Records of Hospitalization
Name:
Jackie Sex:
Female
Age:
40 years
Profession:
Nationality:
Canada Marital
status:
Married
Onset
Season:
Summer
Date of Admission:
Oct. 31st, 2006
Complainer of history:
The patient herself
Reliability:
Reliable
Chief
complaint:
The patient has suffered from amyotrophy of right lower extremity for 2 years
with four-month aggravated condition evidenced by her walking lamely.
Present illness:
Two years ago the patient began to have amyotrophy and weakness of right lower
extremity without any obvious cause. Because of the problem of right lower
extremity, she broke her right ankle. She had an X-ray in a local hospital and
the result was fifth metatarsal fracture. Then she was diagnosed as ALS by MRI
and neurological examination. Though she had been treated in a local hospital,
she got little effect. And during the latest four months the amyotrophy of her
right lower extremity was aggravated, which is evidenced by her walking lamely.
So she came to our hospital for TCM treatment. Her tongue was reddish with thin
whitish coating, and her pulse was sunken and fine.
Past
history:
No history of typhoid, tuberculosis and hepatitis. No allergic history of
medicine and food. No operation history. No history of
preventive vaccination provided.
Personal history:
She was born in Canada, living in a dry environment. No contact history of
schistosomiasis. No addiction to smoke, alcohol or special food. And she was
even-tempered and optimistic.
Menstrual history:
Moderate and red menses without peculiar smell.
Marital history:
She was married at 23 and had given birth to
one son. Her husband and son were healthy all the time.
Family
history:
Her parents were both healthy. No history of special disease.
Physical examination
T 36.8℃，P
80bpm, R 20bpm, BP: 90/60mmHg
She was
mid-nourished and normally developed. Her mind was clear. She was in chronic
distress and has an expression of languidness. She was in a positive position
and cooperative in examination. Her skin was moist. No jaundice in the sclera.
No superficial lymph-node enlargement. Bilateral pupils were round and equal in
size and sensitive to light. No thoracic deformity. Sound of breath was
bilaterally normal on auscultation. No respiratory rales or pleural friction
rub. Heart border was normal. Heart beat 80/min. Cardiac rhythm was regular. No
pathological murmurs on auscultation.
Abdomen was flat and soft without tenderness or rebound tenderness. Liver and
spleen were not palpable. No percussion pain on renal region. Bowel sound was
normal. No Spinal and pelvic deformity or pain. No deformity or inflexibility of
left lower extremity or upper ones. The condition of right lower extremity would
be discussed in the next paragraph. The development of the anus and
pudendum was normal.
Right lower
extremity:
Amyotrophy was obvious in the special examination. The cross-section diameter of
the right thigh measured 12cm above the patella was 35cm, while that of the left
thigh was 40cm. Measured 22cm above the patella, the cross-section diameter of
the right thigh was 42cm, while that of the left thigh was 47cm. Measured around
12cm above the Juxu point, the cross-section diameter of the right leg was 29cm,
while that of the left was 32cm. She walked lamely with her right foot turning
outwards.
Diagnostic examination:
MRI showed ALS.
First
diagnosis:
TCM diagnosis:
Wei-syndrome (flaccidity syndrome)
Symptom
diagnosis: spleen asthenia leading to failure of transportation and
transformation and deficiency of qi and blood; liver and kidney asthenia leading
to insufficiency of yin essence and lack of proper nourishment of muscles.
WM diagnosis:
ALS
First
Medical Record
6:30p.m. Oct. 31st 2006
Jackie, a
40-year female, has suffered from amyotrophy of right lower extremity for 2
years with four-month aggravated condition evidenced by her walking lamely. She
was met by our translator in Zhijiang Airport and arrived in Huaihua Red Cross
Hospital at 5: 30p.m Oct. 31st 2006.
Essentials for diagnosis:
1. The patient
has suffered from amyotrophy of right lower extremity for 2 years with
four-month aggravated condition evidenced by her walking lamely.
