Brief Summary:
On April
10, 2010, the patient Philipp from Russia who has suffered from
ALS
accompanied by
disfluency in speaking for 15 months, worsened by muscular
jumping and weakness in the body for 6 months
was hospitalized in
our hospital. He has achieved obvious improvement after 44 days
comprehensive TCM treatment with herbal tea, acupuncture and
massage in our hospital.
Record of
Hospitalization
Name:
Philipp Sex:
Male
Age:
35 Profession: Businessman
Nationality:
Russia Marital Status:
Married
Date of Admission:
April
10, 2010 Onset Season: Big Chill
Complainer:
The patient
himself Reliability: Reliable
Major complaint: He
has suffered from
disfluency in
speaking for 15 months, worsened by muscular jumping and
weakness in the body for 6 months.
Disease history: No
trigeminal neuritis. No history of hepatitis. No tuberculosis,
schist soma and other infectious diseases. No history of trauma
and surgery.
No allergic history
of medicines or food. No history of blood transfusion. The
history of preventive vaccination was unknown.
Personal history:
He was born in Russia and his living environment was good. No
addiction of wine drinking and smoking. His work was stressful.
He was moderate in temper. He has three children. His wife and
children are healthy.
Family history: His
families do not suffer from the similar disease.
First Medical
Record
Date: April 10,
2010 Time: 16:00 p.m.
Philipp, a
35-year-old male, has suffered from ALS
accompanied by
disfluency in speaking for 15 months, worsened by muscular
jumping and weakness in the body for 6 months. He
was hospitalized in
our hospital for treatment at 19:30 p.m. on April 10,
2010.
Essentials for
Diagnosis:
1. The patient has
suffered from ALS
accompanied by
disfluency in speaking for 15 months, worsened by muscular
jumping and weakness in the four limbs for 6 months.
2. In January 2009,
the patient began to feel the
disfluency in
speaking
without obvious reasons. He was diagnosed with ALS at a local
hospital in September 2009. Then he took some medicines（vitamin
C, etc.）and
injections for 5 months, but there were not good results.
Present symptoms:
Weak speaking was of short breath and slow speed. Colder the
weather was, worse his speaking was. He was easy to be hungry.
There were much phlegm and saliva. He had to eat food every 2 to
3 hours. The swallowing was good. Sometimes he got choking when
he drank water. Sleep was not bad, and the urination and bowel
movement were normal.
3. T 36.2℃，P
80 beats/minute, R 20 times/minute, BP 100/70 mmHg.
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
position and he was cooperative with clear mind. He looks thin.
5. The four limbs
were weak and lack of strength. There was muscular atrophy in
the thenar and hypothenar eminences, tiger’s mouth muscles,
fingers and forearms. The left hand was particularly weak. He
had difficulties in doing the buttons and could not hold up the
knife and fork, and write normally. His weight lost 5 kg in the
recent 3 months. The tongue body was red and the tongue coating
was yellow and thick. The activity of the tongue was not so
flexible.
6. The patient was
checked out with curvature of the spine (thoracic department)
and flat feet.
7. Assistant
examination: Not provided.
Diagnostic Basis:
TCM: The atrophy
and lack of flexibility of the tongue body led to the
difficulties in speaking. There was muscular atrophy in the four
limbs causing the weakness. They are due to lack of nourishment
of the sinews and network vessels. So he was diagnosed with
wilting pattern.
Western medicine:
The patient has suffered from
disfluency in
speaking for 15 months, worsened by muscular jumping and
weakness in the four limbs for 6 months.
There was of muscular atrophy in the upper limbs. With the test
result in the local hospital he was diagnosed with ALS.
Diagnostic
Differentiation:
TCM:
The patient's wilting pattern should be differentiated from
impediment syndrome. The characteristic of wilting syndrome are
powerless sinews and bones,
weakness in the body, there are no pains in the joints
generally. But the impediment syndrome mainly has pains in the
joints of the body. So they are not difficult to be
differentiated from each other.
Western Medicine: The patient's ALS should be
differentiated from all myasthenia gravis. Myasthenia gravis
usually is worse when the patient does the exercise and better
after having a rest; there is no muscular atrophy. Neither does
pseudo-hypertrophy. So they are not difficult to be
distinguished.
First Diagnosis:
TCM diagnosis:
wilting pattern
Pathogenesis:
vacuity of qi and yin, obstruction and stagnation of phlegm and
dampness
Rules of treatment:
boost qi and nourish yin, transform phlegm and diffuse the
lungs.
