Name: Ribka                                                                                                       Sex: Female

Age: 36                                                                                                               Marital Status: Married

Nationality: Dutch                                                                                               Date of Admission: Jan. 2, 2011

Companion: Family

First Medical Record

Date: Jan. 2, 2011                                Time: 15:00 pm

This 36-year-old lady had suffered from weak and heavy limbs for 2 years, accompanied by difficult walking and muscle jumpings all over her whole general body. The patient was hospitalized in our hospital for TCM treatment at 15 pm on January 2, 2011.

Essential for Diagnosis:

1. The patient had been suffering from weak and heavy limbs for 2 years, accompanied by difficult walking and muscle jumpings all over her whole general body.

2. The patient complained of weak lower limbs and difficult walking after childbirth in February of 2009, and later developed into weakness of her upper limbs. On October 10, 2010, her condition was diagnosed as ALS in her local hospital, while she did not take any treatment for that.

3. When the patient hospitalized in our hospital, she had weak four limbs and had difficulty to raise her lower limbs. She could not walk by herself and when she walked, she should be under the help of a walker. It was also difficult for her to stand up. There were pains over her knees and spontaneous spasms over her lower limbs. Fingers of both hands could not stretch straight. Fingers also were weak, but the weak problem did not affect her daily activities at present. She felt a sense of stiffness and heaviness over her whole general body. There were also muscle jumpings over her whole general body and being severe during the night. Sleep in the night was good, but it was difficult for her to turn over her body. Appetite was good. She did not feel dry in her mouth and she liked hot drinking. Urination was good. She suffered occasional constipation. During her menstruation, she suffered occasional abdominal pains.

4. T: 36.2¡ãC   R: 20 times/minute    P: 80 times/minute   BP: 120/80 mmHg

5. She had a chronic diseased facial complexion, with a skinny body. Her spirit activities were normal. The formation and size of the thorax were normal. The breathing sounds of the lungs were clear, with no pathological murmurs. The heart rate was regular.

6. The movement of her four limbs was ok. Bending of both acrotarsiums was not good. There were pains over the joints of her knees. She did not suffer weight loss. Her tongue was slightly red with white and greasy tongue coating. Her pulse was deep and thready.

Diagnostic Basis:

TCM: The patient had been suffering from heavy and weak four limbs for 2 years since her childbirth. She had a sensation of chill. Her tongue was slightly red with white and greasy tongue coating. Therefore, the abovementioned conditions were due to cold and dampness obstructing the channels. Because of deficiency of qi and blood after child birth and improper nourishment of liver and kidneys, her general body presented stiffness. Muscle jumpings over her body were caused by wind-producing due to blood vacuity. From the principle of TCM, vacuity of blood and qi, improper nourishment of liver and kidneys as well as cold-damp obstructing the channels were the characters of atrophy disease.

Western Medicine: The patient¡¯s four limbs were heavy and weak for 2 year. She also suffered muscle jumpings. Meanwhile, according to examination results from the local hospital of her country, she should have suffered from ALS.

Diagnostic Differentiation:

TCM: Atrophy diseases are usually differentiated with Bi syndrome or impediment pattern. Atrophy diseases have such characteristics as atrophy of the limbs¡¯ muscles, the weakness of the limbs and the uselessness of the thin feet. The muscular atrophy and muscle jumpings 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 jumpings. But ALS is caused by lesions of the central nervous system, accompanied by muscular atrophy and muscle jumpings. Therefore, there is no difficulty to differentiate them.

First Diagnosis:

TCM: atrophy disease

Symptom identification: vacuity of blood and qi, improper nourishment of liver and kidneys as well as cold and dampness obstructing the channels.

Western medicine diagnosis: ALS

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢ò care.

3. Companion.

4. Diet with low fat and high protein.

5. Pathogenesis: vacuity of blood and qi, improper nourishment of liver and kidneys as well as cold-damp obstructing the channels.

6. TCM strategy: supplement qi and nourish blood, supplement the liver and kidneys as well as warm yang to dispel dampness and open the channels.

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: Jan. 3, 2011                                          Time: 10:00 am

Professor Yang, paid a visit to the patient. The patient complained of heavy and weak four limbs for 2 years. Her condition was diagnosed as ALS at local hospital of her country. At present, her four limbs were weak. It was difficult for her to raise her lower limbs, to stand up as well as to walk by herself, if not with the help of a walker. There were pains over her both knees and occasional spams on her lower limbs. Fingers of both hands could not stretch straight. Fingers also were weak, but did not affect her daily activities at present. She felt a sense of stiffness and heaviness over her whole general body. There were also muscle jumpings over her whole general body and severe during the night. Sleep in the night was good, but it was difficult for her to turn over her body. Appetite was good. She did not feel dry in her mouth and she liked hot drinking. Urination was good. She suffered occasional constipation. Her tongue was slightly red with white and greasy tongue coating. Her pulse was deep and thready. Professor Yang thought from the TCM principle that the patient¡¯s conditions were due to vacuity of blood and qi, improper nourishment of liver and kidneys as well as cold-damp obstructing the channels. He suffered from atrophy diseases. The TCM formula should have the functions of supplementing qi and nourishing blood, supplementing the liver and kidneys as well as warming yang to dispel dampness and quicken the channels.

Date: Jan. 4, 2011                                          Time: 10:00 am

Feedback of examinations: Blood routine, urine routine as well as the functions of the liver and kidneys were normal. ECG: sinus arrhythmia.