2. Two years
ago the patient began to have amyotrophy and weakness of right lower extremity
without any obvious cause. Because of the problem of right lower extremity, she
broke her right ankle. She had an X-ray in a local hospital and the result was
fifth metatarsal fracture. Then she was diagnosed as ALS by MRI and neurological
examination. Though she had been treated in a local hospital, she got little
effect. And during the latest four months the amyotrophy of her right lower
extremity was aggravated, which is evidenced by her walking lamely. So she came
to our hospital for TCM treatment. Her tongue was reddish with thin whitish
coating, and her pulse was sunken and fine.
3. T 36.8℃，P
80bpm, R 20bpm, BP: 90/60mmHg
4. She was
mid-nourished and normally developed. Her mind was clear. She was in chronic
distress and has an expression of languidness. She was in a positive position
and cooperative in examination.
5. No thoracic
deformity. Sound of breath was bilaterally normal on auscultation. No
respiratory rales or pleural friction rub. Heart border was normal. Heart beat
80/min. Cardiac rhythm was regular.
No pathological murmurs on auscultation.
6. Amyotrophy
of her right lower extremity was obvious in the special examination. The
cross-section diameter of the right thigh measured 12cm above the patella was
35cm, while that of the left thigh was 40cm. Measured 22cm above the patella,
the cross-section diameter of the right thigh was 42cm, while that of the left
thigh was 47cm. Measured around 12cm above the Juxu point, the cross-section
diameter of the right leg was 29cm, while that of the left was 32cm. She walked
lamely with her right foot turning outwards.
7. MRI showed
ALS.
Diagnostic basis
TCM:
Wei-syndrome (flaccidity syndrome)
refers to the
flaccidity and weakness of extremities leading to less liberty in movement or
muscular atrophy. In clinics, amyotrophy and weakness of lower extremities are
eminent. The caused of the disease is complicated.
Wei-syndrome
is a condition when the muscles and meridians lacks nourishment due to damage of
the five internal organs, deficiency of essential body fluid, and depletion of
qi and blood, caused by pathogenic heat or virus infection, emotional
disturbance, irregular diet or overstrain, congenital insufficiency, indulgence
in sexual activities, injuries, exposure to neuro-poisonous drugs.
Western medicine:
Amyotrophy of her right lower extremity was obvious in the special examination.
The cross-section diameter of the right thigh measured 12cm above the patella
was 35cm, while that of the left thigh was 40cm. Measured 22cm above the
patella, the cross-section diameter of the right thigh was 42cm, while that of
the left thigh was 47cm. Measured 12cm above the Juxu point, the cross-section
diameter of the right leg was 29cm, while that of the left was 32cm. She walked
lamely with her right foot turning outwards. MRI showed ALS.
Diagnostic differentiation
TCM: Wei-syndrome
should be differentiated from Bi-syndrome. The advanced stage of Bi-syndrome is
characterized by the prolonged motor impairment due to joint pain, so patients
suffering from it may also have a subsequent muscular thinness. On the contrary,
patients suffering from Bi-syndrome generally have no joint pain. And the
pathogenesis and treatment of Wei-syndrome should also be distinguished from
those of Bi-syndrome.
WM: Wei-syndrome
should be differentiated from myasthenia gravis which can occur at any age and
strikes typically between ages 10 and 35. Women are more often affected than
men. The most obvious characteristic of MG is rapid fatigability of the skeletal
muscles affected, improved with rest in various degrees. The patient’s condition
fluctuates, relatively better in the morning and worse at dusk. The onset is all
of a sudden, often begun with a group of muscles, and as time goes on, the
disease progressively affects other groups. It is most common that the cranial
innervate muscles are often the first group of muscles to be affected evidenced
by the fact that about 90 percent of persons with MG have such initial symptoms
as drooping eyelids (ptosis) and double vision (diplopia). And the bulbar
muscles and girdle muscles are often the second group of muscles to be affected.
MG patients of different ages often have different clinical manifestations and
courses which are different from those of Wei-syndrome paients.
First
diagnosis:
TCM diagnosis:
Weizheng (flaccidity syndrome)
Symptom
diagnosis: spleen asthenia leading to failure of transportation and
transformation and deficiency of qi and blood; liver and kidney asthenia leading
to insufficiency of yin essence and lack of proper nourishment of muscles and
tendons.
