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Record of Herbal Treatment Of Shafali from Sri Lanka Improvement Of  ALS

 

 

 

 

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Brief Summary: On Sep.11, 2009, Shafali from Sri Lanka, who had had difficulty in speaking, swallowing and walking for two years, was hospitalized in our hospital. She was diagnosed as ALS in March of 2008. However, she has achieved good improvement after 89 days TCM treatment here.

Records of Hospitalization

Name: Shafali                                                       Birthplace: Sri Lanka

Sex: Female                                                          Age: 53

Religion: Muslim                                                   Date of Admission: Sep.11, 2009

Marital Status: Married                                      Date of Record: Sep.11, 2009

Onset Season: White Dew                                   Complainer: The patient herself

 

First Medical Record

Date: Sep.11, 2009                                 Time: 20: 00 p. m.

Shafali, a 53-year-old female, who had had difficulty in speaking, swallowing and walking for two years, was hospitalized in our hospital on Sep.11, 2009.

Essentials for Diagnosis:

1. The patient has suffered from ALS, accompanied with the difficult walking and loss of her balance of the two lower limbs for two years. Besides, she had difficulty in speaking and swallowing.

2. Two years ago, the patient began to have difficulty in walking. But she did not pay much attention to it. Then the condition became worse gradually. At the same time, she had difficulty in speaking and swallowing. In March of 2008, she was diagnosed as ALS by MRI in her local hospital.

3. T 36, P 80 times/minute, R 20 times/minute, BP 120/80mmHg.

4. She grew normally with medium-level nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. Her body was cooperative with his mind.

5. No thoracic deformity. The sound of breath was bilaterally normal on auscultation. No sound of pleural friction. The heart border was not enlarged. The heart beat was 80 times/minute. The cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The knee joint of her left leg was swollen as well as her both acrotarsium. Besides, her pulse was weak.

7. Accessory examinations: Absent.

Diagnostic Basis:

TCM: The patient's two lower limbs were inactive. Besides, she had had difficulty in speaking and swallowing for 2 years. She was easy to feel tired. It was due to qi vacuity of the spleen and lungs, insufficiency of the qi and blood. Qi and blood could not supplement the body, sinews and the network vessels, so there was weakness of the body. Her tongue body was dark red. Her tongue coating was thin and white. Her pulses were wiry and weak. According to the symptoms of the tongue and pulse, she was diagnosed with wilting pattern.

Western Medicine: The patient's two lower limbs are inactive. Besides, she had had difficulty in speaking and swallowing for 2 years. Besides, the knee joint of her left leg was swollen as well as her both acrotarsium. In March of 2008, she was diagnosed as ALS by MRI in her local hospital.   

Diagnostic Differentiation:

TCM: The patient's wilting pattern should be differentiated from impediment pattern. Wilting pattern is mainly characterized by limp, weak, and emaciated limbs with the numbness of the muscles. But the patient usually has no joint pains. On the contrary, impediment pattern is generally characterized by the joint pains. So they are not difficult to be distinguished.

Western Medicine: ALS should be differentiated from progressive muscular dystrophy, which is characterized by obvious muscular dystrophy in the legs. But there is no muscular trembling in the fascicle. The disease can be diagnosed clearly by the examination of MRI.

First Diagnosis:

TCM diagnosis: Wilting pattern

Symptom identification: vacuity of the liver and the kidneys, obstruction of phlegm-damp in the network vessels.  

Western Medicine diagnosis: ALS

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Accompanied by assistants.

4. Low-fat and high-protein diet.

5. TCM treatment strategy: Fortify the liver and boost the kidneys, move qi and supplement the blood.

6. Herbal tea: one dosage a day and drink twice.180ml once

7. Acupuncture and massage: once a day.

8. Supplement each examination for admission.

 

Date: Sep.12, 2009                                       Time: 10: 00 a. m.

Two years ago, the patient began to have difficulty in walking. But she did not pay much attention to it. Then the condition became worse gradually. At the same time, she had difficulty in speaking and swallowing. In March of 2008, she was diagnosed as ALS by MRI in her local hospital. Presently the patient had weakness of the lower limbs and she could not walk by herself. So she had to sit in the wheelchair. Her urine and stool were regular. The spasms of the four limbs were obvious. According to the symptoms of the tongue and pulses, Professor Zhang believed that the patient had suffered from wilting pattern. So our treatment strategy for her was to fortify the liver and boost the kidneys, move qi and quicken the blood.

