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Record of Herbal Treatment Of Juan from USA Improvement Of ALS

 

 

 

 

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Brief Summary: On March 20, 2010, the patient Juan from USA who has suffered from ALS, accompanied by weakness in the four limbs, especially the upper limbs almost paralyzed, muscular dystrophy on the shoulders, weakness of lifting the forearms and bad walking with the lower limbs, muscular twitching all over the body, slurred and nasal-sounding speech, difficulty in chewing or swallowing, was hospitalized in our hospital. After about 76 days comprehensive TCM treatment with herbal tea, acupuncture and massage in our hospital, he achieved significant improvement in his symptoms, especially in muscular twitching, difficulty in chewing or swallowing, constipation. His strength increased.

 

Record of Hospitalization

Name: Juan                                            Sex: Male

Age: 42                                                  Profession: Policeman

Nationality: USA                                  Marital Status: Married

Onset Season: Vernal Equinox              Date of Admission: March 20, 2010  

Complainer: The patient himself             Reliability: Reliable

 

First Medical Record

Date: March 20, 2010                  Time: 8:30 p.m.

Juan, who has suffered from ALS, accompanied by weakness in the four limbs, especially the upper limbs almost paralyzed, muscular dystrophy on the shoulders, weakness of lifting the forearms and bad walking with the lower limbs, muscular twitching all over the body, slurred and nasal-sounding speech, difficulty in chewing or swallowing, was hospitalized in our hospital.

 

Essentials for Diagnosis:

1. The patient has suffered from weakness in his four limbs for 3 years, and the condition has worsened for about 8 months.

2. In October 2007, the patient began to feel the weakness of his right hand without obvious reasons. He went to a local hospital and did a MRI examination and was diagnosed as ALS. He was suggested to use Riluzole by the local doctor but with little effect, followed by weakness in his left hand and then all over the body. In August 2009, the patient could not walk with his lower limbs, accompanied by difficulty in speaking, chewing and swallowing. There were also hurried cough when drinking; blocking of throat by phlegm, muscular twitching and cramping in the whole body. The test results showed that atrophy had happened in both of the upper limbs, shoulders. The arms could not raise or bend. The griping power of his hands was 0.

3. T 36.3℃P 80 beats/minute, R 20 times/minute, BP 120/80 mmHg.

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.

5. No thoracic deformity. Sound of breath was short on auscultation. No sound of pleural friction. Cardiac rhythm was regular.

6. The patient felt the weakness in his four limbs. Atrophy appeared in supraspinatus, biceps brachii, musculusdorsalisantibrachii, thenar, hypothenar, and gastrocnemius. His hands were unable to hold things and the feet were unable to walk. He needed to use wheelchair. Muscular spasms appeared in the four limbs. The muscular strength of the upper limbs was level  = 1 \* ROMAN I and the strength of the lower limbs was level  = 2 \* ROMAN II. The patient had fever, dry mouth, yellowish urine, dry stool and difficulty in defection, slightly atrophic and reddish tongue body, thin and yellowish tongue coating, fissured tongue body. There were teeth marks on the edges of the tongue. The pulse was thin, weak and rapid.

7. Assistant examination: Not provided.

 

Diagnostic Basis:

TCM: The patient has suffered from weakness of the four limbs for three years, and the condition has been aggravated for 8 months. This is due to depletion of liver and kidneys, lack of nourishment of liquid blood to the sinews. The other symptoms are weakness of the whole body, slightly atrophic and reddish tongue body, thin and yellowish tongue coating, fissured body, teeth marks on the edges of the tongue. The pulse was weak, thin and rapid. All the signals of her tongue and pulse belong to the symptoms of qi vacuity of the lungs and spleen, depletion of the liver and kidneys. According to the above symptoms, he was diagnosed as wilting pattern.

