlegm was difficult to be coughed up. His tongue was thin and white. His tongue coating was thick. These symptoms are the manifestation of vacuity of the lungs and spleen, phlegm-damp obstructing the channels and network vessels.

Western Medicine:

1. The patient has suffered from the difficulties in speaking and swallowing for one year.

2. He was diagnosed with ALS in the local hospital.

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: The patient¡¯s ALS should be differentiated from apoplexy sequelae, which also has the difficulties in speaking and swallowing. Besides, the patient suffering from apoplexy sequelae has the symptom of paralysis of one side of the body. The disease can be diagnosed definitely by CT examination.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Wilting pattern

Symptom identification: vacuity of the lungs and spleen, phlegm-damp obstructing the channels and network vessels.

Western Medicine diagnosis: 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. Acupuncture and massage: once a day.

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

Main herbs used in the herbal tea: chenpi (tangerine peel), shanyao (dioscorea root), sharen (amomum fruit), etc.  

 

Date: Feb. 13, 2009                                      Time: 11: 00 a. m.

The patient said he could feel slight improvement of his swallowing. There was the symptom of reflux in the past when he was drinking, but now he could drink the water completely and there was no reflux. Besides, there was phlegm in the throat. He could not speak clearly. Continue to take the same prescription. 4 dosages in total. (From Apr. 14 to Apr. 17)

 

Date: Feb. 17, 2009                                      Time: 11: 00 a. m.

The patient said the function of drinking water was better in the recent two days and there was no reflux. The flexibility and atrophy of the tongue were improved. His pronunciation was better than before. Since he had slight cold yesterday afternoon, there was the symptom of running nose. But now he had no cough. Occasionally, he could feel two times of transient muscular jumping of the right shoulder within a day, but there were no pains of the joints and muscles.

 

Date: Feb. 22, 2009                                      Time: 11: 00 a. m.

The function of swallowing and drinking water was basically normal. His pronunciation was further improved. Saliva secreted by glands in the mouth lessened 50%. His diet and sleep were normal. The prescription was as follows: fuling (Poria), huangqi (astragalus root), sharen (amomum fruit), etc. 5 dosages in total. (From Apr. 23 to Apr. 27)

 

Date: Feb. 27, 2009                                      Time: 11: 00 a. m.

The function of swallowing was further improved. Saliva secreted by glands in the mouth lessened. The flexibility of the tongue was better, but there was no much improvement of his speaking in the recent days. His sleep and diet were normal.

 

Date: Mar. 2, 2009                                       Time: 11: 00 a. m.

His speaking and swallowing were further improved. Secretion in the mouth lessened. His spirit and sleep were good. Yesterday there were slight pains of his left abdomen. The prescription was changed as follows: sharen (amomum fruit), shegan (belamcandae root), chuanxiong (ligusticum root), etc. 5 dosages in total. (From Mar. 5 to Mar. 9)

 

Date: Mar. 9, 2009                                       Time: 11: 00 a. m.

His condition was basically good. His diet and sleep were normal. There were no pains of the waist. The function of speaking was no obvious improvement in the recent days. The prescription was changed as follows: taizishen (pseudostellaria root), xuanshen (scrophularia root), digupi (lycium root bark), etc. 5 dosages in total. (From Mar. 10 to Mar. 14)

 

Date: Mar. 14, 2009                                      Time: 11: 00 a. m.

The flexibility of the tongue was better than before. Secretion in the mouth lessened.  There were stasis macules on the tongue. He had slimy yellow tongue. So the treatment strategy was to quicken the blood circulation and transform stasis.

 

Date: Mar. 19, 2009                                      Time: 11: 00 a. m.

He consciously felt obvious improvement of the pronunciation in the recent days. His drinking, diet and sleep were good. There was slight muscular jumping of the right eye socket. The prescription was changed as follows: chenpi (tangerine peel), danggui (tangkuei), baizhu (ovate atractylodes root), etc. 5 dosages in total. (From Mar. 20 to Mar. 24)

 

Date: Mar. 24, 2009                                      Time: 11: 00 a. m.

His pronunciation was further improved. He felt the function of swallowing and drinking water was basically good. His sleep was normal. The amount of secretion in the mouth was nearly the same as the normal condition, but there was slightly increasing of the secretion after tiredness. There was no jumping of the muscles. His mood was comparatively good, with no grief. The atrophy of the tongue was further improved. The stasis macules on the tongue obviously lessened. The prescription was changed as follows: digupi (lycium root bark), honghua (carthamus flower), dangshen (codonopsis root), etc. 5 dosages in total. (From Mar. 25 to Mar. 29)

 

Date: Mar. 28, 2009                                      Time: 15: 00 p. m.