WM diagnosis:
ALS
Plan
of treatment and care
1. On routine
care of traditional Chinese internal medicine
2. On grade II
care
3. Under care
of a companion
4.
High-protein diet
5. Herbal tea:
one dosage a day and drink by twice
6. Acupuncture
and massage: once a day
7. Have a
positive and optimistic attitude towards your disease
8. Functional
exercise for lower extremities: once a day
9. Have more
medical examinations if necessary
Date:
1st of December 2006
Time: 9:00 a.m.
When Dr. Yan
made the rounds of the wards, the patient told him that she had hypodynamia and
obvious amyotrophy of right lower extremity and difficulty in walking manifested
as walking lamely.
Examinations: T 36.8℃，P
80bpm, R 20bpm, BP: 90/60mmHg. Amyotrophy of her right lower extremity was
obvious in the special examination. The cross-section diameter of the right
thigh measured 12cm above the patella was 35cm, while that of the left thigh was
40cm. Measured 22cm above the patella, the cross-section diameter of the right
thigh was 42cm, while that of the left thigh was 47cm. Measured 12cm above the
Juxu point, the cross-section diameter of the right leg was 29cm, while that of
the left was 32cm. She walked lamely with her right foot turning outwards.
Dr. Yan’s
analysis:
1. The patient
has suffered from amyotrophy of right lower extremity for 2 years with
four-month aggravated condition manifested as walking lamely.
2. Amyotrophy
of her right lower extremity was obvious in the examination result.
3. The patient
had MRI and check of the vascular system in a local hospital which showed ALS.
4. According
to its manifestations, this disease falls into the category of
Wei-syndrome (flaccidity syndrome)
which
refers to the flaccidity and weakness of extremities leading to less liberty in
movement or muscular atrophy. In clinics, amyotrophy and weakness of lower
extremities are eminent. The caused of the disease is complicated.
Wei-syndrome
is a condition when the muscles and meridians lacks nourishment due to damage of
the five internal organs, deficiency of essential body fluid, and depletion of
qi and blood, caused by pathogenic heat or virus infection, emotional
disturbance, irregular diet or overstrain, congenital insufficiency, indulgence
in sexual activities, injuries, exposure to neuro-poisonous drugs.
5. Symptom
diagnosis: spleen asthenia leading to failure of transportation and
transformation and deficiency of qi and blood; liver and kidney asthenia leading
to insufficiency of yin essence and lack of proper nourishment of muscles and
tendons.
6. Principle
of TCM treatment: Strengthening the spleen and supplementing qi; Tonifying the
liver and nourishing yin essence. Herbal tea prescribed for three days included
cooked rehmannia, astragalus root, tangkuei, cornus, cimicifuga, deerhorn glue,
eucommia, cinnamon twig, tangerine peel, dipsacus root, achyranthes, jujube,
dioscorea, amomum, and so on. A daily dosage should be decocted twice.
7. Other
treatments or examinations: daily acupuncture and massage; daily dirigation;
have more medical examinations if necessary.
Date:
2nd of December 2006 Time:
9:00 a.m.
The patient
had hypodynamia and obvious amyotrophy of her right lower extremity and
difficulty in walking manifested as walking lamely. No nausea or vomit. No
aversion to cold. No fever, headache, or dizziness. Her spirit, appetite and
sleep were normal. Her bowel movement and urination were normal. Her heart and
lungs were normal. Her abdomen was flat. Her tongue was reddish with thin and
whitish coating. Her pulse was deep and fine.
Date:
3rd of December 2006
Time: 9:00 a.m.
The patient
had hypodynamia and obvious amyotrophy of her right lower extremity and
difficulty in walking manifested as walking lamely. No nausea or vomit. No
aversion to cold. No fever, headache, or dizziness. Her spirit, appetite and
sleep were normal. Her bowel movement and urination were normal. Her heart and
lungs were normal. Her abdomen was flat. Her tongue was reddish with thin and
whitish coating. Her pulse was deep and fine.
Date:
6th of December 2006
Time: 9:00 a.m.