Western medicine
diagnosis: ALS
Plans for treatment
strategy and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade = 3 \*
ROMAN III care.
3. Under the care
of a companion.
4. High protein and
low fat
diet.
5. Rules of
treatment: boost qi and nourish yin, transform phlegm and
diffuse the lungs.
6. Herbal tea: Take
four dosages of the herbal tea, one dosage a day and drink
twice.
7. Acupuncture and
massage: once a day.
8. Have more
medical examinations if necessary.
Date: April 12,
2010 Time: 10:00 a.m.
The patient has
suffered from
disfluency in
speaking for 15 months, worsened by muscular jumping and
weakness in the four limbs for 6 months.
There was of muscular atrophy in the upper limbs. He was
diagnosed with ALS at a local hospital in September 2009. Then
he took some medicines（vitamin
C, etc.）and
injections of gene for 5 months, but there were not good
results. Present symptoms: Weak speaking was of short breath;
slow speed. Colder the weather was, worse his speaking was. He
was easy to be hungry. There were much phlegm and saliva. He had
to eat food every 2 to 3 hours. The swallowing was good.
Sometimes he got choking when he drank water. Sleep was not bad,
and the urination and bowel movement were normal. The tongue
body was red and the tongue coating was yellow and thick. The
activity of the tongue was not so flexible. The pulse of the
left hand was small and thready. The pulse of the right hand was
weak and thready. According to the tongue and pulse, his
condition was due to vacuity of qi and yin, obstruction and
stagnation of phlegm and dampness. So our treatment principle
was to boost qi and nourish yin, transform phlegm and diffuse
the lung. 4 dosages in total.
Date: April 13,
2010 Time: 16:00 p.m.
Routine examination
of blood (－),
urine (－),the
functions of the liver and kidneys were normal. The formula was
the same as the first one.
3 dosages in total.
Date: April 16,
2010 Time: 10:00 a.m.
The patient said
that the activity of the tongue was much flexible. Tulip was
added into the formula to strengthen the effects of transforming
the phlegm and diffusing the lungs. 5 dosages in total.
Date: April 21,
2010 Time: 10:00 a.m.
The patient's
condition was stable, but he felt the shortness of breath
sometimes. So astragalus was added to supplement central and
boost qi. 6 dosages in total.
Date: April 26,
2010 Time: 10:00 a.m.
The patient had to
return to his country to attend the neural medication test in
Moscow University. So he left the hospital at noon, he will back
to our hospital again within 3 weeks and continue the treatment
here.
Date: May 26,
2010 Time: 10:00 a.m.
The patient was
back from Russia today. Still there were difficulties in
speaking. When he talked long time, then he could not pronounce
properly. He got choking sometimes when he drank water. The
breathing was stable. He told us that he lost 2 kg of weight
during his stay at home. There was obvious muscular atrophy in
the forearms. The hands were weak. He had an expression of
chronic illness and fatigue. The tongue body was dark red and
the tongue coating was white. The pulse was thin and weak. His
condition was due to vacuity of qi and yin, stagnation of phlegm
and obstruction of the network vessels. Rules of treatment:
boost qi and nourish yin, transform phlegm and free the network
vessels. 5 dosages in total.
Date: June 1,
2010 Time: 10:00 a.m.
The patient felt
more powerful in speaking and pronunciation. The speaking speed
was faster than before. The other symptoms were the same as
before. So the treatment focused on speaking, pronunciation and
swallowing from today. The strategy was to enrich yin and
supplement qi, transform phlegm and help pronunciation. 5
dosages in total.
Date: June 6,
2010 Time: 10:00 a.m.
The patient's
condition was good. The herbal formula changed as to boost qi
and nourish yin. 5 dosages in total.
Date: June 11,
2010 Time: 10:00 a.m.
The patient's
condition was stable. The formula was the same as last one. 5
dosages in total.
Date: June 16,
2010 Time: 10:00 a.m.
The patient said
that the speaking and pronouncing were better. The activities of
the four limbs were relatively good. Sleep was good at night.
Urination and bowel movement were normal. The tongue body was
slightly red and the tongue coating was thin and yellow. The
pulse was thready. 5 dosages in total.
Date: June 21,
2010 Time: 10:00 a.m.
The patient's condition was stable and he had to take part in
the medical test in Moscow again. But he will back to our
hospital within one month and continue the treatment here.
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