Name: Francisco                                                                                                Sex: Male

Age: 50                                                                                                              Marital Status: Married

Nationality: Mexican                                                                                          Date of Admission: Sep. 7, 2011

Companion: Alone

First Medical Record

Date: Sep. 7, 2011                                Time: 14:00 pm

Francisco, male, 50-year-old, has suffered from moving difficulty in the four limbs for 2 years and speech difficulty for 3 months. There was muscle atrophy of his whole body, especially of the two upper limbs, accompanying with muscle jumpings and muscle pains. The patient was hospitalized in our hospital for TCM treatment at 10:00 am on September 7, 2011.

Essential for Diagnosis:

1. The patient had suffered from moving difficulty in the four limbs for 2 years and speech difficulty for 3 months.

2. The patient had complained of weakness of his right upper limb, muscle jumpings and muscle pains without any obvious cause in September, 2009, and he did not pay too much attention to that. Till January, 2010, his condition became worse, accompanying with flesh-losing on both of the two upper limbs, and then he went to the local hospital for electromyography check showing no motor nerve damage. Combined with clinical symptoms, the final diagnosis of the local hospital was ALS. He had taken the medicine Rilutec and some other replenishers, but the effects were not so good. In recent years, his condition was becoming worse and worse, and eight months ago, the muscular atrophy was evident, accompanied by the limitation of motion. He could not even walk by himself, except with the help of wheelchair. 3 months ago, the motion of the tongue was not good, accompanied by slow tempo, unclear speech and bad deglutition. There was not too much change in his physical conditions.

3. When the patient hospitalized in our hospital, there were limitation of motion of his four limbs, weakness of the two upper limbs and difficulty in raising his hand, especially the right one. He could not even walk by himself, and even though with help of our hospital staff, he only walked forward for about 1 meter. There were muscle jumpings and muscular atrophy over the whole body, especially on the upper limbs. His lower limbs were trembling, heavy and stiff when he was walking. Easy to be tired. He had short breath and hard breathing. He liked to drink cold water and felt dry in the mouth and over the throat. There were other conditions such as speech difficulty, choking when drinking water, abdominal distension, night sweating, and the purple color of the four limbs ends with edema. His stool was dry. His urination was normal, and he had night urination 2-3 times.

4. T: 36.5¡ăC   R: 20 times/minute    P: 80 times/minute   BP: 120/70mmHg

5. He grows with normal development. He had conscious mind and natural facial expression. He cooperated with doctors when did the physical examination. He had passive physique, and he almost could not walk by himself.

6. His tongue-coating was red but thin. The pulse was powerless.

Diagnostic Basis:

TCM: The TCM diagnostic basis was damp-heat staying in the channels and joint points, qi vacuity, blood stasis and deficiency of liver and lungs. The patient felt weakness of the four limbs, accompanied by difficulty in raising his two upper limbs. Difficult breathing and fatigue were due to qi deficiency. He suffered from qi vacuity for a long time, so there was blood stasis, and bluish discolorations of the skin showed on the two lower limbs end. Pitting edema over the two legs pertained to the character of blood stasis. Dry taste feeling in the mouth and throat, preferring to cold drinking, heavy sense of the lower limbs, dry stools and yellow urine were the symptoms of body heat and dampness.

TCM: Atrophy diseases are usually differentiated with Bi syndrome or impediment pattern. Atrophy diseases have such characteristics as atrophy of muscles of the limbs, the weakness of the limbs and the uselessness of the thin feet. The muscular atrophy and muscle jumping are the main symptoms of atrophy diseases. The impediment patterns are reflected by the pains or tense pains on the body joints. So it is easy to differentiate them.

Western Medicine diagnosis: ALS should be differentiated with myasthenia gravis. Myasthenia gravis would be aggravated after exercises and it would be reduced after some rest. Almost no muscle atrophy and muscle jumping. But ALS is caused by lesions of the central nervous system, accompanied by muscular atrophy and muscle jumpings. Therefore, there was no difficulty to differentiate them.

First Diagnosis:

TCM: atrophy disease

Symptom identification: dampness and heat staying in the channels and joint points, qi vacuity and blood stasis, and deficiency of the livers and lungs.

Western medicine diagnosis: ALS

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢̣ care.

3. Companion.

4. Common diet.

5. Pathogenesis: dampness and heat staying in the channels and joint points, qi vacuity and blood stasis, and deficiency of the livers and lungs.

6. TCM strategy: removing heat and dispelling dampness, tonifying qi, invigorating the circulation of blood and eliminating blood stasis, smoothing the channels and vessels and nourishing the livers and lungs.