Today the
patient had hypodynamia and obvious amyotrophy of her right lower extremity and
difficulty in walking manifested as walking lamely. The involuntary muscular
jitters of the right lower extremity, shoulders and back was less than before.
No nausea or vomit. No aversion to cold. No fever, headache, or dizziness. Her
spirit, appetite and sleep were normal. Her bowel movement and urination were
normal. Her heart and lungs were normal. Her abdomen was flat. Her tongue
coating was thin and whitish. Her pulse was deep and fine. The herbal tea was
the same as before.
Date:
9th of December 2006
Time: 9:00 a.m.
Today the
patient had hypodynamia and obvious amyotrophy of her right lower extremity and
difficulty in walking manifested as walking lamely. The involuntary muscular
jitters of the right lower extremity, shoulders and back was less than before.
No nausea or vomit. No aversion to cold. No fever, headache, or dizziness. No
other discomfort. Her spirit, appetite and sleep were normal. Her bowel movement
and urination were normal. Her tongue coating was thin and whitish. Her pulse
was deep and fine. The herbal tea was the same as before.
Date:
12th of December 2006
Time: 9:00 a.m.
Today the
patient had hypodynamia and obvious amyotrophy of her right lower extremity and
difficulty in walking manifested as walking lamely. No obvious improvement in
walking ability. The involuntary muscular jitters of the right lower extremity,
shoulders and back was less than before. No nausea or vomit. No aversion to
cold. No fever, headache, or dizziness. No other discomfort. Her spirit,
appetite and sleep were normal. Her bowel movement and urination were normal.
Her tongue coating was thin and whitish. Her pulse was deep and fine. The herbal
tea was the same as before.
Date:
15th of December 2006
Time: 9:00 a.m.
Today the
patient had hypodynamia and obvious amyotrophy of her right lower extremity and
difficulty in walking manifested as walking lamely. No obvious improvement in
walking ability. The involuntary muscular jitters of the right lower extremity,
shoulders and back was reduced a lot. No other discomfort. The cross-section
diameter of the right thigh measured 12cm above the patella was 37cm, while that
of the left thigh was 42cm. Measured 22cm above the patella, the cross-section
diameter of the right thigh was 43cm, while that of the left thigh was 48cm.
Measured 12cm above the Juxu point, the cross-section diameter of the right leg
was 28cm, while that of the left was 32cm. She had gotten certain improvement.
Principle of TCM treatment was the same as before: strengthening the spleen and
supplementing qi; tonifying the liver and nourishing yin essence. Other
treatments continued: daily acupuncture and massage; daily dirigation.
Date:
18th of December 2006
Time: 9:00 a.m.
Today the
patient had hypodynamia and obvious amyotrophy of her right lower extremity. She
walked less lamely than had done before. The involuntary muscular jitters of the
right lower extremity, shoulders and back was obviously lessened. No nausea or
vomit. No aversion to cold. No fever, headache, or dizziness. No other
discomfort. Her spirit, appetite and sleep were normal. Her bowel movement and
urination were normal. Her tongue was light red with thin and whitish coating.
Her pulse was deep and fine. The herbal tea was the same as before. Continue
with strengthened functional training and combination therapy.
Date:
20th of December 2006
Time: 9:00 a.m.
Today the
patient had hypodynamia and obvious amyotrophy of her right lower extremity
which was a little better than before. She walked in a swaying gait but less
lamely. The involuntary muscular jitters of the right lower extremity, shoulders
and back almost disappeared. No nausea or vomit. No aversion to cold. No fever,
headache, or dizziness. No other discomfort. Her spirit, appetite and sleep were
normal. Her bowel movement and urination were normal. Her tongue coating was
thin and whitish. Her pulse was deep and fine. The new herbal tea included such
herbal as cooked rehmannia, dioscorea, millettia, cornus, dispascus, epimedium,
astragalus root, morinda root, achyranthes root, tangkuei, tortoise plastron
glue (melting by heat), and cibotium root, etc. A daily dosage should be
decocted twice. Continue with strengthened functional training and combination
therapy.
Date:
23rd of December 2006
Time: 9:00 a.m.
