Brief Summary:
On February 17, 2010, Vito from
USA, who suffered from ALS,
was
hospitalized in our hospital. He had the symptoms of
difficulties with speech and swallowing for 3 years, weakness in
the left hand, and stiffness of his neck, somnolence, and weight
loss obviously. After 88 days TCM treatment, he achieved
significant improvement, he could speak clearer than before, and
had obviously improvement with swallowing as well as his mental
condition, there was no cold sense of his limbs.
Record of Hospitalization
Name:
Vito
Sex: Male
Age:
47 Profession: Businessman
Nationality: USA Marital
Status: Married
Onset
Season:
Spring Equinox
Date of Admission: February 17,
2010
Complainer:
The patient himself Reliability: Reliable
Major
Complaint:
The patient has suffered from difficulties with speech and
swallowing for 3 years.
Present Illness:
3 years ago, the patient felt the difficulties with speech and
swallowing and his condition became worse and worse. He was
given MRI
examination in the local hospital and was diagnosed with ALS.
From then on, he was been offering Rilutek
tablets,
while there was no obvious improvement. And when he came here,
he had the symptoms of difficulties with speech and swallowing,
weakness of the left hand, obviously muscular jumping,
fatigue, and stiffness of the neck, much saliva in the mouth,
thick phlegm, cough sometimes and drowsiness. He had the cold
sense of the four limbs, and
obvious loss of weight.
He seldom walked. He had normal bowel movement and urination.
Disease History:
The patient was healthy before. No history of typhoid,
hepatitis, tuberculosis, malaria or other infectious diseases.
No allergic history of medicine or food. No operation or trauma
history. History of preventive vaccination provided was unclear.
Personal History:
He
was born in America. No contact history of schistosomiasis. No
addiction to special food. He was even-tempered. And his living
and working environment were fine.
Marital History:
He got married at the age of 25. He has 5 sons. All of them have
been healthy all the time.
Family History:
No
family history of the similar disease.
Physical Examination:
T 36.1℃，P
94
beats/minute, R 20
times/minute, BP 120/80 mmHg.
He grew normally
with common nourishment. His mind was clear. He had natural
expression, his motion was limited slightly. He was cooperative
in examination. There was no
xanthochromia of the skin all
over the body and sclera. No superficial
lymph-node enlargement. Bilateral pupils were round, equal in
size, and sensitive to light. He had normal size and shape of
the head and
the
five sense organs. No enlargement of both of his tonsils. He had
soft neck. Trachea was in the midline. No enlargement of the
thyroid gland.
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 94 times/minute. No
pathological murmurs on
auscultation. Abdomen touched flat and soft without tenderness
or rebounding tenderness. The liver and spleen were not
palpable. No pressing pains in renal region. There was obvious
muscular jumping in his four limbs. His tongue was
light-colored
with white tongue coating. His pulse was
slippery.
Assistant Examination:
MRI shows ALS
First
diagnosis:
TCM
diagnosis: Wilting syndrome
Symptom identification: Vacuity of the liver and kidneys,
phlegm-damp obstructing the network channels.
Western medicine diagnosis:
Amyotrophic Lateral Sclerosis (ALS)
First
Medical Record
February 17, 2010
The
patient, Vito, a 47-year-old male, has suffered from
difficulties with speech and swallowing for 3 years. He was
picked up by our staff at Zhijiang Airport, and arrived in our
TCM hospital for treatment at 13:00 p.m. on February 17,
2010.
Essentials for Diagnosis:
1. The patient has suffered from
difficulties with speech and swallowing for 3 years.
2.
The patient felt difficulties with speech and swallowing without
obvious
factors 3 years ago, and
his condition has been aggravated.
He was given MRI
examination in the local hospital and was diagnosed with ALS.
From then on, he was been offering Rilutek
tablets,
while there was no obvious improvement. And when he came here,
he had the symptoms of difficulties with speech and swallowing,
weakness of the left hand, obviously muscular jumping,
fatigue, and stiffness of the neck, much saliva in the mouth,
thick phlegm, cough sometimes and drowsiness. He had the cold
sense of the four limbs, and
obvious loss of weight.
