Record of
Herbal Treatment Of Peter from Holland Improvement Of
ALS
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Brief Summary:
Peter, from Holland, suffering from ALS, stayed in our
hospital for five months. The abilities of his voice and
swallowing have been improved a lot. The ability of the
legs and arms is stabilized. He was quite satisfied with
our treatment result.
Nationality: The
Netherlands Marital Status: Married
Onset Season: Summer
Date of Admission: Nov. 10,2007
Complainer: The patient
himself Reliability: Reliable
First Medical Record
Nov.
10,2007
Peter,
a 41-year-old male, has suffered from weakness of the upper limbs, along with
difficulty in flexibility of finger joints for two years, and the condition has
been aggravated for one year. He was picked up by our staff in Zhijiang Airport
and arrived in Huaihua Red Cross Hospital for further treatment at 20: 10 p.m.
on Nov. 11,2007.
Essentials for Diagnosis:
1. The
patient has suffered from weakness of the upper limbs, along with difficulty in
flexibility of finger joints for two years, and the condition has been
aggravated for one year.
2. In
the beginning of Nov. 2005, the patient began to feel weakness of the upper
limbs without any obvious causes. At that time, the patient paid no attention to
it, and did no examination or treatment about it. Therefore, the disease was
developing progressively. Three months later, the patient had difficulty in the
movement of fingers of both hands. The finger joints were not able to do any
flexible movement. But he still took no examination or treatment. In Oct. 2006,
the patient went to a local hospital for a diagnosis. After the MRI examination,
he was diagnosed with amyotrophic lateral
sclerosis (ALS). The
hospital prescribed him
rilutek capsule. After one-month medicine taking, he stopped taking it due to
some discomfort. Then he did no other treatment. In Nov. 2006, the patient¡¯s
condition was aggravated, with symptoms of weakness of the lower limbs, the
delay of his movement, and difficulty in speaking. To seek for a further
comprehensive treatment, he arrived in our hospital at 19: 30 p.m. on July 18,2007. Since he got the disease, his spirit and appetite were both normal.
His sleep was slightly poor. His bowel movement and urination were both normal.
3. T
36.3¡æ£¬P
83 beats/minute, R 20 times/minute, BP 130/80 mmHg.
4. He
grew normally with common nourishment. His mind was clear. He had an expression
of chronic illness and languidness. His body was in a positive posture and he
was cooperative in examination.
5.
He has suffered from weakness of the
upper limbs and slightly muscular atrophy of double arms. There were obvious
atrophy on the muscles of
thenar eminence and hypothenar of his double hands. His fingers of double hands
had difficulty in flexible movement with poor fine movement. The experiment on his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty
in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hypertonicity. The muscles all over his limbs beat
uncontrollably and frequently. He had the symptoms of short of breath, weakness,
as well as with difficulty in speaking. His tongue surface was uneven, and there
were teeth marks at the edge of his tongue.
6. No
thoracic deformity. Chest percussion noted resonance. Sound of breath is
bilaterally clear on auscultation. No sound of pleural friction.
7.
Diagnostic examination: Not provided
Diagnostic Basis:
TCM: The patient has suffered from
weakness of the upper limbs, along with difficulty in flexibility of finger
joints for two years, and the condition has been aggravated for one year. His
limbs were atrophic and weak with languid spirit and
pale face. He had difficulty in speaking. His tongue was red with thin and white
tongue coating. His pulse was string-like. Because of the insufficiency
of the liquids, abnormality of the qi and blood, and the lungs heat scoring the
lobes, his limbs lose the nourishment. The deficiency of spleen and kidneys
leads to deficiency of yin. Then it gradually resulted in flaccidity.
Western medicine: The patient has suffered from weakness of the upper limbs,
along with difficulty in flexibility of finger joints for two years, and the
condition has been aggravated for one year. His upper limbs were weak with
slightly muscular atrophy of his arms. There were obvious atrophy on the muscles
of thenar eminence and
hypothenar of his double hands. His fingers of double hands had difficulty in
flexible movement with poor fine movement. The experiment on his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty
in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hypertonicity. The muscles all over his limbs beat
uncontrollably and frequently. He had the symptoms of short of breath, weakness,
as well as with difficulty in speaking. His tongue surface was uneven, and there
were teeth marks at the edge of his tongue. In Oct. 2006, he went to a local
hospital for a MRI examination, and was diagnosed with amyotrophic lateral sclerosis (ALS).
