Name: Ramzi                                                                                                         Sex: Male

Age: 47                                                                                                                 Marital Status: Married

Nationality: Lebanese                                                                                           Date of Admission: Dec. 27, 2011

Companion: Wife

First Medical Record

Date: Dec. 25, 2011                                Time: 12:00 am

This 47-year-old gentleman had been suffering from weakness of the four limbs for one and a half years. His conditions became worse, and then developed into a dysfunctional problem of his upper limbs. The patient was hospitalized in our hospital for TCM treatment at 11:00 am on December 27, 2011.

Essential for Diagnosis:

1. The patient had been suffering from weakness of the four limbs for one and a half years. His conditions became worse, and then developed into a dysfunctional problem of his upper limbs.

2. The patient had complained of weakness of his right fingers without any cause, one and a half years ago, and then his arms and left hand became weak also, accompanied by muscle atrophy and muscle jumpings. His condition was diagnosed as ALS, a kind of motor neuron disease according to the results of a MRI examination at a local hospital. He used to take Rilutek, but the therapeutic effect was not so perfect, so 3 months ago, he stopped taking this medicine. Around four months ago, weakness appeared in his lower limbs, with walking difficulty, especially over the right lower limb. About 2 months ago, his speech became unclear with limited motion of his tongue body. He lost weight about 5kg since he suffered from this disease. 

3. When the patient was hospitalized in our hospital, he suffered from weak limbs and muscle atrophy over his whole general body, especially on his upper limbs. Muscle jumpings appeared over his whole body. It was difficult for him to raise or rotate his upper limbs. His fingers could not extend fully. His two lower limbs were weak, with a walking problem. He could only walk around 500 meters, and was easy to be fatigued. He walked in a pigeon-toed gesture, with stiff and heavy legs and occasional spasms. Speech was not clear or fluent. Swallowing was ok. The motion of his tongue body was not good. He also had shortness of breath and a dry taste in his mouth. It was difficult for him to open his eyes even after being awake about ten minutes. He had sweating on his head, hands and feet. His four limbs were cold. Urination and stool were normal. He had night urination of about 1 to 2 times. His tongue was red with yellow and greasy tongue coating. There were cracks on the surface of his tongue. His pulse was sunken and weak.

4. T: 36.4¡ãC   R: 20 times/minute    P: 73 times/minute   BP: 120/80mmHg

5. His spirit activity was good. The patient was of a chronic and sick complexion with painful expressions. He grew normally. His diet was of common nutrition.

6. Physical check: the patient¡¯s upper limbs were almost half-paralyzed with muscle atrophy. He had difficulty in raising and rotating his upper limbs. His fingers could not extend fully. There was muscle atrophy over his fingers muscles, supraspinatus as well as the muscles of hypothenar and thenar. It was difficult for him to bend his elbows. His pulse was sunken and weak. His heart rate was 73 times per minute, with no murmurs. His tongue was red with yellow and greasy tongue coating. There were cracks on the surface of his tongue.

7. MRI check on October, 2010 presented the examination result of ALS.

Diagnostic Basis:

TCM: The patient was now 47 years old. The period of this age is easy to be attacked by this kind of disease and the disease starts gradually with a long duration. Therefore, the qi and blood are easy to be damaged. The spleen is in charge of the muscles and four limbs, and due to the deficiency of the spleen, the patient suffered from weakness over his general body, with walking difficulty. In TCM, qi is the captain of the blood, while the blood is the mother of qi. Qi vacuity can lead to blood vacuity. The muscles could not be nourished by blood due to the vacuity of blood; therefore, muscle atrophy appeared in the patient¡¯s body. His shortness of breath was due to qi vacuity of intestine and kidneys. Cold limbs were due to qi vacuity leading to the decrease in the function of warming the body. Muscle jumpings were due to the deficiency of the liver and kidneys. Dryness in the mouth, white and greasy tongue coating with cracks on it presented that there was internal heat. So, in consideration of the symptoms of tongue and pulse and from the principles of TCM, his conditions could be diagnosed as atrophy disease, due to qi vacuity and blood stasis, deficiency of the liver and kidneys as well as stagnation of internal heat.

Western Medicine: First, he was at the age of easily being attacked by such kind of disease. Secondly, the patient suffered from muscle atrophy, muscle jumpings and weakness over his whole general body. Thirdly, the result of his MRI examination pointed out that he was attacked by ALS.

First Diagnosis:

TCM: atrophy disease

Symptom identification: qi vacuity and blood stasis, deficiency of livers and kidneys as well as stagnation of internal heat.

Western medicine diagnosis: ALS

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢ò care.

3. Companion.

4. Common diet.

5. Pathogenesis: qi vacuity and blood stasis, deficiency of the liver and kidneys as well as stagnation of internal heat.

6. TCM strategy: increasing qi and nourishing the blood, coursing channels and network channels, nourishing the liver and kidneys as well as nourishing yin and clearing internal heat.

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: Dec. 29, 2011                                         Time: 9:00 am

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

The patient said there was no big change in his conditions.  

Date: Dec. 30, 2011                                         Time: 16:00 am

 Feedbacks of examinations: Blood routine and the functions of livers and kidneys were normal.

Date: Dec. 31, 2011                                          Time: 9:00 am

Professor Zhang Xiukui paid a visit to the patient. He said his conditions changed a little for the better. The strength of his right upper limb increased slightly. The spasms over his lower limbs were better. Appetite was good, but sleep and spirit were not so perfect. Bowel movement was normal. He had 1 to 2 times of night urination. Other conditions were just as before. The tongue was red with yellow, greasy and slightly thick tongue coating. The pulse was sunken and weak.