During the recent two days, the patient could feel mouth dry at 3: 00 o¡¯clock in the morning. Besides, there was the symptom of headache when he got up. The difficulty of speaking became worse. His tongue was moist and slippery. His tongue coating was slimy and yellow. The prescription was changed as follows: baizhu (ovate atractylodes root),  honghua (carthamus flower), danggui (tangkuei), etc. 3 dosages in total. (From Mar. 29 to Mar. 31)

 

Date: Mar. 31, 2009                                      Time: 15: 00 p. m.

The dryness of the mouth basically disappeared. He felt his throat was comfortable. The secretion in the mouth was in moderate amount. There was no difficulty in swallowing. The former prescription was changed a little. 4 dosages in total. (From Apr. 1 to Apr. 4)

 

Date: Apr. 4, 2009                                       Time: 15: 00 p. m.

The function of his swallowing was good. He didn¡¯t feel mouth dry. He felt his throat was comfortable. The secretion in the mouth was in moderate amount. The atrophy of the tongue was further improved. His pronunciation was sonorous. Slimy yellow tongue coating became thin. It was a good change. Continue to take the same prescription. 3 dosages in total. (From Apr. 5 to Apr. 7)

 

Date: Apr. 7, 2009                                       Time: 12: 00 a. m.

The patient felt his throat was comfortable. There was slightly increasing of the secretion in the mouth. The atrophy of the tongue was further improved. His tongue coating was thin and yellow. The prescription was changed as follows: danggui (tangkuei), baizhu (ovate atractylodes root), chuanxiong (ligusticum root), etc. 3 dosages in total. (From Apr. 8 to Apr. 10)  

 

Date: Apr. 11, 2009                                      Time: 16: 00 p. m.

His condition was stable. The secretion in the mouth was in moderate amount. He didn¡¯t feel mouth dry. His diet and sleep were good. But he felt the chewing strength lessened in the recent week and there was slight muscular jumping of the eye sockets. The prescription was changed as follows: danggui (tangkuei), chenpi (tangerine peel), ciwujia (manyprickle acathopanax root), etc. 3 dosages in total. (From Apr. 12 to Apr. 14)

 

Date: Apr. 14, 2009                                      Time: 16: 00 p. m.

His condition was stable. There was no improvement of his speaking. He felt slight headache for one day. There was still slight muscular jumping of the eye sockets. The prescription was changed as follows: danggui (tangkuei), chenpi (tangerine peel), dangshen (codonopsis root), etc. 3 dosages in total. (From Apr. 15 to Apr. 17)

 

Date: Apr. 17, 2009                                      Time: 12: 00 a. m.

His condition was generally good. There was no difficulty in swallowing. His pronunciation was better than before. He didn¡¯t feel headache and slight muscular jumping of the eye sockets. The prescription was changed as follows: pangdahai (sterculia), chenpi (tangerine peel), baizhu (ovate atractylodes root), etc. 3 dosages in total. (From Apr. 18 to Apr. 20)

 

Date: Apr. 20, 2009                                      Time: 17: 00 p. m.

His condition was generally good. There was no difficulty in swallowing. Compared with before, his pronunciation was better. There was slight muscular jumping of the eye sockets. The secretion in the mouth was increasing. He felt his throat was sticky. The prescription was changed as follows: danggui (tangkuei), tianma (gastrodia), pangdahai (sterculia), etc. 1 dosage in total. (Apr. 21)

 

Date: Apr. 21, 2009                                       Time: 9: 00 a. m.

The patient had the difficulty in speaking. He could speak simple words and the pronunciation was not clear. Besides, there was slight difficulty in swallowing. He was easy to cough up when drinking. His spirit was not good. He had the problem of the flexibility of the tongue. His tongue was tender with cracks in the middle of the tongue. He had rough and trembling tongue. His tongue coating was pale yellow and slightly slimy. His pulse was thready and weak. So the treatment strategy was to boost qi, enrich yin, dispel phlegm and extinguish wind. The prescription was changed as follows: faxia (pro formula pinellia), gouqi (lycium berry), danshen (salvia root), etc. 5 dosages in total. (From Apr. 22 to Apr. 26)

 

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