Diagnostic Differentiation:
TCM:
The patient¡¯s wilting syndrome should be differentiated from impediment
syndrome. Wilting syndrome is characterized by the limp, weak, and emaciated
limbs with muscular atrophy. A patient who has suffered from wilting syndrome
may even become unable to hold an object or to stand without any support.
Besides, the patient¡¯s lower limbs are more often affected, though he or she
usually has no joint pains. On the contrary, impediment syndrome is generally
characterized by aching pains, fixed heaviness and inflexibility of sinews,
bones, muscles and joints, with occasional numbness or swelling, though, no
paralytic manifestations. They are not difficult to be distinguished in clinics.
Western
medicine: Wilting syndrome should be differentiated from grave myasthenia
gravis, which is an acquired autoimmune disease with the transferring obstacles
of nerve-muscles, and is caused by the autoimmune reaction resulting from the
acetylcholine receptor (AchR) of the striated muscle. It can occur at any age
and there are about 60 percent people stricken before 30 years old. Women are
more often affected than men are. The most obvious characteristic of MG is rapid
fatigability of the skeletal muscles affected, improved with rest or medicines
that inhibits the activity of cholinesterase. It can involve cardiac muscle and
smooth muscle. MG patients of different ages often have different clinical
manifestations and courses, which are different from those of wilting syndrome
patients.
Western medicine diagnosis: Amyotrophic Lateral
Sclerosis (ALS)
Plans
for treatment strategy and nursing:
1.
Routine care of traditional Chinese internal medicine.
2.
Grade II care.
3.
Under care of a companion.
4.
high-protein diet.
5.
Herbal tea (to nourish the lungs and supplement the kidneys, soften the liver
and extinguish the wind): 5 dosages in total. One dosage a day and drink twice.
Main
herbs used in the herbal tea: huangqi (astragalus root), taizishen
(pseudostellaria root), danshen (salvia root), etc.
6.
Acupuncture and massage: once a day.
7.
Have more medical examinations if necessary.
Date:
Nov. 13,2007 Time: 10:00 a.m.
After
the examinations of ECG,
B-ultrasonicand chest radiography, the patient
was found no abnormality. The three regular examinations and the examinations of
the functions of his liver and kidneys as well as the examination of E4A
were all normal. According
to the above information, the doctor advised him to continue to take herbal tea
of the former prescription.
Date:
Nov. 22,2007 Time: 10:00 a.m.
The
patient¡¯s diet has increased. The weakness of his lower limbs has got some
improvement, and the incontrollable beating of the muscles all over his body was
lessened. At night, there were some paroxysmal spasms on his limbs. His sleep
was poor with dreaminess. His tongue body was thin, atrophic and tender. The
surface of his tongue was uneven and trembling with teeth marks at the edge of
the tongue. The patient would continue to take the same herbal tea.
Date:
Dec. 5,2007 Time: 10:00 a.m.
The
stiffness and weakness of his lower limbs, and difficulty in walking have been
improved altogether. The incontrollable beating of the muscles all over his body
and paroxysmal spasms on his limbs were lessened. Besides, the difficulties in
speaking and breathing have become better. The doctor advised him that the
herbal tea should be followed by the former prescription.
Summary Stage
Date: Dec. 9,2007 Time: 9:00 a.m.
Peter, a 41-year-old
male, has suffered from
weakness of the upper limbs, along with difficulty in flexibility of finger
joints for two years, and the condition has been aggravated for one year.
The patient was hospitalized in our Red Cross Hospital
at 20:10 p.m. on Nov.11,2007. He has been hospitalizing for 30 days.
Condition of
admission:
T 36.3¡æ£¬P
83 beats/minute, R 20 times/minute, BP 130/80 mmHg.