He seldom walked. He had normal bowel movement and urination.
3.
T 36.1℃，P
94
beats/minute, R 20
times/minute, BP 120/80 mmHg.
4. He grew normally
with common nourishment. His mind was clear. He had natural
expression, his motion was limited slightly. He was cooperative
in examination.
5. 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 94 times/minute.
Heart beat was regular.
No pathological
murmurs on auscultation.
6. Obviously muscular jumping.
His tongue was
light-colored
with white tongue coating. His pulse was
slippery.
7. Assistant
Examination:
The
patient was diagnosed with ALS
by MRI examination in local hospital.
Diagnostic Basis:
TCM:
The patient has suffered from difficulties of speech and
swallowing for 3 years. Currently, the patient had difficulties
of speech and swallowing with the symptoms of weakness of the
left hand, obvious muscular jumping,
fatigue, stiffness of the neck, much saliva in the mouth, thick
phlegm, cough sometimes and drowsiness. He had the cold sense of
the four limbs, and
obvious loss of weight.
The
main symptom was weakness of the limbs,
so it was not
difficult to be diagnosed as wilting pattern.
Western medicine: 1. The patient has suffered from difficulties
of speech and swallowing for 3 years. 2.
Obviously muscular jumping of the whole body. 3. The
patient was diagnosed with ALS
by MRI examination in local hospital.
Diagnostic Differentiation:
TCM:
The patient's wilting pattern should be differentiated from
impediment pattern. Wilting pattern is characterized by wilting
the sinews and bones, weakness of the four limbs. Generally, it
is
irrelative with the 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
Myasthenia Gravis.
For the
Myasthenia Gravis patients, the condition would be worse after
exercise, improved after rest. It rarely occurred for muscular
atrophy patients, and there is no pseudohypertrophy. They could
be distinguished.
First
diagnosis:
TCM
diagnosis: Wilting syndrome
Symptom identification: Vacuity of the liver and kidneys,
phlegm-damp obstructing the network channels.
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. Low-fat,
high protein diet.
5. Herbal tea: (herbs need to be decocted with water) one dosage
a day and drink twice, 180ml per time.
6.
Acupuncture and massage: once a day.
7. Perfect examinations of
hospitalization.
Date:
February 18, 2010 Time:
9:00 a.m.
The
patient has suffered from difficulties with speech and
swallowing for 3 years. He felt difficulties with speech and
swallowing without obvious
factors 3 years ago, and
his condition has been aggravated.
He was given MRI
examination in the local hospital and was diagnosed with ALS.
From then on, he was been offering Rilutek
tablets,
while there was no obvious improvement. And when he came here,
he had the symptoms of difficulties with speech and swallowing,
weakness of the left hand, obviously muscular jumping,
fatigue, and stiffness of the neck, much saliva in the mouth,
thick phlegm, cough sometimes and drowsiness. He had the cold
sense of the four limbs, and
obvious loss of weight.
He seldom walked. He had normal bowel movement and urination.
His tongue
was
light-colored
with white tongue coating. His pulse was
slippery.
According to the signs of the tongue and pulse, Dr. Yang
diagnosed the patient as wilting pattern which is caused by
spleen-kidney vacuity, phlegm damp obstructing the network
channels.
The treatment for him is to fortify the spleen and boost the
kidneys, transform phlegm and free the network channels.
Doctor’s requirement is to take five dosages of herbal tea of
the same formula. One dosage a day and drink twice. Acupuncture
and massage for once a day.
Date:
February 19, 2010 Time:
10:00 a.m.
Examination: Blood
R (-)，Urine
R (-),
hepatic/renal function (-)
Date:
February 22, 2010 Time:
10:00 a.m.
The patient felt a
little improvement with speech and swallowing, but there was
much saliva in the mouth, cough sometimes. The prescription was
changed a little. 6 dosages in total.
Date:
February 28, 2010 Time:
9:00 a.m.
The patient’s
condition was stable.
The
symptoms of the patient were improved.
