Brief Summary: On March 27, 2010, Charles, who has suffered from ALS, accompanied by the symptoms of weakness in the right part of his body; failure in walking without a crutch; loss of balance; obvious atrophy in the muscles of the forearm, hypothenar and greater thenar; pitting edema in his lower limbs, was hospitalized in our hospital. After 84 days  comprehensive TCM treatment here, he got big improvements in weakness in the right part of his body, failure in walking without a crutch, loss of balance. The symptoms of muscular twitching, pitting edema in his lower limbs have disappeared. He could walk without the crutch or any help when leaving the hospital.

 

Record of Hospitalization

Name: Charles                                                                                                    Birthplace: the United States

Sex: Male                                                                                                           Profession: Electrician

Age: 60                                                                                                               Date of Admission: March 27, 2010

Nationality: USA                                                                                                Date of Record: March 27, 2010

Marital Status: Married                                                                                      Onset Season: Vernal equinox

Complainer: The patient himself

 

First Medical Record

Date: March 27, 2010                                       Time: 10: 00 a. m.

Charles, who has suffered from ALS, accompanied by the symptoms of weakness in the right part of his body for about 1 year and worsened for about half a year; failure in walking without a crutch; loss of balance; obvious atrophy in the muscles of the forearm, hypothenar and greater thenar; pitting edema in his lower limbs, was hospitalized in our hospital. Diarrhea occasionally occurred. Muscular spasms all over his body, especially in his legs and back. He lost 8 pounds of weight. He liked to drink a lot of water because of his dry mouth. His tongue body was reddish with white coating. His lips were red. The pulse was slippery and fast.

Essentials for Diagnosis:

1. The patient had had weakness in the right part of his body for about 1 year and became worse for about half a year.

2. A year ago, the patient had weakness in the right part of his body without obvious reasons. He didn't pay much attention to this. In September 2009, the muscles of his right side of the body began to wither and he started to lose weight. So he came to a local hospital to take an EMG test. He was diagnosis as ALS with the EMG results. Still he didn't take any treatment but stayed at home for a rest. When he came to our hospital, he had the symptoms of weakness in the right part of his body, failure in walking without a crutch, loss of balance, obvious atrophy in the muscles of the forearm, hypothenar and greater thenar, muscular spasms all over his body, pitting edema in his lower limbs, diarrhea, especially in his leg and back, dry mouth, night sweat. His tongue body was reddish with white coating. There were teeth marks on the edges of the tongue. His lips were red. The pulse was slippery and rapid. The gripping strength of the left hand was 25.7 kg. The gripping strength of the right hand was 1.6 kg.

3. T 36.5≧, R 20 times/minute, P 82 times/minute, BP 130/85mmHg.

4. He grew normally with medium nutrition. His mind was clear. He had an expression of chronic illness and tiredness. His body was cooperative with his mind. His walking was lame.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. No pathological murmurs on auscultation.

6. The patient had weakness in the right part of his body, obvious atrophy in the muscles of the forearm, hypothenar and greater thenar, muscular spasms all over his body, pitting edema in his lower limbs, diarrhea, especially in his leg and back, dry mouth, night sweat. His tongue body was reddish with white coating. His lips were red. The pulse was slippery and rapid. The level of muscular strength was grade ‰. The muscle tension was decreased.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient had weakness in the right part of his body for about 1 year and worsened for about half a year. Insufficiency of essence-blood, sinews and vessels deprived of nourishment, liver-kidney depletion, liquid-blood could not provide enough nutrition to the sinews.

Western Medicine: The patient had had weakness in the right part of his body for a year and became worsened for half a year. There was atrophy in the muscles of the forearm, hypothenar and greater thenar; muscular spasms all over his body especially in his leg and back, pitting edema in his lower limbs, diarrhea. He needed a crutch to walk and his walking was gimpy and lamely. The level of muscular strength was ‰. The muscle tension was decreased. The results of EMG and MRI in his local hospital showed that he had ALS. 

Diagnostic Differentiation:

TCM: The patient's wilting pattern should be differentiated from impediment pattern. Wilting pattern is mainly characterized by emaciated sinews and bones, weakness of the muscles, thin. When it improves to a serious stage, the patient would unable to hold thing or walk. However, impediment pattern is generally characterized by joint pains. So they can be distinguished from each other.

Western Medicine: The patient's ALS should be differentiated from myasthenia gravis. The symptoms of myasthenia gravis always increase after exercise and work and reduce after rest.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Wilting pattern.

Symptom identification: depletion and vacuity of spleen qi, depletion of kidneys and liver, stagnant water-damp.

Western Medicine: ALS.

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. Treatment strategy: boost qi, fortify spleen, enrich and nourish the liver and the kidneys, disinhibit water, transform dampness.

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

7. Acupuncture and massage: once a day.

8. Have more medical examination if necessary.

 

Date:  March 27, 2010                                     Time: 9: 00 a. m.