Western medicine: The patient has suffered from weakness of the four limbs for three years, and the condition has been aggravated for 8 months. He did MRI exam in 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: It should be differentiated from myasthenia gravis, which will be worse after sports and work while it will decrease after having a rest. But this situation is rare in ALS.

First Diagnosis:

TCM diagnosis: Wilting Pattern

Symptom identification: lung-spleen qi vacuity, liver-kidney depletion

Treatment strategy: fortifying the spleen, boosting the lung, enriching and supplementing the liver and kidneys.

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 the care of a companion.

4. Low-fat and high-protein diet.

5. TCM treatment strategy: to fortify the spleen, boost the lungs, enrich and supplement 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: March 20, 2010.                                               Time: 08: 00 a. m.

The patient had had weakness in all the four limbs for three years and had worsened for 8 months; especially in the upper limbs which were almost paralyzed. He had short and weak breath, difficulties in speaking, chewing and swallowing; hurried cough when drinking; blocking of throat by phlegm, twitching and cramping of muscles in the whole body. The test results showed that atrophy had appeared in both of the upper limbs, arms and shoulders. His limbs could not raise or bend. He also had muscular dystrophy on the shoulders; weakness in lifting his forearms and walking with lower limbs; slight atrophy and reddish tongue body, thin and yellow tongue coating; fissured tongue body. There were teeth marks on the edges of the tongue. The pulse was weak, thin and rapid.

 

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

The patient complained that he had shortness of breath and difficulty in breathing when lying on the back or talking. Stiffness of the lower limbs increased when walking. His tongue was red-purple, shivering and fissured. His lips were of red-purple. There were teeth marks on the edges of tongue. His pulse is thin and rapid. The treatment strategy was the same as before.

 

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

The patient complained that he had too much saliva and all the four limbs couldn't move freely due to the weakness. There was stiffness of ankle joints. The times of twitching and cramping of muscles in the whole body reduced a bit. Then according to his latest condition, we changed his formula a little. 6 dosages in total. 

 

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

The patient's feedback was good. The strength of the upper limbs increased; the toes could move up and down, the times of twitching and cramping of the muscles reduced. His sleep and appetite were good. According to his latest condition and progress, we adjusted his formula a little again. 4 dosages in total.

 

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

The patient's weakness in the four limbs and difficulties in speaking improved a lot. He complained that there was too much saliva, and the mouth felt dry. He also had hurried cough when drinking. His sleep and appetite were good. Then we adjusted his formula a little for the third time to let him get further progress.  10 dosages in total.

 

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

The patient complained his burning sense in the eyes. So we added two kinds of herbs to the formula and make it into herbal tea for 6 days.

 

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

The patient's strength in fingers, lower limbs and neck increased. The frequency of muscular jumping reduced. The difficulty in breathing improved. The old pain in hip joint reduced, too. His eyes still felt a little sense of burning. With thick and yellowish tongue coating, taut and thin pulse. According to his feedback, we adjusted the formula again. 5 dosages in total.

 

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

The strength of the patient's lower limbs, neck and finger increased continually. The times of muscular jumping in his right leg reduced obviously. According to his feedback, we adjusted the formula again. 6 dosages in total.

 

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

The patient got big improvement in the burning sense of the eyes. The amount of phlegm reduced. The pain in his left hip joint was alleviated too. The formula is the same as before.

 

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

The patient got obvious improvement of his weakness in the four limbs, especially in the upper limbs and neck. The breath became normal. The symptoms of difficulty in speaking and inarticulateness improved a lot. The ability of swallowing was fine. The function of the fingers improved too. He could go out for a walk and play on the flat ground without using the wheel chair today.

 

Date: June 3, 2010.                                                 Time: 10: 00 a. m.

Compared with before, the patient's conditions got obvious improvement. After the 76 days of comprehensive treatment here including herbal tea, massage and acupuncture, all his symptoms improved a lot. His spirit, appetite and sleeping were very good. The patient decided to leave the hospital tomorrow. 

 

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