Brief Summary: On June 6, 2010, Susan from Australia, who has suffered from ALS, was hospitalized in our hospital. She has achieved obvious improvement after 13 days TCM treatment here.

 

                                                                 Record of Hospitalization

Name: Susan                                                                                 Birthplace: Australia

Sex: Female                                                                                   Profession: Businesswoman

Age: 56                                                                                          Date of Admission: June 6, 2010

Nationality: Australia                                                                     Date of Record: June 7, 2010

Marital Status: Married                                                                 Onset Season: Grain in ear

Complainer: The patient herself

　

Major complaint: She has had the weakness of her four limbs for 3 years, accompanied with muscular atrophy for 2 years.

Disease history: No history of hepatitis, trigeminal neuritis. No tuberculosis, schistosoma and other infectious diseases. No history of trauma and surgery. No allergic history of food or medicine. No history of blood transfusion. The history of preventive vaccination was unknown.

Personal history: She was born in Australia. No addiction of wine drinking. She does not smoke. She had menopause for three years and her living environment is not bad. She is moderate in temper.

Family history: Her parents do not suffer from the similar disease.

 

                                                                                                                                 First Medical Record

Date: June 7, 2010                                          Time: 11: 00 a. m.

Susan, a 56-year-old female, has suffered from weakness of her four limbs for 3 years, accompanied with muscular atrophy for 2 years. She was hospitalized in our hospital for treatment at 20: 00 p. m. on June 6, 2010.

 

Essentials for Diagnosis:

1. The patient has suffered from weakness of her four limbs for 3 years, accompanied with muscular atrophy for 2 years.

2. In 2006, the patient felt the weakness of her left hand without obvious reason. It gradually spread to her right hand and then to the four limbs. She was diagnosed with ALS at a local hospital. But she had not taken any treatment.

Her present symptoms were as follow: weakness of the four limbs, difficulty in raising the hands especially the right upper limb, slightly muscular jumping of the lower limbs, weak and slow walking, dropping sense of the legs. Speaking and swallowing were normal. Diet was proper. Good sleep at night. Urination and bowel movement were normal.

3.T 36.0≧, R 20 times/minute, P 80 times/minute, BP 140/80mmHg.

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

5. There was weakness of the four limbs, interphalangeal joint stiffness. The tongue body was dark with a thick tongue coating. The pulse was thin and like a thread. There were different degrees of atrophy in the muscles of the upper limb, the tiger's mouth of the hand, extensor pollicis, supraspinatus and biceps. The atrophy of the lower limbs was not obvious. The two legs were dropping especially the right leg. The back could not bend. 

Diagnostic Basis:

TCM: The patient's weakness of the four limbs and atrophy are due to improper supplement of the sinews and pulse. The symptoms accompanied with muscular jumping, dark tongue body and thin pulse. All these symptoms are due to yin vacuity of the liver and kidneys. So the patient was diagnosed as flaccid paralysis.

Western Medicine: The patient has felt the weakness of four limbs for 3 years, accompanied with muscular atrophy for 2 years. With the diagnosis of the local hospital, she was diagnosed with ALS.  

Diagnostic Differentiation:

TCM: The patient's flaccid paralysis should be differentiated from paralysis. Flaccid paralysis's main symptoms are flaccid of the sinews and bones, weakness of the limbs, generally without pains in the joints. But pains in the joints are the main symptoms of paralysis. So they are not difficult to be distinguished.

Western Medicine: The patient's ALS should be differentiated from all myasthenia gravis. ALS usually is worse when the patient does the exercise and the condition gets better when she relaxes. And the muscular atrophy and pseudo-hypertrophy do not appear usually. So they are not difficult to be distinguished.

 

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: flaccid paralysis

Symptom identification: yin vacuity of the liver and kidneys

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. Lower fat and high protein diet.

5. Herbal tea: enriching the liver and kidneys, soothing the sinew and freeing the network vessels

The main herbs as follows: bupleurum, bitter orange, etc.

Using the water to decoct it, four dosages in total, one dosage a day and drinking twice.

6. Acupuncture and massage once each day.

7. Do the exercises on the four limbs.

8. Perfect all the examinations.

 

Date: June 8, 2010                              Time: 11: 00 a. m.

The patient did not complain any special discomfort. The spirit and appetite were fine. The urination and bowel movement were normal. So the treating strategy was the same as before. 

　

Date: June 12, 2010                              Time: 10: 00 a. m.

The patient did not complain any special discomfort today.

　

Date: June 16, 2010                              Time: 10: 00 a. m.

The patient said that the condition of the upper limbs and stiffness of the interphalangeal joints got better than before. The muscular power of the lower limbs was stronger. The activity of the ankle was also better. Appetite was good. Good sleep at night. The tongue body was slightly red with a light white tongue coating. The pulse was thready.

　

Date: June 20, 2010                              Time: 10: 00 a. m.

Today the patient said that the activities of the upper limbs were improved obviously. She could raise and uplift the right hand better. Also, the stiffness of the interphalangeal joints got better than before. The muscular power of the lower limbs was stronger. The dropping sense of the legs was better. She asked to leave the hospital the next day. The doctor advised her to pay attention to diet, avoid wind-cold, keep in good mood.　

 

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