So the prescription
was the same as the one on
February 22. 5 dosages in total.
Date:
March 5, 2010 Time: 9:00
a.m.
Recently, the
weather changes very obviously. The patient felt very tired, and
sleeping was not so good. The
muscular jumping was obvious. The prescription was changed. 5
dosages in all.
Date:
March 10, 2010 Time:
9:00 a.m.
The
spirit of the patient was good. The sleeping and
appetite
were good, too. The feeling of
fatigue was improved obviously. But there was still much saliva.
The prescription was changed a little. 5 dosages in total.
Date:
March 15, 2010 Time:
9:00 a.m.
The condition of
the patient was stable, the sleeping and appetite were good.
The
patient’s bowel movement and urination were normal. There was
more saliva. The prescription was changed a little. 5 dosages in
total.
Date:
March 20, 2010 Time:
9:00 a.m.
The patient said
the sleeping of last night was not good, he felt
difficult to fall asleep.
There was much saliva in the mouth. Sometimes, the patient
coughed as
laryngeal itching. The treatment for him is mainly to fortify
the spleen and boost qi, dry dampness, transform phlegm and free
the network vessels. The prescription was changed. 5 dosages in
total.
Date:
March 25, 2010 Time:
9:00 a.m.
The patient had
good sleeping. But there was much saliva in the mouth,
his
speech was still unclear. The prescription was changed. 6
dosages in total.
Date:
March 31, 2010 Time:
9:00 a.m.
The patient said
that there was still much saliva in the mouth which influenced
his speech. His sleeping and appetite were good. His
bowel movement and urination were normal. The prescription was
changed. 5 dosages in total.
Date:
April 5, 2010 Time: 9:00
a.m.
The patient said
that the saliva in the mouth had reduced. His speech has been
improved. The other symptoms were good. The prescription was not
changed. 5 dosages in total.
Date:
April 8, 2010 Time: 9:00
a.m.
The patient had
watery diarrhea, 4-5 times a day. The prescription was changed a
little. 2 dosages in total.
Date:
April 10, 2010 Time:
9:00 a.m.
The condition of
the patient was stable. No
diarrhea. The prescription was the same with the one on March
31. 5 dosages in total.
Date:
April 15, 2010 Time:
8:40 a.m.
The patient felt
good in sleeping and appetite. The
bowel movement and urination were normal. The symptom of
swallowing was improved. He complained much
saliva which was
much less than before. The prescription was the same with
before. 5 dosages in total.
Date:
April 20, 2010 Time:
8:30 a.m.
The patient felt
good in sleeping. He slept 7 hours last night. His appetite was
good. The
bowel movement and urination were normal. His speech and
swallowing were improving. The prescription was the same. 5
dosages in total.
Date:
April 25, 2010 Time:
8:30 a.m.
Because of
having a cold yesterday, the patient had cough, nasal discharge,
felt tired. He had slightly reddish tongue body, thin tongue
coating, thin pulse body like thread. The prescription was
adjusted accordingly. 5 dosages in total.
Date:
April 30, 2010 Time:
8:40 a.m.
The condition of
the patient was good. There were no cough,
nasal discharge, headache and body aches. His sleeping and
appetite were good. His speech was much clearer. His
saliva was less. He
had cough when he was in the diet sometimes.
He
had slightly reddish tongue body, thin tongue coating, and
powerful pulse. The prescription was the same with the one on
March 31. 5 dosages in total.
Date:
May 5, 2010 Time: 8:50
a.m.
The patient said
everything was normal. His speech and swallowing have improved a
lot.
He
had slightly reddish tongue body, thin tongue coating, and
powerful pulse. The prescription was the same with last time. 5
dosages in total.
Date:
May 10, 2010 Time: 8:40
a.m.
The condition of
the patient was stable. His sleeping and appetite were good. His
bowel movement and urination were normal. His tongue body was
slightly reddish, his tongue coating was white, and he had
string-like pulse. The prescription was the same.
Date:
May 15, 2010 Time: 8:00
a.m.
The patient decided to leave the hospital tomorrow.
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