The prescription was as follows: bai shao (white peony root), dang gui (tangkuei), etc. 4 dosages in total. 

 

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

The feedback of the examination today was as follows: Blood R (), Urine R (). The function of the liver was normal as well as the kidneys.

 

Date: Sep.20, 2009                                       Time: 10: 00 a. m.

The patient’s walking had not got much improvement. She still felt the weakness of the whole body. Her urine and stool were regular. Besides, the swallowing had improved to some extent. Her spasms of the four limbs also had got some improvement. According to her latest symptoms, our expert prepared a new formula for her.   

 

Date: Sep.25, 2009                                       Time: 10: 00 a. m.

The patient had not had headache up to now. The pains of the joints had become better. However, she said that the speaking condition became worse and the swallowing still had not got much improvement. Then the prescription was changed a little bit. 

 

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

The patient had cough sometimes. Her two lower limbs were stiff. Then our treatment was to boost qi and enrich yin, fortify the spleen and harmonize the blood. So our experts change the formula again according to her latest condition. 

 

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

The patient’s cough disappeared. She also had no headache. Besides, the swallowing had got some improvement. Her other conditions were stable. Then she was told to use the same formula to consolidate the result. 

 

Date: Oct.20, 2009                                       Time: 10: 00 a. m.

The patient said that her health condition did not get much improvement in recent days. She had not pains. The swelling of her right food was obvious. Then our experts changed her formula a little. 

 

Date: Oct.25, 2009                                       Time: 10: 00 a. m.

The patient felt the weakness of the two lower limbs. The speaking and swallowing became worse. Her pulses were weak and her tough body was pale. Then she was told to use the prescription of Sep.12. And our experts added another two kinds of herbs to let her get more improvement.

 

 Date: Oct.29, 2009                                       Time: 10: 00 a. m.

The patient was hospitalized in our hospital on Sep.11, 2009. She had had difficult in speaking and swallowing for two years. After 48-day treatment of fortifying the liver, boosting the kidneys, moving qi and supplementing the blood, her health condition had not got obvious improvement. Then our experts prepared a new formula again according to her condition.

The prescription was as follows: bai ren shen (white ginseng), fu ling (Poria), she gan (belamcandae root), etc..

 

Date: Nov.6, 2009                                       Time: 10: 00 a. m.

The patient’s speaking and swallowing had got some improvement. Her appetite became better than before. The tongue body was pale and the pulses were weak. So our experts prescribed a new formula for the third time to fortify the spleen and boost qi.

 

Date: Nov.11, 2009                                       Time: 10: 00 a. m.

The patient’s health condition had got some improvement. Her tongue body was still pale and pulses were weak. Then we added another kind of herb to the formula.

 

Date: Nov.16, 2009                                       Time: 10: 00 a. m.

The patient’s health condition was stable. She continued to use the same formula to get further improvement.

 

Date: Nov.21, 2009                                       Time: 10: 00 a. m.

After 10-day treatment of supplementing the spleen and boosting the lungs, the patient’s health condition had got obvious progress. Her appetite was good. Besides, her urine and stool were regular. At present, the main problem was that her heels were weakness and still she had difficulty in walking. Then according to her latest symptoms, our experts changed her formula to supplement the spleen, boost the kidneys and strengthen the sinews and bones.

 

Date: Nov.26, 2009                                       Time: 10: 00 a. m.

The patient could feel the strength of the four limbs. She could walk slowly by holding the wheelchair. Her other condition was stable.

 

Date: Dec.1, 2009                                       Time: 10: 00 a. m.

The patient’s condition was stable. The main problem was the weakness of her left lower limb. Then our strategy was to continue to supplement the spleen, boost the kidneys and strengthen the sinews and bones.

 

Date: Dec.6, 2009                                       Time: 10: 00 a. m.

The patient still could feel the weakness of her left part of body. Her other condition was in normal. Then she still used the same formula.

 

Date: Dec.9, 2009                                       Time: 10: 00 a. m.

After 89-day treatment of boosting the lungs, supplementing the spleen, boosting the kidneys, strengthening the sinews and bones, 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 today with 60 dosages of herbal tea back home for continuous treatment.

 

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