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Record of Herbal Treatment Of Ramzi from Lebanon Improvement Of  ALS

 

 

 

 

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Brief Summary: On April 19, 2012, Fatima, from Libya, who had been suffering skin impediment in traditional Chinese medicine (TCM) or systemic sclerosis in the concept of western medicine, accompanied by tightness, atrophy and ulcer over the skin of her face, elbows and the parts below her knee joints for 19 years, was hospitalized in our hospital. She achieved significant improvement after 74 days TCM treatment.

 

Record of Hospitalization

 

Name: Fatima                                   Sex: Female

Age:47                                             Marital Status: Married

Nationality: Libyan                           Date of Admission: Apr. 19, 2012

Companion: Her Husband

 

First Medical Record

Date: Apr. 19, 2012                               Time: 11:00 am

This 47-year-old lady had been suffering from skin impediment, accompanied by tightness, atrophy and ulcer over the skin of her face, elbows and the parts below her knee joints for 19 years. The patient was hospitalized in our hospital for TCM treatment at 00:00 am on April 19, 2012.

 

Essential for Diagnosis:

1. The patient had been suffering from tightness, atrophy and ulcer over the skin of her face, elbows and the parts below her knee joints for 19 years. She had entered menopause for 18 years.

2. When the patient came to our hospital, skins over her face, elbows and regions below knee joints were tight. Fingers and toes suffered ulcers. Hands felt cold. The four limbs were stiff and heavy. She felt feverishness in palms and soles sometimes. She could walk for 1 km, but if walked for a long time, she felt burning and pricking pains over her feet. She had slightly headache. She had occasional dizziness and tinnitus. She suffered vision loss. Her eyes were dry and itchy. She could not open her mouth fully. She felt dryness and slight bitterness in her mouth. She liked drinking warm water. Her throat was dry without phlegm. Swallowing was not very smooth. Her appetite was good. She had no gastric pains or abdominal distension. Bowel movement was once in one or two days. Urine sometimes was clear, while sometimes was yellowish.

3. T: 36.5°C   R: 20 times/minute    P: 71 times/minute   BP: 120/70mmHg

4. The patient was alert and cooperative and had a positive body position. She grew normally with emaciation and old face. Her scalp became thin and her hair became sparse. Her facial complexion was dark without any luster. Her face was full of dark red spots, and when pressing these spots, the color faded. Her skin was stiff and atrophy. Skins over her forehead and tips were shrinking.  Both eyes were depressed and her nose wing was thin and sharp. Auricle became small with stiff skin and low elasticity. She could not open her mouth fully. She felt tired to extend her tongue. She suffered loss of teeth and wore dentures. Skins over her neck, upper arms, legs and buttocks were rough. Pigmentation was seen from the elbow tips to the wrists and over the knees. The joints were shrinking with dark brown color. Joints of the fingers and toes were stiff and deformed and shortened. Finger-tip and toe-tip bones were of intercept shape. There were ulcers over her hands and feet. Reflection of her knee tendons was reduced. Skins over her front chest, her back, and joints of her wrists and ankles were shrinking. Pigment loss was seen over her hand back and finger joints; and skins over these pigment loss region were white. Her tongue was red with yellowish coating. Her pulse was thready, wiry but rapid.

 

Diagnostic Basis:

TCM: Skin over the patient’s face and elbows and below the knees became hard and atrophic, accompanied with ulcers for 19 years. Skin over her whole general body was rough. These symptoms belong to the skin impediment in TCM. She suffered deficiency of the liver and kidneys since she entered the menopause period, which caused that the liver-blood could not nourish the skin and muscle. Kidney deficiency led to tinnitus. Due to long duration of the disease, it caused blood stasis and abnormal circulation of blood and qi; therefore, ulcer, color mottles, burning pains and pricking pains were seen. So, her conditions could be diagnosed as skin impediment, due to the deficiency of the liver and kidneys and the stagnation of blood and blockage of channels.

Western Medicine: Skin over the patient’s face and elbows and below the knees became hard and atrophic, accompanied with ulcers for 19 years. Skin over her whole general body was rough, with color mottles in some parts of the body and pigmentation. The joints of her fingers and toes were stiff, deformed and shortened. She felt limitation on opening her mouth. Her condition had been diagnosed as systemic scleroderma at her local hospital.

  

First Diagnosis:

TCM: Skin impediment.

Symptom identification: the deficiency of liver and kidneys as well as the stagnation of blood and blockage of channels.

Western medicine diagnosis: Systemic sclerosis.

 

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade care.

3. Common diet.

4. Pathogenesis: the deficiency of the liver and kidneys and the stagnation of blood and blockage of channels.

5. TCM strategy: nourishing the liver and kidneys, promoting blood circulation and removing blood stasis.

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

7. Acupuncture and massage: once a day

8. Have more medical examination if necessary.

 

Date: Apr. 20, 2012                                             Time: 9:00 am

Doctor Zhu Ming paid a visit to the patient. The patient complained that skin over her face, elbows and regions below knee joints was tight. Fingers and toes suffered ulcer. Hands felt cold. The four limbs were stiff and heavy. She felt feverishness in palms and soles sometimes. She could walk for 1 km. But if walked for a long time, she felt burning and pricking pains over her feet. She had slightly headache. She had occasional dizziness and tinnitus. She suffered vision loss. Her eyes were dry and itchy. She could not open her mouth fully. She felt dryness and slight bitterness in her mouth. She liked drinking warm water. Her throat was dry without phlegm. Swallowing was not very smooth. Skin over her forehead and tips was shrinking.  Both eyes were depressed and her nose wing was thin and sharp. Auricle became small with stiff skin and low elasticity. She could not open her mouth fully. She felt tired to extend her tongue. She suffered loss of teeth and wore dentures. Finger-tip and toe-tip bones were of intercept shape. There were ulcers over her hands and feet. Her tongue was red with yellowish coating. Her pulse was thready, wiry but rapid.