The patient had had weakness in the right part of his body for a year and became worse for half a year. A year ago, the patient had weakness in the right part of his body without obvious reasons. He didn't pay much attention to this. In September 2009, the muscles of his right body began to wither and he began to lose weight. So he came to a local hospital to take an EMG test. He was diagnosed as ALS with the EMG results. The patient had weakness in the right part of his body for a year and became worse for half a year, atrophy in the muscles of the forearm, hypothenar and greater thenar, muscular spasms all over his body especially in his leg and back, pitting edema in his lower limbs, diarrhea, and night sweat. His appetite and sleep were good. His urination was normal. His tongue body was reddish with white coating. There were teeth marks on the edges of the tongue. The gripping strength of the left hand was 25.7kg. The gripping strength of the right hand was 1.6kg.

According to his overall problems, professor Zhang prescribed the first formula for him. 5 dosages in total.

 

Date: March 28, 2010                                      Time: 15: 00 p. m.

Yesterday's test results:

Routine blood test: normal

Electrolyte test: Ca 1.8mnol/l

Urine test: normal

Function of liver: normal

Function of kidneys: normal

According to the test result, we suggested the patient to supply more calcium.

　

Date: March 28, 2010                                       Time: 15: 00 p. m.

According to the feedback, there was no abnormality of the examination of urine R. Besides, his functions of the liver and kidneys were all in normal condition. His RF and ESR were a little higher than normal level. 

　

Date: March 29, 2010                                      Time: 10: 00 a. m.

The patient's health condition was stable. There was no specific change. So the treatment strategy stayed the same. We suggested him to do some exercise to strengthen the function of his four limbs.

　

Date: April 6, 2010                                       Time: 10: 00 a. m.

The patient said that the strength of his limbs had been increasing. He got improvement in walking, as he could walk about 50 meters without a crutch. The pitting edema in his lower limbs had disappeared. There were muscle spasms in the guadriceps femoris and gastrocnemius. Both his appetite and sleep were good. His urination and stool were normal. According to his progress and feedback, we changed the formula to see further improvement.

  　

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

The patient complained that there were pains on the joint of his left knee especially after doing some activities. Muscular spasms still appeared. Both his appetite and sleep were good. His urination and stool were normal. Two herbs were added into the formula, 5 dosages.

　

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

The patient said that there were pains on the joint of his left knee especially after doing some activities. The strength of his lower limbs increased. His right fingers were more flexible than before. The balance became better, too. He got big improvement in walking. He can walk for 20 minutes with a crutch everyday. According his latest feedback, we adjusted the formula once again. 4 dosages.　

　

Date: April 24, 2010                                       Time: 10: 00 a. m.

The patient told us he had had an operation in the joint of his left knee. This part still felt painful. The pain increased when the patient take some activities. According to this matter, we changed the formula to take care of this new problem. 6 dosages in all.

　

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

The pains in the joint of the patient's left knee reduced a lot. The strength of his right upper limb and lower limb increased a lot. When the patient was standing or walking, the color of his lower limbs¨ skin changed to cyanotic and the lower limbs became swelling. We analyzed that it was because of the obstacle of blood reflux. So we changed the formula a little to deal with this problem. 6 dosages.  

　

Date: May 5, 2010                                       Time: 9: 00 a. m.

The patient complained that the pains in the joint of the knee had reduced a lot. There was no obvious change in the strength of the whole body. His legs were cyanotic due to the long time walk. The part bellow the ankle was a bit edema. And he felt heavy sense of his legs. Slightly cough. We adjusted the formula again.

　

Date: May 14, 2010                                       Time: 10: 00 a. m.

The patient's balance had changed a lot, the edema improved too. He could walk a longer time than before. But he still felt weak. The color of his leg was change to normal. The cough had disappeared. The new formula mainly focused on the enrichment of liver and kidneys.

　

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

The patient had diarrhea again. It is because he didn't pay attention to his diet. He drank some cold beverage. Other healthy conditions were still the same. The formula was the same as before.

　

Date: May 31, 2010                                       Time: 10: 00 a. m.

The patient complained that he had gotten a bad cough which made him vomit twice and diarrhea four times. His stools were watery. We prescribed two herbal products to him. After taking them, the symptoms of vomitting and diarrhea disappeared. Also, we changed the formula again.

　

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

The patient said that his weakness, difficulty in walking and imbalance all had gotten obvious improvement. He could walk without a crutch at all. Symptoms as followed became much better: muscle spasms all over his body especially in his leg and back, pitting edema in his lower limbs, diarrhea, and night sweat. Both his appetite and sleep were good. The formula was the same as before.

　

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

The patient said all his symptoms were much better, so he wanted to leave the hospital tomorrow morning. He took three months' herbal tea back home to continue and stabilize the treatment.

 

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