Date: Jan. 6, 2011                                           Time: 10:00 am

The patient said muscles of the back of her shin were stiff, tense and jumping. Other conditions were of no evident development. Last night, she began her menstruation, and she had a little bit vomiting sensation. But now, there was no such kind of symptom. Her tongue was slightly red with white tongue coating. Her pulse was sunken and thready.

Date: Jan. 11, 2011                                           Time: 10:00am

The patient said stiffness of muscles of her shins was reduced. Her lower limbs were powerful than before. Muscle jumpings were reduced. On January 7, menses stopped. She did not suffer breast pains and waist pains during the menstruation. Her pulse was thready. Her tongue was slightly red with thin and white tongue coating.

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

After more than 10 days TCM treatment in our hospital, the patient felt her spiritual activities were better than before. Strength of her body was increasing. Stiff sense of the muscles was reduced. At present, her lower limbs were weak and heavy. There were muscle jumpings over her body. Balance was better. She could walk by herself without the walker for more than 10 steps. Her tongue was slightly red with thin tongue coating. Her pulse was weak.

Date: Jan. 21, 2011                                          Time: 10:00 am

The patient felt her hands still weak. There was numb sense on her finger tips. Both knees were weak. It was difficult for her to stand up if without any other help. There were muscle jumpings over her general body, sometimes more and sometimes less. The above mentioned symptoms were much better than before. Her tongue was slightly red with thin and white tongue coating. Her pulse was slight stronger.

Date: Jan. 26, 2011                                          Time: 10:00 am

The patient said stiff sense on the front part of her legs was reduced somewhat, but the back part was still stiff. Muscle jumpings were reduced, and at present, muscle jumpings mainly happened over her elbows and the knee joints. Strength of her arms was increasing, while her hands were weaker than before. Her knees were still powerless and she could not stand up by herself. She slept well at night. Urination and bowel movement were normal. Appetite was good. Her tongue was slightly red with white tongue coating. Her pulse was slight weak.

Date: Feb. 1, 2011                                           Time: 10:00 am

The patient complained more muscle jumpings during the night of January 30. But now it was the same as days before. Muscle jumpings still mainly happened over her elbows and knee joints. Her tongue was slightly red with whit tongue coating. Her pulse was slight weak.

Date: Fed. 6, 2011                                           Time: 10:00 am

Muscle jumpings over her arms were reduced somewhat. Her lower limbs and knee joints were still weak. She could not stand up by herself. Heavy sense of her general body was reduced. Body movement was more flexible than before. Menses started on Feb. 2 and stopped on Feb. 5. The quantity was still poor with dark color discharge.

Date: Feb. 11, 2011                                         Time: 10:00 am

The patient said strength of her upper limbs was increasing a little bit. She could do exercise for a little longer time and she did not feel tired. Strength of her lower limbs was also increased. There was no evident improvement in muscle jumpings. Her tongue was slightly red with white tongue coating. Her pulse was slightly weak.

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

The patient complained of severe pains over the joints of her limbs without any cause at the night of Feb. 13. Professor Yang gave her the medicine of Piaoyan Pain for oral use, and now the pains almost dispelled. In the morning of today, she felt heavy and weak lower limbs. Muscle jumpings were reduced a little bit. Her tongue was slightly red with white and slightly thick tongue coating. Her pulse was weak.

Date: Feb. 21, 2011                                            Time: 10:00 am

The patient complained of chest depression and burning sense in her gastric cavity. Other conditions were stable. Her tongue was slightly red with white and slightly thick tongue coating. Her pulse was weak.

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

Muscle jumpings did not change much. Heavy sense of both legs still existed.

Date: Feb. 26, 2011                                            Time: 10:00 am

The patient said chest depression and gastric discomfort disappeared. She still felt weakness and heaviness over her lower limbs. There were cramps over her ankles. Last night, muscle jumpings were a little bit more. Her tongue was slightly red with white and slightly thick tongue coating. Her pulse was weak.

Date: Mar. 1, 2011                                            Time: 10:00 am

There was no evident improvement in her conditions.

Date: Mar. 6, 2011                                            Time: 10:00 am

The patient complained of chest depression again and these days her appetite was not good. Muscle jumpings were less. Muscle jumpings over her shoulders and shoulder blades were obvious. Her tongue was slightly red with white and slightly thick tongue coating. Her pulse was weak.  

Date: Mar. 11, 2011                                            Time: 10:00 am

Appetite and sleep were good these days. Urination and bowel movement were normal. Muscle jumpings were less. Her lower limbs were still weak. She would feel pains over her knee joints after a little bit longer walking. Her tongue was slightly red with white and slightly thick tongue coating. Her pulse was weak. 

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

After more than 2 months TCM treatment, the patient requested to leave hospital today. After treatment in our hospital, the patient¡¯s conditions were much better than before. Muscle jumpings over her whole general body were under effective control now. Strength of her lower limbs was increasing. She now could walk for a short distance even without the help of the walker. Her lower limbs were still weak. Strength of her right hand increased somewhat, while her left hand did not improve evidently. Stiffness and heaviness were reduced. Her four limbs were warmer than before. Appetite and sleep were good. Urination and bowel movement were normal. Her spirit was good. Her tongue was slightly red with thin and white tongue coating. Her pulse was slightly weak.

Doctor¡¯s advice after leaving hospital:

1. Maintain good moods.

2. Take 90 days herbal medicine back for continuing treatment.

3. Avoid wind-cold and be careful with the cold.