Brief Summary: On Feb. 06, 2015, Demberel, came from Mangolia, who suffered from ALS. He had the following symptoms such as weakness, muscle atrophy and difficult breathing. And he got trachea intubation for 5 months. He was hospitalized in our hospital. He achieved significant improvement after 29 days TCM treatment.

 

Record of Hospitalization

Name: Demberel                                               Sex: Male

Age: 36                                                            Marital Status: Married

Nationality: Mangolia                                    Date of Admission: Fe. 06, 2015

Companion: his wife

 

First Medical Record

Date: Feb. 06, 2015                                Time: 11:00 am

This 36-year-old man had suffered from ALS, accompanied with weakness, muscle atrophy and difficult breathing. And he got trachea intubation for 5 months. The patient was hospitalized in our hospital for TCM treatment at 11:00 pm on Feb. 06, 2015.

 

Essential for Diagnosis:

1. The patient felt weak in 2011, and in 2012 he had obvious symptoms. And the patient felt the weakness was serious. And he had loss of weight, from 78kg down to 63kg. He had difficult breathing and shortness of breath. His four limbs were weak, especially the upper limbs. He had pains over his right rib because of siting for a long time. He had sweating on his head. The sweating was serious at night. He had muscle jumpings. He felt thirsty at night. He had insomnia. He just slept 2 to 3 hours a day. The patient took our treatment for 3 months at home, his condition was improved. In order to get better effect, the patient came to our hospital for comprehensive treatment.

2. When the patient was hospitalized in our hospital, he was a little thin, and he felt tired, accompanied with difficult breathing and shortness of breath. He got trachea intubation. His respiration is 30 to 40 times a minute. His four limbs were weak, and his upper limbs were obviously weak. He had pains over his right rib because of siting for a long time. He had sweating on his head, and the sweating was serious at night. He had muscle jumpings. He felt thisrty at night. He had insomnia, and he just slept 2 to 3 hours a day.

3. T: 36.5°C   R: 36 times/minute    P: 79 times/minute   BP: 130/80 mmHg

4. His spirit status was normal. He cooperated with doctors when the physical examinations were made. He was a little thin and had difficult walking. There was no yellow skin or yellow sclera over his whole body. There was no enlargement over his superficial lymph node. The pupils were round and approximately equal in size. The pupillary reaction to light was sensitive. His ears were normal without discharge. And his head and the five sense organs were normal. His hearing was normal. The bilateral mastoid had no pressing pains. His nose was normal. There were no stuffy nose and discharge. His lips were blue jaundice. There were no congestion in his throat and no enlargement over his tonsil. His neck was soft with no resistance. There was no distention of jugular vein. And the thyroid was normal. His trachea was symmetrical, yet he got trachea intubation. His chest was also symmetrical. The muscles were thinner without varicosity. Sound of breathing in the lungs was not clear, while without any rhonchi. The interatrial septum was narrow. Rhythm of his heart was 79 times per minute. Heart rate was regular with no murmurs. The patient had scaphoid abdomen with no pressing pains and rebound tenderness. The four limbs had loss of power with muscle jumpings, especially his upper limbs. There was movement limitation over his upper limbs. The meningeal irritation was negative. There was no pathological reflections, but the physiological reflections existed. His tongue body was dark red. There was no coating on the tip of his tongue. The pulse was wiry and rapid.

4. The patient was diagnosed with ALS in South Korea hospital.

　

First Diagnosis:

TCM: 1. Atrophy disease

      2. Stasis of qi and stagnation of blood.

Western medicine diagnosis: ALS

 

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Ⅱ care.

3. Companion.

4. Diet with low fat and high protein.

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

6. Acupuncture and massage: once a day

7. Have more medical examination if necessary.

 

Date: Feb. 06, 2015                                Time: 12:00 am

Dr. Ming, doctor-in-charge, paid a visit to the patient this morning. When the patient hospitalized in our hospital, he was a little thin, and he felt weakness over his four limbs, especially his upper limbs, and accompanied with difficult breathing and shortness of breath. He had pains over his right rib because of siting for a long time. He had sweating on his head. The sweating was serious at night. He had muscle jumpings. He felt thirsty at night. He had insomnia, and he just slept 2 to 3 hours a day. His tongue body was dark red. There was no coating on the tip of his tongue. The pulse was wiry and rapid.

 

Date: Feb. 07, 2015                                Time: 10:00 am

The patient had shortness of breath, 36 times per minute. He needed the breathing machine to help his breathing. The doctor asked his wife to notice his phlegm. To keep his breathing smooth. 

　

Date: Feb. 08, 2015                                Time: 10:00 am

The patient said he still felt the shortness of breath. The doctor asked him to continue oxygen therapy with low concentration. Half an hour each time. He had too much phlegm in his throat, the doctor adjusted the formula for eliminating phlegm. 

　

Date: Feb. 11, 2015                                Time: 10:00 am

The patient said he felt thirsty. The shortness of breath was relieved, but it still was over 30 times per minute. The color of urine was slightly yellow. The pulse was deep and rapid.  

　

Date: Feb. 14, 2015                                Time: 10:00 am

The patient said the phlegm reduced. And his sleep was better, but dreaminess. His breathing rate was 27 times per minute. The muscle jumpings were worse. The doctor adjusted the formula. 

 

Date: Feb. 17, 2015                                Time: 10:00 am

The patient said the breath was shorter when he was lying. His sleep was not good. He felt tired. But his appetite was good. His face was pale. The pulse was deep and wiry. 

　

Date: Feb. 20, 2015                                Time: 10:00 am

The patient said the breathing was stable. His sleep and his appetite were better. And the muscle jumpings were improved. The pulse was deep and rapid. There was no much phlegm in his throat. 

　

Date: Feb. 24, 2015                                Time: 10:00 am

The patient felt the muscles over his upper limbs increased. His sleep and his appetite were good. And the vital signs of patient were stable. 

　

Date: Feb. 28 2015                                Time: 10:00 am

The breathing was stable, 24 times per minute. There was no sweating. But the patient said the muscle jumpings were frequent. The doctor adjusted the formula for focusing on his breathing and muscle jumpings. 

　

Date: Mar. 03, 2015                                Time: 10:00 am

The vital signs of the patient were stable. To continue the same formula.

　

 Date: Mar. 06, 2015                                Time: 10:00 am

The patient decided to leave our hospital today. His breathing was improved. And the muscles of his upper limbs increased. No sweating at night. And appetite and sleep were normal.

 

Doctor’s advice after leaving hospital:

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

2.      Keep doing exercises.

Take herbal medicine back for continuing treatment.