His heart and lungs were
normal, and his abdomen was soft and flat. He has
suffered from weakness of
the upper limbs and slightly muscular atrophy of double arms. There were obvious
atrophy on the muscles of
thenar eminence and hypothenar of his double hands. His fingers of double hands
had difficulty in flexible movement with poor fine movement. The experiment on his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty
in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hypertonicity. The muscles all over his limbs beat
uncontrollably and frequently. He had the symptoms of short of breath, weakness,
as well as with difficulty in speaking. His tongue was uneven, and there were
teeth marks at the edge of his tongue. His spirit,
appetite and sleep were all poor. Both of his bowel movement and urination were
normal.
Western medicine
diagnosis: Amyotrophic Lateral
Sclerosis (ALS)
The Course of
Diagnosis:
Since the patient was
hospitalized, he was prescribed herbal tea
to nourish the lungs and supplement the kidneys, soften the liver and extinguish
the wind. One dosage a day and drink twice. 100ml each
time, accompanied with acupuncture and massage once a day for a comprehensive
treatment. The patient¡¯s condition got some improvement.
The Current
Condition:
T 36.3¡æ£¬P
83 beats/minute, R 20 times/minute, BP 130/80 mmHg.
.His
heart and lungs were normal, and his abdomen was soft and flat. The difficulties
in his speaking, breathing and walking have got some improvement, so have the
weakness and stiffness of lower limbs and the incontrollable beating of the muscles all over his
body. There is no obvious improvement in the weakness and tightness of his upper
limbs. His spirit, appetite and sleep were all normal. Both of his bowel
movement and urination were normal.
Western medicine
diagnosis: Amyotrophic Lateral
Sclerosis (ALS)
Plans for treatment
strategy:
1. Continue to take
the herbal tea.
2. Acupuncture and
massage for once a day.
3. Keep a pleasant
mood and open-minded spirit.
Date:
Dec. 15,2007 Time: 9:00 a.m.
The incontrollable beating of the
muscles all over his body and paroxysmal spasms on his limbs were lessened a
lot. His sleep was normal, sometimes with a drumming in the ears. He continued
to take the herbal tea of the same prescription.
Date:
Dec. 20,2007 Time: 9:00 a.m.
The
thin and tender tongue body became better, so did the uneven and trembling
surface of his tongue. Besides, his tongue coating was white. His general
strength has increased with pleasant spirit. What¡¯s more, the difficulty in
walking has been improved. He would continue to take the former formula.
Date:
Dec. 30,2007 Time: 9:00 a.m.
Today
the patient said that he had difficulty in speaking with unclear and influent
speech. Besides, he felt difficulty in breathing with the symptoms of short of
breath and weakness. His stiffness and weakness in the lower limbs, the
difficulty in walking and the muscular beating all over the body all have got
some improvement. There was no improvement in the tight and weak upper limbs. In
the examination, his heart and lungs were normal, and his abdomen was flat and
soft. His spirit, appetite and sleep were all normal. His bowel movement and
urination were both normal too. His tongue was red with thin and white tongue
coating. His pulse was thready and weak. The herbal tea would keep the same as
before.
Summary Stage
Date: Jan. 9,2007 Time: 9:00 a.m.
Peter, a 41-year-old
male, has suffered from
weakness of the upper limbs, along with difficulty in flexibility of finger
joints for two years, and the condition has been aggravated for one year.
The patient was hospitalized in our Red Cross Hospital
at 20:10 p.m. on Nov.11, 2007. He has been hospitalizing for 60
days.
Condition of
Admission:
T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 130/80 mmHg.
His heart and lungs were
normal, and his abdomen was soft and flat. He has
suffered from weakness of
the upper limbs and slightly muscular atrophy of double arms. There were obvious
atrophy on the muscles of
thenar eminence and hypothenar of his double hands. His fingers of double hands
had difficulty in flexible movement with poor fine movement. The experiment on his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty
in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hypertonicity. The muscles all over his limbs beat
uncontrollably and frequently. He had the symptoms of short of breath, weakness,
as well as with difficulty in speaking. His tongue was uneven, and there were
teeth marks at the edge of his tongue. His spirit,
appetite and sleep were all poor. Both of his bowel movement and urination were
normal.
Western medicine
diagnosis: Amyotrophic Lateral
Sclerosis (ALS)
The Course of
Diagnosis:
Since the patient was
hospitalized, he was prescribed herbal tea
to nourish the lungs and supplement the kidneys, soften the liver and extinguish
the wind. One dosage a day and drink twice. 100ml each
time, accompanied with acupuncture and massage once a day for a comprehensive
treatment. The patient¡¯s condition got some improvement.