From the view of TCM, Zhu Ming, the doctor thought that the case of the patient could be diagnosed as skin impediment, due to the deficiency of liver and kidneys as well as the stagnation of blood and blockage of channels.

 

Date: Apr. 21, 2012                                             Time: 9:00 am

Examination feedback: WBC 3.8*109/L, Urine-R (-), Stool-R (-), Blood-LF (-), SPS (-), BS (-), HIV (-); ECG: sinus rhythm, P-R interphase shortened. The functions of the liver, gallbladder, spleen, pancreas and kidneys were normal. Uterine adnexas were not clear.

 

Date: Apr. 22, 2012                                             Time: 9:00 am

The patient said there was no obvious improvement in her conditions. Continued the previous prescription.

 

Date: Apr. 25, 2012                                             Time: 9:00 am

The patient felt more flexibility over her ankle joints. Pains over her feet were reduced somewhat.

 

Date: Apr. 28, 2012                                             Time: 9:00 am

The patient said she felt her body was more relaxed than before. At the same time, she could walk longer than before.

 

Date: May 3, 2012                                              Time: 9:00 am

Ms. Fatima said skins over her whole body were softer than before and her ankle joints were flexible than before. There was no heat over her palms and soles. Pains over her ulcer were reduced somewhat. Her tongue was red with yellowish coating. Her pulse was thready and wiry but rapid.

 

Date: May 7, 2012                                              Time: 9:00 am

The patient’s condition was stable without any special changes. Her tongue was pale with yellowish coating. Her pulse was thready and wiry but rapid.

 

Date: May 12, 2012                                              Time: 9:00 am

The patient said her condition was better. Skins over her whole body were softer. Pains over the ulcer regions of her limbs end were reduced. Her tongue was slightly red with yellowish coating. Her pulse was thready and rapid.

 

Date: May 17, 2012                                              Time: 9:00 am

The patient said her conditions were better. Wrists joints were much more flexible than before. Her tongue was slightly white, with teeth marks on the tongue sides. The tongue coating was yellow and greasy in the middle of the tongue.

 

Date: May 21, 2012                                              Time: 9:00 am

The patient said there were pains over the ulcer regions of her soles. Other symptoms were just like before. Her tongue was slightly white with yellowish and greasy coating. Her pulse was thready and wiry.

 

Date: May 24, 2012                                              Time: 9:00 am

Condition of the patient was stable. Pains over her ulcer regions were reduced.

 

Date: May 28, 2012                                              Time: 9:00 am

The patient complained that there still were pains over the ulcer region of her soles. Joints movement of her ankles and wrists were more flexible. Her tongue was white with yellowish tongue coating. Her pulse was thready and wiry.

 

Date: Jun. 1, 2012                                               Time: 9:00 am

The patient suffered burning feeling over her stomach last night. Other conditions were just like before.

 

Date: Jun. 4, 2012                                               Time: 9:00 am

The patient said that there were no burning feelings over her stomach. Pains over the ulcer regions of her soles were better. Her tongue was slightly red with yellowish coating. Her pulse was thready and wiry. 

 

Date: Jun. 7, 2012                                               Time: 9:00 am

The patient said her condition was better. The ulcer surface had been scabby. Skins over her whole general body were softer than before. Black brown parts on her front chest, elbows and knees became lighter. Her tongue was slightly red with yellowish coating. Her pulse was thready and wiry.

 

Date: Jun. 10, 2012                                               Time: 9:00 am

The patient said her condition was the same as days before.

 

Date: Jun. 15, 2012                                               Time: 9:00 am

The patient said her condition was the same as days before. She had no difficulty in swallowing. There was no uncomfortable feeling over her throat or burning feeling over her stomach. Her tongue was pale with yellowish tongue coating. Her pulse was wiry and thready.

 

Date: Jun. 18, 2012                                               Time: 9:00 am

The patient said her condition was the same as days before. There was no special improvement in her condition. Her tongue was pale with yellowish tongue coating. Her pulse was wiry and thready.

 

Date: Jun. 21, 2012                                               Time: 9:00 am

The patient said skins over her whole general body were softer than before. Pains also were reduced a lot. Her tongue was pale with yellowish tongue. Her pulse was wiry and thready.

 

Date: Jun. 24, 2012                                               Time: 9:00 am

Condition of the patient was stable. Her tongue was pale with yellowish tongue coating. Her pulse was wiry and thready. Continued the previous treatment prescription.

 

Date: Jun. 27, 2012                                               Time: 9:00 am

The patient complained of slight edema over her feet back. Other symptoms were the same as days before. Her tongue was pale with yellowish tongue coating. Her pulse was wiry and thready.  

 

Date: Jul. 1, 2012                                                Time: 9:00 am

Fatima said edema over her feet back was better. Skin over her whole body was softer than before. Pains over her ulcer regions were reduced evidently. She no longer felt cold over her hands and feet. No more abnormal heat over her palms and soles. Stiffness of the joints of her four limbs changed better. Dizziness and tinnitus were gone. Eyes were no longer dry and itchy. She no longer felt bitter in her mouth and dry in her throat. Swallowing was normal. Facial complexion was much lustrous than before. The color of pigmentation region was fade out somewhat. Joints of her fingers and toes were flexible than before. For the expiration of visa, Ms. Fatima asked to leave our hospital today.

 

Doctor’s advice after leaving hospital:

1. Avoid wind-cold, maintain good moods, and take care of the diet. 

2. Take herbal medicine back for continuing treatment.