Date: Jan. 4, 2011                                          Time: 9:00 am

The patient felt less muscle jumpings. There was some increase in the motion of his joints, but still occasional spasms during his night sleep. Sleep was not good. There were some improvement in shortness of breath, dryness in the mouth and sweating. The tongue was red with yellow, greasy and slightly thick tongue coating. The pulse was sunken and weak.

Date: Jan. 4, 2012                                           Time: 19:00 pm

Feedbacks of examinations: Stool and urine routines were normal.

Date: Jan. 7, 2012                                           Time: 9:00 pm

The patient said the strength of his whole body was increased. His walking balance was better. He could walk 600 to 700 meters long now. Muscle jumpings over his right upper limb and left lower limb reduced. Shortness of breath and dryness in his mouth were better. He suffered from lumbar pains. The tongue was red with yellow, greasy and slightly thick tongue coating. The pulse was sunken and weak.

Date: Jan.10, 2012                                            Time: 9:00 am

The patient said all his conditions were better, except for bad sleep due to the lower pillow and lumbar pains due to the hard mattress. He could now walk around 1000 meters without any help from others. The tongue was slightly purple with yellow, dry and greasy tongue coating. The pulse was sunken and weak.  

Date: Jan.13, 2012                                            Time: 9:00 am

The patient said pains on his back and backbone reduced. There were spasms over the left leg and the muscles of the left shoulder. The front part of his arms could rise higher than before. Sleep and spirit were not perfect.

Date: Jan.16, 2012                                             Time: 9:00 am

The patient said spasms were less. There was good improvement in his walking problem. Balance was better. The movement of lower limbs were still restrained and of weak. His spirit and appetite were good. Sleep was not good. The tongue was slightly red with yellow and greasy tongue coating. The pulse was sunken and weak.

Date: Jan. 20, 2012                                             Time: 9:00 am

His conditions were stable, except for pains on the back of his right foot, which might be due to a sprain when he did exercise. He has night urination of 2 times. Bowel movement was normal. The tongue was slightly red with yellow and greasy tongue coating. The pulse was sunken and weak.

Date: Jan. 24, 2012                                             Time: 9:00 am

The patient said his fatigue was reduced, but he suffered from severe back pains. The pulse was sunken and weak. The tongue coating was yellow and greasy. He had night urination of 2 times.  

Date: Jan. 28, 2012                                             Time: 9:00 am

The patient said his fatigue was reduced a lot. His sleep was good. He did not like drinking water. The pulse was sunken and weak. Spirit was good.  

Date: Jan. 31, 2012                                             Time: 9:00 am

The patient said that in the past three days the strength of his right limb was much improved. The urine was a little yellow.

Date: Feb. 3, 2012                                             Time: 9:00 am

The patient said spasms over his whole general body were much less than a week ago. He still felt weak. He experienced joint pains over the ring finger of his left hand. Walking problem also improved. Spirit and appetite were normal. Sleep changed better for around 6 hours each night. The tongue was red with thin and yellow tongue coating. The pulse was sunken and weak.

Date: Feb. 6, 2012                                             Time: 9:00 am

The patient complained of more muscle jumpings in the recent days, while spasms improved. Joint pains of the ring finger of his left hand still existed. He could not extend his fingers fully. Spirit and appetite were good. Other conditions were same as days before.

Date: Feb. 9, 2012                                             Time: 9:00 am

The patient complained of no special improvement in the weakness of his upper limbs in recent days. Muscle jumpings had increased. Spasms of the four limbs reduced a lot. Stiffness over the whole body and the back pains were better. There were pressing pains on his right shoulder. Appetite was good. Sleep was not so perfect, due to too much thought. He still had walking problem. There was no improvement in balance these days. Bowel movement and urination were normal. The tongue was red with thin and yellow tongue coating. The pulse was weak.

Date: Feb. 12, 2012                                             Time: 9:00 am

Ramzi complained of unstable conditions in the recent days. Muscle jumpings and spasms over his whole body were sometimes better, while sometimes worse. The movement of his fingers was better. The thumb, middle finger and little finger of his right hand could extend fully now. Pains over the ring finger of his left hand were almost dispelled. In the past two days, his walking was better, and balance improved. Appetite was good. Spirit was ok. Due to too much thought these days, he did get good sleep. The tongue was dark red with thin and yellow tongue coating. The pulse was weak and thready.

Date: Feb. 15, 2012                                             Time: 9:00 am

Ramzi¡¯s conditions improved greatly from before he came to our hospital. The patient decided to leave the hospital today. After TCM treatment in our hospital for 50 days, the strength of his lower limbs increased a little bit. The fingers of his hands could occasionally extend fully. Muscle jumpings and muscle spasms were reduced. Balance improved when he walked. He felt fatigue after walking for 2 hours. Stiffness and heaviness of his lower limbs were better. His speech now was clear. Shortness of breath was also better. He no longer felt dryness in his mouth. There were evident improvements in sweating over his palms and feet, cold limbs and lumbar pains. His spirit was ok. Appetite was normal. Sleep was not so good. Bowel movement and urination were normal. The tongue was red with thin and yellow tongue coating. The pulse was sunken and thready, but more powerful.

Doctor¡¯s advice after leaving hospital:

1. Avoid wind-cold, take care of cold, and maintain good moods.

2. Take herbal medicine back for continuing treatment.

3. Keep doing exercises on the limbs and the tongue body.