TCM China:  

Record of Herbal Treatment Of Michel from Brazil Improvement Of  ALS
 

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Brief Summary: On Mar. 2, 2009, Michel from Brazil, who has suffered from ALS, accompanied with the symptoms of the weakness of his right fingers for 10 months and hoarse voice for 4 months, was hospitalized in our hospital. He has achieved significant improvement after 30 days TCM treatment here.

 

Record of Hospitalization

Name: Michel                                                                                                      Birthplace: Brazil

Sex: Male                                                                                                            Profession: Retired

Age: 70                                                                                                               Nationality: Brazil

Marital Status: Married                                                                                     Onset Season: The Summer Solstice

Date of Admission: Mar. 2, 2009                                                                       Date of Record: Mar. 2, 2009

Complainer: The patient himself

 

First Medical Record

Date: Mar. 2, 2009                                        Time: 2: 00 a. m.

Michel, a 70-year-old male, has suffered from the symptoms of the weakness of his right fingers for 10 months and hoarse voice for 4 months. His condition became more serious, so he was hospitalized in our hospital for treatment on Mar. 2, 2009.

Essentials for Diagnosis:

1. The patient has suffered from the symptoms of the weakness of the right fingers for 10 months and hoarse voice for 4 months. His condition became more serious.

2. Last May, the patient felt the weakness of his right fingers without obvious reasons. At that moment, he didn¡¯t pay much attention to this and had not taken any examination and treatment. Later his condition gradually became worse. So last October he went to local hospital for EMG examination and was diagnosed with ALS, then the doctor prescribed Rilutek capsules for treatment, twice a day. Now he felt the weakness of the hands, especially the right hand. The flexibility of his right fingers declined. There were slight spasms and jumping of the muscles all over the body. In recent four months, the patient felt his condition obviously became more serious. He had hoarse voice when he was speaking. There was no obvious improvement after the treatment, so he came to our hospital for further treatment. He had pale tender-red tongue. There were teeth marks on the edges of the tongue and cracks in the middle of the tongue. He had wiry pulse. His spirit, appetite, urine and bowel movement were normal.

3. T 36.5¡æ, P 80 times/minute, R 20 times/minute, BP 190/90mmHg.

4. He grew normally with common nutrition. His mind was clear. He had an expression of chronic illness and tiredness. His body was in a positive posture and he was cooperative with clear 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. The patient felt the weakness of the hands, especially the right hand. The flexibility of his right fingers declined. There were slight spasms and jumping of the muscles all over the body. He had hoarse voice when he was speaking. His blood pressure was a little high. The gripping power of his left hand was 15.6 kg, and that of his right hand was 6.8 kg. He had pale tender-red tongue. There were teeth marks on the edges of the tongue and cracks in the middle of the tongue. He had wiry pulse.

7. Accessory examination: EMG showed that he had ALS.

Diagnostic Basis:

TCM: The patient has suffered from the weakness of the right fingers for 10 months and hoarse voice for 4 months. These conditions became more serious. He felt the weakness of the hands, especially the right hand. The flexibility of his right fingers declined. There were slight spasms and jumping of the muscles all over the body. He had hoarse voice when he was speaking. The patient was mainly characterized by disabled wilted limbs, so it was not difficult to be diagnosed as wilting pattern.

Western Medicine: The patient has suffered from the weakness of the right fingers for 10 months and hoarse voice for 4 months. These conditions became more serious. He felt the weakness of the hands, especially the right hand. The flexibility of his right fingers was good as before. There were slight spasms and jumping of the muscles all over the body. He had hoarse voice when he was speaking. The gripping power of his left hand was 15.6 kg, and that of his right hand was 6.8 kg. So last October he was given EMG examination which showed that he had 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 tumor of spinal cord, which is characterized by nerve root pains of the upper limbs, but without extensive trembling of the muscle bundles. Besides, there is disturbance of sensation and obstruction of the subarachnoid cavity. The disease can be diagnosed clearly by the examination of CT or MRI.

First Diagnosis:

TCM (Traditional Chinese Medicine) diagnosis: Wilting pattern

Symptom identification: Depletion of liver-kidney, obstruction of qi and blood.

Western Medicine diagnosis: 1. ALS

                                            2. Hypertension

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: supplement the liver, boost the kidneys, quicken the blood and free the channels and 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: Mar. 3, 2009                                       Date: 10: 30 a. m.

