Brief Summary: Miss Betty, from Australia, has received our treatments for 50 days due to suffering from motor neuron disease. After the doctors'efforts, she has got much improvement. Her treatment is successful.

　

Records of Hospitalization

Name: Betty                                                                                                      Birthplace: Australia

Sex: Female                                                                                                      Occupation: Business woman 

Age: 35                                                                                                             Date of Admission: Oct. 31, 2009

Nationality: Australia                                                                                        Date of Record: Oct. 31, 2009

Marital Status: Unmarried                                                                                Onset Season: Beginning of winter

Complainer: The patient herself.

　

First Medical Record

Date: Oct. 31, 2009                                                     Time: 10:00 a. m.

Betty, a 35-year-old female, who had had difficulty in speaking for one year, was hospitalized in our hospital for comprehensive treatment at 22:40 p.m. on Oct. 31, 2009.

Essentials for Diagnosis:

1. The patient had had difficulty in speaking for one year.

2. In Oct. of 2008, the patient felt that she had difficulty in speaking without obvious reason. However, she did not pay much attention to it and did not take any examination or treatment. Then the condition became worse gradually. On April of 2009, she was examined by MRI at a local hospital (name unknown) and did not find any abnormal. In Sep. of this year, she was diagnosed as motor neuron disease. Then she was given ＾Rilutek￣ to take orally for her treatment. But she had not got much improvement. She had difficulty in speaking and swallowing. Besides, she had weakness of four limbs especially the upper limbs. To pursue improvement, she came to our hospital for the comprehensive treatment on Oct. 31, 2009.

3. T 36.0≧, P 78 times/minute, R 20 times/minute, BP 90/50mmHg.

4. She grew normally with medium nutrition. Her mind is conscious. She looked tired with a feeling of chronic illness.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The patient had difficulty in speaking and swallow. Besides, she had weakness of four limbs especially the upper limbs.

7. Accessory examination: none.

Diagnostic Basis:

TCM: The patient had had difficulty in speaking for one year. Lung-spleen qi vacuity and liver-kidney yin vacuity are the main pathogenesis of this disease. The tongue body was thin and slightly reddish. There were cracks in the middle of the tongue. Her pulse was slippery. According to the symptoms of the tongue and pulse, she was diagnosed as wilting pattern.

Western Medicine: The patient had difficulty in speaking and swallowing. Besides, she had weakness of four limbs especially the upper limbs. In Sep. of 2009, she was diagnosis as motor neuron disease.

Diagnostic Differentiation:

TCM: The patient's wilting pattern should be differentiated from impediment pattern. Wilting pattern is mainly characterized by limp, emaciated sinews and bones, with weakness of the muscles. However, impediment pattern is generally characterized by joint pains. So they are not difficult to be distinguished.

Western Medicine: The motor neuron disease should be differentiated from syringomyelia. The syringomyelia can cause the spinal swollen. The disease can be diagnosed clearly by the examination of MRI.

First Diagnosis:

TCM diagnosis: Wilting pattern

Symptom identification: Lung-spleen qi vacuity and liver-kidney yin vacuity

Western Medicine diagnosis: motor neuron disease

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Under the care of a companion.

4. Food with high protein.

5. TCM treatment strategy: boost lungs and fortify spleen, enrich the liver and kidneys.

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

7. Acupuncture and massage: once a day.

8. Have more medical examinations if necessary

 

Date: October 31, 2009                                       Time: 10: 00 a. m.

The patient felt that she had had difficulty in speaking for one year. However, she did not pay much attention to it, so that the condition became worse gradually. In April of 2009, she was examined by MRI at the local hospital (name unknown) and did not find abnormal phenomenon. She was diagnosed as wilting pattern by TCM. Accordingly, our treatment strategy is to boost the lungs, fortify the spleen and enrich the liver and kidneys. Then our expert team prepared a special formula for her.

　

Date: December 01, 2009                                       Time: 10: 00 a. m.

The patient¨s liver and kidneys were all in the normal condition. To prevent the flu, we added another kind of herb to clear heat and resolve toxin.

　

Date: December 02, 2009                                       Time: 10: 00 a. m.

The patient had no abnormal phenomenon. Then she continued to use the same formula.

　

Date: December 05, 2009                                       Time: 10: 00 a. m.

The patient told us that her headache had got some progress. Besides, the swallowing condition had improved a lot. She had muscular spasms sometimes. Her emotion was in a good condition. According to her latest symptoms, we prepared a new formula for her to get further improvement.

　

Date: December 10, 2009                                       Time: 10: 00 a. m.

The patient¨s swallowing condition was stable. She told us that she had had no headache for recent days. She also slept well at night. However, she still had muscular spasms sometimes. Then we changed the formula a little for her.

　

Date: December 14, 2009                                       Time: 10: 00 a. m.

The patient¨s speaking and swallowing conditions all had got much improvement. The pains of the upper limbs¨ and spasms had got obvious progress. Sometimes she had a feeling of nausea when she taking our tea. According to her latest condition, we changed her formula again to let her get more comprehensive improvement.

　

Date: December 18, 2009                                       Time: 10: 00 a. m.

Her health condition continued to become better. Then she was told to use the same formula to consolidate the result.

　

Date: December 23, 2009                                       Time: 10: 00 a. m.

The patient¨s health condition had got obvious improvement. Besides, she had no the feeling of nausea when she took our herbal tea. Her emotion was good. So she continued to take the same formula.

　

Date: December 30, 2009                                       Time: 10: 00 a. m.

The patient had spasms of the four limbs sometimes. She felt that she had sight pains on the back of the head. Then we prepared a new formula again for her.

　

Date: November 7, 2009                                       Time: 10: 00 a. m.

Her condition was in normal. Then our experts prepared a special formula according to her condition.

　

Date: November 10, 2009                                       Time: 10: 00 a. m.

The patient¨s speaking and swallowing conditions were all stable. Her other conditions were all in normal. She only had spasms sometimes. Then we changed her formula a little. 

　

Date: November 15, 2009                                       Time: 10: 00 a. m.

The patient¨s speaking condition became normal and her swallowing condition also became normal. Besides, the spasms had got much improvement. The pains on the back side of the head also became better. Then we prepared a new formula again according to her latest condition.

　

Date: November 18, 2009                                       Time: 10: 00 a. m.

After 50-day treatment of boosting the lungs and fortifying the spleen, enriching the liver and kidneys, and adjusting the treatment according to her symptoms, together with acupuncture and massage, the patient had got obvious improvement. The patient decided to leave the hospital tomorrow with 70 dosages of herbal tea back home for continuous treatment.