The Current
Condition:
T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 130/80 mmHg.
.His
heart and lungs were normal, and his abdomen was soft and flat. The strength of
his lower limbs has increased, and the incontrollable beating of the muscles all over his
body has been
lessened. Besides, there was no obvious improvement in the weakness of his upper
limbs. His speech was unclear and influent. While his
spirit, appetite and sleep were all normal. Both of his bowel movement and
urination were normal. His tongue was red with thin and white tongue coating.
His pulse was string-like.
The
strength of his lower limbs has increased, and the muscular beating all over his
body has been lessened. There was no obvious improvement in his upper limbs.
Besides, his speech was still unclear. He kept a normal sleep. The patient said
that his deafness began at his early age.
Date:
Jan. 20,2008 Time: 9:00 a.m.
The
thinness and tenderness of his tongue body, along with the uneven tongue surface
has been improved markedly. What¡¯s more, the trembling in the tongue body has
been lessened significantly, and the strength of his lower limbs has also
increased a lot. There was still no obvious improvement in his upper limbs. He
would continue to take the former herbal tea.
Date:
Jan. 31,2008 Time: 9:00 a.m.
The
pains of his lower limbs¡¯ joints have almost disappeared. The doctor would make
some changes on the basis of his former herbal tea.
Summary Stage
Date: Feb. 9,2007 Time: 9:00 a.m.
Peter, a 41-year-old
male, has suffered from
weakness of the upper limbs, along with difficulty in flexibility of finger
joints for two years, and the condition has been aggravated for one year.
The patient was hospitalized in our Red Cross Hospital
at 20:10 p.m. on Nov.11,2007. He has been hospitalizing for 90 days.
Condition of
Admission:
T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 130/80 mmHg.
His heart and lungs were
normal, and his abdomen was soft and flat. He has
suffered from weakness of
the upper limbs and slightly muscular atrophy of double arms. There were obvious
atrophy on the muscles of
thenar eminence and hypothenar of his double hands. His fingers of double hands
had difficulty in flexible movement with poor fine movement. The experiment on his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty
in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hypertonicity. The muscles all over his limbs beat
uncontrollably and frequently. He had the symptoms of short of breath, weakness,
as well as with difficulty in speaking. His tongue was uneven, and there were
teeth marks at the edge of his tongue. His spirit,
appetite and sleep were all poor. Both of his bowel movement and urination were
normal.
Western medicine
diagnosis: Amyotrophic Lateral
Sclerosis (ALS)
The Course of
Diagnosis:
Since the patient was
hospitalized, he was prescribed herbal tea
to nourish the lungs and supplement the kidneys, soften the liver and extinguish
the wind. One dosage a day and drink twice. 100ml each
time, accompanied with acupuncture and massage once a day for a comprehensive
treatment. The patient¡¯s condition got some improvement.
The Current
Condition:
T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 130/80 mmHg.
His heart and lungs were
normal, and his abdomen was soft and flat. The strength of his lower limbs has
increased, and the incontrollable beating of the muscles all over his
body has been
lessened. Besides, there was no obvious improvement in the weakness of his upper
limbs. His speech was unclear and influent. While his
spirit, appetite and sleep were all normal. Both of his bowel movement and
urination were normal. His tongue was red with thin and white tongue coating.
His pulse was string-like.
Western Medicine
diagnosis: Amyotrophic Lateral
Sclerosis (ALS)
Plans for treatment
strategy;
1. Continue to take
the herbal tea.
2. Acupuncture and
massage for once a day.
3. Keep a pleasant
mood and open-minded spirit.
Date:
Feb. 16,2008 Time: 9:00 a.m.
In
recent days, the patient has had a slightly cold. Besides, the symptoms of the
pharyngeal itching and expectoration have been aggravated.
The doctor made some changes on the basis of his former herbal tea.
Date:
Feb. 23, 2008 Time: 9:00 a.m.
Recently, his repeated cold, cough has almost recovered. There still existed
muscular beating in the upper limbs and paroxysmal spasms in his fingers. His
diet and sleep were both normal. The herbal tea keeps the same as before.
Date:
Mar. 5,2008 Time: 9:00 a.m.