The patient has suffered from the weakness of the right fingers for 10 months and hoarse voice for 4 months. These conditions became more serious. Last May, he felt the weakness of the right fingers without obvious reasons, so he was given EMG examination in October which showed that he had ALS. Then he began to take Rilutek for treatment since Nov. 5, 2008. At present, he felt the weakness of the hands, especially the right hand. The flexibility of his right fingers declined. There were slight spasms and jumping of the muscles all over the body. He had hoarse voice when he was speaking. His blood pressure was a little high. His breath was normal. There were no symptoms of stomach pains and distension. His urine and bowel movement were normal. He didn¡¯t feel mouth dry and was fond of cold drink. His sleep was good, but he was easy to wake up and feel tired. He had pale tender-red tongue. There were teeth marks on the edges of the tongue and cracks in the middle of the tongue. He had wiry pulse. According to the symptoms of the tongue and pulse, Professor Yang believed that he had suffered from wilting pattern due to depletion of liver-kidney, obstruction of qi and blood, so the treatment strategy was to supplement the liver, boost the kidneys, quicken the blood and free the channels and network vessels. The prescription was as follows: baishao (white peony root), shanyao (dioscorea root), huangqi (astragalus root), etc. 3 dosages in total.

 

Date: Mar. 4, 2009                                       Time: 14: 30 p. m.

According to the feedback, the routine examinations of the blood and urine were normal. The function of the liver and kidneys were also normal except total bilirubin (20 umol/L) which was a little high compared with normal figure 5.1 umol/L-19 umol/L. 

 

Date: Mar. 5, 2009                                        Time: 9: 00 a. m.

His spirit and sleep were good. His urine and bowel movement both were normal. There were no obvious changes about the weakness and flexibility declining of the right fingers. Because the treatment period was comparatively short, the doctor suggested him take the same herbal tea. 4 dosages in total.

 

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

His spirit and sleep were good. His urine and bowel movement both were normal. The patient complained that there was obvious trembling of the muscles of his upper arms. He felt the weakness of the hands, especially the right hand. The other condition was normal. So the doctor added some herbs to extinguish wind and check tetany. 4 dosages in total.

 

Date: Mar. 9, 2009                                       Time: 12: 00 p. m.

The patient fell down due to incaution at 11 o'clock in the morning. He felt obvious pains of his left ankle joint, so the former prescription was changed a little. 4 dosages in total. Meanwhile, he was given X-ray examination of his left ankle joint.

 

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

He felt pains of his left ankle joint, so he was given CT and X-ray examination which showed that he had fracture of the left fibula¡¯s far end. Then he was given the plaster to fix the end of the fracture, and the doctor suggested him lie down to have a good rest.

 

Date: Mar. 13, 2009                                       Time: 8: 40 a. m.

His condition was stable. He didn¡¯t complain about the pains of his left ankle joint, but there was slight swelling of his left foot. Compared with before, the trembling of the muscles of his upper limbs had lessened. The condition of his right limb was better than the left limb. The prescription was as follows: jixueteng (millettia root and stem), danggui (tangkuei), honghua (carthamus flower), etc. 4 dosages in total.

 

Date: Mar. 17, 2009                                      Time: 10: 00 a. m.

His condition and sleep were good. His urine and bowel movement both were normal. The patient didn¡¯t complain about the pains of his left ankle joint and there was no swelling of his left foot. He said the jumping of the muscles of his pectoralis major, etc. obviously lessened. To some extent, the jumping of the muscles of his upper limbs also lessened. Continue the same prescription. 4 dosages in total.

 

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

His condition was stable. There were no obvious discomforts. His sleep was good. His urine and bowel movement were normal. Continue the same prescription. 5 dosages in total.

 

Date: Mar. 26, 2009                                       Time: 9: 30 a. m.

He didn¡¯t complain any discomforts. The jumping of the muscles obviously lessened. There was no swelling of his left foot. His sleep was good. His urine and bowel movement were normal. He said he had black stool in recent two days, but there was no abnormality when he passed the stool. Today he was given the routine examination of the stool. The former prescription was changed a little. 5 dosages in total.

 

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

The patient decided to leave the hospital tomorrow and he took six months herbal tea for continuous treatment.

 

30/03/09

After a month of treatment, I feel confident and hopeful, like I never felt before, because I see now signs of improvement, little signs but visible ones. Tomorrow I will be going back to my country, Brazil, carrying with me enough herbs for six months, where I will continue the treatment. I hope signs of improvement will show magic and stronger, and I will recover somehow. My wife and I, wish to thank you all, doctors, nurses, translators and staff for your help and kindness.

 Michel Sallouti

Check the original handwriting here

 

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