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

8. Acupuncture and massage: once a day

9. Have more medical examination if necessary.

Date: Sep. 7, 2011                                          Time: 10:00 am

Zhuming, doctor-in-charge, paid a visit to the patient. The patient complained of limitation of motion for 2 years and speech problem for 3 months. When hospitalized in our hospital, he suffered from the difficulty in moving his four limbs and in holding things by his two hands. He almost could not walk by himself with his two lower limbs, and even with the help of our hospital staff, he just walked forward for about 1 meter. When walking, he had trembling and heaviness of the body and stiffness of the lower limbs. He showed short breath after exercises. He also had difficult breath, fatiguability and dry taste in the throat. The movement of his tongue was not flexible. The tempo of his speech was very slow and his speech was ambiguous and weak. Swallowing was not so good, and sometimes he suffered from choking. He was weak all over his body, accompanied by the muscle atrophy and muscle jumpings over the body, especially of the two upper limbs. Bluish discolorations of the skin showed over the four limbs end. He felt dry in the mouth and liked cold drinking. He had other symptoms, such as night sweating, abdominal distension and general spirit. His appetite was good. One time of bowel movement every day. Urination was good. The color of urine was yellow. The tongue body with dark color was a little bit large. The tongue coating was yellow and slightly dry. The patient¡¯s pulse was wiry.

Dr. Ming thought from the TCM views that the patient¡¯s conditions were caused by damp-heat staying in the channels and joints, qi vacuity and blood stasis, malnutrition of muscles and vessels, and deficiency of the livers and lungs. So it was atrophy disease. TCM treatment was to select herbs that had the functions of removing heat and dispelling dampness, of tonifying qi, invigorating the circulation of blood and eliminating blood stasis, of smoothing the channels and vessels and of nourishing the livers and lungs.

Date: Sep. 8, 2011                                          Time: 10:00 am

There was no special change as to the patient¡¯s conditions. In consideration of the stiffness of his lower limbs, some changes were made on the formula.

Date: Sep. 12, 2011                                          Time: 10:00 am

The patient said there were less muscle jumpings and pains over the neck and shoulders. He felt much more relaxed than before. Spirit, sleep and appetite were good. Pitting edema over the two legs below the knee joints were still shown. Night urination had been reduced from at least 3 times per night to 1-2 times per night.

Date: Sep. 14, 2011                                          Time: 10:00 am

The patient said he could walk by himself for about 30 meters yesterday and felt easy to put his upper limbs up. The muscle jumping almost dispelled.

Date: Sep. 16, 2011                                           Time: 10:00 am

The patient felt better and was in good mood. Muscle jumpings had been reduced at least 90%. Edema over the lower limbs almost was gone. The skin-color of the feet gradually turned from purple to red. Dry taste in the mouth turned better. The patient could straighten both legs during the night sleep.

Date: Sep. 23, 2011                                          Time: 10:00 am

The patient felt better these days. The sense of distension on the tongue was reduced. Speech was much clearer than days before. The tongue was red and the tongue coating was yellow. The pulse was weak.   

Date: Sep. 26, 2011                                          Time: 9:00 am

The patient¡¯s conditions were stable these days. The tongue was red with thin tongue coating. The pulse was wiry.

Date: Sep. 30, 2011                                          Time: 9:00 am

The condition of the patient was stable. There was some increase in the strength of the upper limbs. There was still existing muscle jumpings. The movement of the shoulders was increasing. Edema of the lower legs almost dispelled with the skin-color turning from purple to red. There was distinct reduction of heaviness and stiffness of the lower limbs. The patient felt much relaxed when he walked. No more pains over the neck, shoulders and back. There were still pains over the sole of the feet, but better than before. He sweated a little bit. Spirit and appetite were good.

Date: Oct. 13, 2011                                          Time: 9:00 am

The patient said recently he achieved great improvement on his conditions. Now he could stand up by himself. There was distinct reduction of muscle jumpings. The power of the lower legs was increasing. No more special change on the speech. Swallowing was good with less choking. The tongue was red with yellow tongue coating. The pulse was wiry.  

Date: Oct. 21, 2011                                            Time: 9:00 am

Recently, the patient¡¯s conditions kept turning better. Saliva was reducing.

Date: Oct. 25, 2011                                            Time: 9:00 am

Muscle jumpings almost dispelled. And pains over the lower limbs and the sole of the feet also almost dispelled. The tongue was red with thin tongue coating. The pulse was wiry.

Date: Oct. 28, 2011                                            Time: 9:00 am

The patient kept taking a change for the better on his conditions. The tongue was red with thin tongue coating. The pulse was wiry.

Date: Oct. 31, 2011                                            Time: 10:00 am

The patient said there were no more pains over the body. The power of the lower limbs was increasing, and the heavy and stiff sense of the legs was turning better. It was much more relaxed for him to walk. Muscle jumpings on the upper limbs were reduced to less than 10%. There was no obvious change on the strength of the upper limbs. Fingers of two hands were weak and stiff. The back of the hands was of a little edema. Spirit and appetite were good. Night urination was normal. The tongue was red with yellow tongue coating. The pulse was wiry.

Date: Nov. 21, 2011                                            Time: 9:00 am

The patient complained of weakness and stiffness of the upper limbs and of swelling of the back of hands. Except that, all other conditions changed for the better. Spirit and appetite were good. Night urination was normal. The tongue was red with yellow tongue coating. The pulse was wiry.

Date: Nov. 21, 2011                                            Time: 9:00 am