The
patient had too much saliva with poor sleep. His sometimes shoulder pains and
muscular beating have been lessened. The herbal tea keeps the same as before.
Summary stage
Date: Mar. 9,2007 Time: 9:00 a.m.
Peter, a 41-year-old
male, has suffered from
weakness of the upper limbs, along with difficulty in flexibility of finger
joints for two years, and the condition has been aggravated for one year.
The patient was hospitalized in our Red Cross Hospital
at 20:10 p.m. on Nov.11,2007. He has been hospitalizing for 120
days.
Condition of
Admission:
T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 130/80 mmHg.
His heart and lungs were
normal, and his abdomen was soft and flat. He has
suffered from weakness of
the upper limbs and slightly muscular atrophy of double arms. There were obvious
atrophy on the muscles of
thenar eminence and hypothenar of his double hands. His fingers of double hands
had difficulty in flexible movement with poor fine movement. The experiment on his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty
in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hypertonicity. The muscles all over his limbs beat
uncontrollably and frequently. He had the symptoms of short of breath, weakness,
as well as with difficulty in speaking. His tongue was uneven, and there were
teeth marks at the edge of his tongue. His spirit,
appetite and sleep were all poor. Both of his bowel movement and urination were
normal.
Western medicine
diagnosis: Amyotrophic Lateral
Sclerosis (ALS)
The Course of
Diagnosis:
Since the patient was
hospitalized, he was prescribed herbal tea
to nourish the lungs and supplement the kidneys, soften the liver and extinguish
the wind. One dosage a day and drink twice. 100 ml
each time, accompanied with acupuncture and massage once a day for a
comprehensive treatment. The patient¡¯s condition got some improvement.
The Current
Condition:
T 36.5¡æ£¬P
80 beats/minute, R 20 times/minute, BP 130/80 mmHg.
His heart and lungs were
normal, and his abdomen was soft and flat. The strength of his lower limbs has
increased, and the incontrollable beating of the muscles all over his
body has been
lessened. Besides, there was no obvious improvement in the weakness of his upper
limbs. His speech was unclear and influent. While his
spirit, appetite and sleep were all normal. Both of his bowel movement and
urination were normal. His tongue was red with thin and white tongue coating.
His pulse was string-like.
Western medicine
diagnosis: Amyotrophic Lateral
Sclerosis (ALS)
Plans for treatment
strategy:
1. Continue to take
the herbal tea.
2. Acupuncture and
massage for once a day.
Date:
Mar. 20,2008 Time: 9:00 a.m.
The
pains of his shoulder joints and hip joints have been lessened, so have the
symptoms of the muscles all over his body and his fingers. He still felt weak in
raising his arms. He has kept a sound sleep as well as pleasant spirit and
normal diet. In the examination, his tongue body has broadened, and the uneven
tongue surface with trembling and the teeth marks at the edge of his tongue have
got some improvement. He would continue to take the herbal tea.
Date:
Mar. 31,2008 Time: 9:00 a.m.
The
thin and atrophic tongue body as well as the uneven tongue surface has been
improved significantly, so has the slow and unclear speech. Besides, the
stiffness and weakness of his lower limbs along with the difficulty in walking
has also been improved significantly. His short of breath, poor spirit and sleep
has turned out to be normal. While there were still no obvious changes in some
of his symptoms, such as the muscular atrophy and weakness on his upper limbs,
the difficulty in joints¡¯ flexible movement, and the disability of laying his
arms flat or raising his arms. All the symptoms have kept stable condition.
Date:
Apr. 11,2008 Time: 9:00 a.m.
The
stiffness and weakness of his lower limbs along with the difficulty in walking
has been improved significantly. Besides, the thin and atrophic tongue body, as
well as the uneven tongue surface and teeth marks at the edge of the tongue also
has got much improvement, so has his slow and unclear speech. What¡¯s more, the
incontrollable beating of the muscles all over his body and paroxysmal spasms on
his lower limbs were also lessened significantly. He has recovered with normal
sleep and diet as well as pleasant spirit. He felt no tiredness with a good
mood. He spoke highly of our TCM treatment, especially satisfied with his
treatment results. Today he demanded to leave the hospital with two-month herbal
tea for home taking.
