Brief Summary: On November 19, 2009, Sherry from Canada, who has suffered from ALS, was hospitalized in our hospital. She had weakness of the right side body. And she had had difficulty in walking for 1 year. She has achieved obvious improvement after 83 days TCM treatment here.

 

Record of Hospitalization

Name: Sherry                                                                                                          Birthplace: Canada

Sex: Female                                                                                                             Profession: Pet cleaner

Age: 60                                                                                                                    Date of Admission: November 19, 2009

Nationality: Canada                                                                                                 Date of Record: November 19, 2009

Marital Status: Married                                                                                           Onset Season: Autumnal Equinox

Complainer: The patient's herself

 

First Medical Record

Date: November 19, 2009                                       Time: 1: 00 a. m.

Sherry from Canada, who has suffered from ALS, was hospitalized in our hospital on November 18, 2009. She had weakness of the right side body. And she had had difficulty in walking for 1 year.

Essentials for Diagnosis:

1. The patient had weakness of the right side body. And she had had difficulty in walking for 1 year.

2. The patient began to feel weakness one year ago. Besides, she felt that her right leg had difficulty in walking. Then she had muscular pains and spasms. She did not do any examination. One weak ago, she went to a local hospital and she was diagnosed as ALS. At last, she decided to come to our hospital to get the comprehensive treatment.

3. T 36.2≧, R 20 times/minute, P 81 times/minute, BP 140/80mmHg.

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

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. Her left hand's grip strength was 28.9 kg and the right hand was 17.5 kg. Her pulse was wiry.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient had suffered from weakness of the body for 1 year. She had difficulty in walking. She had muscular spasms and pains sometimes. Her sleeping was not good and she was easy to wake up. The tongue body was pale. Her pulse was weak and wiry. According to the symptoms of the tongue and pulse, she was diagnosed as wilting pattern.

Western Medicine: She had weakness of the right side of the body. And she had had difficulty in walking for 1 year. Her left hand's grip strength was 28.9 kg and the right hand was 17.5 kg. Her pulse was wiry. She was given MRI examination in the local hospital and was diagnosed as ALS.

Diagnostic Differentiation:

TCM: The patient's wilting pattern should be differentiated from impediment pattern. Wilting pattern is 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 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 spleen and the kidneys, obstruction of channels and network vessels.

Western Medicine diagnosis: ALS (amyotrophic lateral sclerosis)

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. Low-fat and high-protein diet.  

5. TCM treatment strategy: fortify the spleen, boost qi and the kidneys, quicken the blood and free the network vessels.

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: November 19, 2009                                       Time: 10: 00 a. m.

The patient began to feel weakness one year ago. Besides, she felt that her right leg had difficulty in walking. Then she had muscular pains and spasms. She did not do any examination. One weak ago, she went to a local hospital and she was diagnosed as ALS. Her tongue body was pale. Her condition is due to vacuity of the spleen and the kidneys, obstruction of channels and network vessels. So our treatment strategy is to fortify the spleen, boost qi and the kidneys, quicken the blood and free the network vessels. Then we prepared a special formula for her.

　

Date: November 22, 2009                                       Time: 10: 00 a. m.

The patient's weakness and walking had no obvious progress. But her sleeping was good. There were no spasms. Then she still used the same formula to see the effect. 

　

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

The patient said that her walking had improved a little. Then she was told to use the same formula. 

　

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

The patient said that her walking had got much improvement. Her sleeping was good and she did not have uncomfortable feeling. 

　

Date: December 5, 2009                                       Time: 10: 00 a. m.

The patient said that she felt well. We changed the above formula a little for the first time.

　

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

The patient said that weakness of the lower limbs had got obvious improvement. She could walk to a longer distance than before. Then we added another kind of herb to her formula for the second time.  

　

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

The patient said that everything was good. Her condition continued to become better. So she continued to use the above formula.

　

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

Her condition continued to become better. Then she still used the same formula.

　

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

The patient said that she felt well and everything was good. So she continued to use the same formula.

　

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

The patient had diarrhoea and constipation. So we changed her formula a little for the third time.

　

Date: January 5, 2010                                         Time: 10: 00 a. m.

The patient had no uncomfortable feeling. She did exercise every day. Then she still used the same formula.

　

Date: January 10, 2010                                         Time: 10: 00 a. m.

The patient said that her condition was stable. She could feel the muscular jumpings sometimes. Then we did not change her formula.

　

Date: January 15, 2010                                         Time: 10: 00 a. m.

The patient's condition was stable. So she was told to use the same formula to consolidate the result.

　

Date: January 20, 2010                                         Time: 10: 00 a. m.

The patient said that she was good. Her tongue body was red and her pulse was wiry. Then we change the formula a little.

　

Date: January 25, 2010                                         Time: 10: 00 a. m.

The patient's condition was stable. So she was told to use the same formula to consolidate the result.

　

Date: January 30, 2010                                         Time: 10: 00 a. m.

The patient said that she had cough sometimes. Then we prepared another formula according her condition.

　

Date: February 9, 2010                                         Time: 10: 00 a. m.

Compared with before, her condition got obvious improvement. After the 83 days of comprehensive treatment here including herbal tea, massage and acupuncture, the symptoms improved a lot. Her condition was stable. The patient decided to leave the hospital tomorrow.