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Brief Summary: On May 28, 2009, Vladimir from Israel, who has suffered from ALS, accompanied with the symptom of the weakness of the hands for 1 year, was hospitalized in our hospital. He has achieved much improvement after 51 days TCM treatment here. Compared with before, his speaking was clearer and more fluent. The gripping power of his hands increased. The slight muscular jumping of the arms and prothorax completely disappeared.

 

Record of Hospitalization

Name: Vladimir                                                                                                      Birthplace: Israel

Sex: Male                                                                                                              Profession: Businessman

Age: 69                                                                                                                 Date of Admission: May 28, 2009

Religion: Muslim                                                                                                   Date of Record: May 28, 2009

Marital Status: Married                                                                                        Onset Season: Summer begins

Complainer: The patient himself

 

First Medical Record

Date: May 28, 2009                                       Time: 1: 00 a. m.

Vladimir, a 69-year-old male, has suffered from ALS, accompanied with the symptom of the weakness of the hands for 1 year. He was hospitalized in our hospital at 1: 00 a. m. on May 28, 2009.

Essentials for Diagnosis:

1. The patient has suffered from the symptom of the weakness of the hands for 1 year.

2. Last May, the patient began to feel the weakness of the hands without obvious reasons, but he didn¡¯t pay much attention to this and hadn¡¯t taken any examination and treatment. Then the condition gradually became worse. In April 2009, he was given MRI examination in the local hospital and was diagnosed with ALS. The doctor told him there was no treatment for ALS except for Rilutek capsules. Besides, he didn¡¯t take any treatment. So he came to our hospital on May 28, 2009 for further treatment.

3. T 36.3¡æ, R 20 times/minute, P 80 times/minute, BP 140/80mmHg.

4. He grew normally with common 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 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, sometimes accompanied with pains. His hands were delicate and the ability to act was declining. The flexibility of the fingers was good. The gripping power of the left hand was 10.2 kg and that of the right hand was 9.2 kg. There was slight muscular jumping of the arms and prothorax. The function of his speaking declined. Sometimes he had the symptom of dry cough when drinking water.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient has suffered from the weakness of the hands for 1 year. He felt the weakness of the hands, sometimes accompanied with pains. His hands were delicate and the ability to act was declining. The flexibility of the fingers was good. The gripping power of the left hand was 10.2 kg and that of the right hand was 9.2 kg. There was slight muscular jumping of the arms and prothorax. The function of his speaking declined. Sometimes he had the symptom of dry cough when drinking water. His tongue was dark. His tongue coating was yellow and slimy. His pulse was wiry, thready and slippery. The patient was mainly characterized by limp, weak, and emaciated limb. According to the symptoms of the tongue and pulse, he was diagnosed with wilting pattern.

Western Medicine: The patient has suffered from the weakness of the hands for 1 year. He felt the weakness of the hands, sometimes accompanied with pains. His hands were delicate and the ability to act was declining. The gripping power of the left hand was 10.2 kg and that of the right hand was 9.2 kg. There was slight muscular jumping of the arms and prothorax. The function of his speaking declined. Sometimes he had the symptom of dry cough when drinking water. He was given MRI examination in the local hospital and was diagnosed with ALS in April 2009.

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 diagnosis: Wilting pattern

Symptom identification: qi vacuity and blood stasis, damp-heat obstructing the channels and network vessels.

Western Medicine diagnosis: 1. ALS

                                             2. Chronic hyperplasia of prostate gland

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: boost qi, quicken the blood circulation, clear heat, dispel dampness 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: May 28, 2009                                       Time: 9: 00 a. m.

The patient has suffered from the weakness of the hands for 1 year. Last May, he began to feel the weakness of the hands without obvious reasons and his condition was gradually worse. In April 2009, he was given MRI examination and was diagnosed with ALS. Then he took Rilutek capsules for 1 month. Presently the patient felt the weakness of the hands, sometimes accompanied with pains. His hands were delicate and the ability to act was declining. The function of his speaking declined. Sometimes he had the symptom of dry cough when drinking water. Besides, there was slight cough. He had the history of chronic obstructive pulmonary disease and hyperplasia of prostate gland. His mouth was dry and he drank much water. There was slight muscular jumping of the arms and prothorax. His weight reduced 5-8 kg in the recent months. He was easy to be tired. His heart was ok. His walking was normal. His urine was ok, but he had constipation. There was no obvious muscular atrophy all over the body. His BP was 140/80mmHg. The gripping power of the left hand was 10.2 kg and that of the right hand was 9.2 kg. His pulse was wiry, thready and slippery. His tongue was dark. His tongue coating was yellow and slimy. According to the symptoms of the tongue and pulse, Professor Yang believed that the patient had suffered from wilting pattern due to qi vacuity and blood stasis, damp-heat obstructing the channels and network vessels. So the treatment strategy for him was to boost qi, quicken the blood circulation, clear heat, dispel dampness and free the channels and network vessels. The prescription was as follows: baizhu (ovate atractylodes root), chuanxiong (ligusticum root), etc. 5 dosages in total.

 

Date: May 29, 2009                                       Time: 9: 00 a. m.

The feedback of the examination was as follows: Blood R (£­), Urine R (£­), Stool R (£­). The function of the liver and kidneys as well as blood fat was normal. The examination of type-B ultrasonic showed that the echo of liver parenchyma became thick. Doctor considered it as fatty liver. Besides, he had cyst in the left kidney.

 

Date: May 31, 2009                                       Time: 9: 00 a. m.

There was slight improvement of the weakness of the hands. But there was no obvious change of the muscular jumping. His sleep was ok. His urine and stool were normal. His tongue was pale red. His tongue coating was thin and yellow. His pulse was thready and slippery. The former prescription was changed a little. 5 dosages in total.

 

Date: Jun. 1, 2009                                       Time: 10: 00 a. m.

His speaking was clearer. The strength of the upper limbs increased, but there was slight muscular jumping of the arms and prothorax. There was discomfort in the throat and he consciously felt there was phlegm. The prescription was made a little change.

 

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

He felt the weakness all over the body and slight heavy sense. The other condition was ok. Doctor thought it was due to his diarrhea on Jun. 3 which had relation with dietary irregularities. So the prescription was changed and the doctor added some herbs to fortify the spleen and transform dampness. 5 dosages in total.

 

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

The strength increased and his speaking was clearer compared with before. He didn¡¯t feel the heavy sense all over the body. He had dry mouth, especially in the night. The prescription was changed. 5 dosages in total.

 

Date: Jun. 15, 2009                                       Time: 9: 30 a. m.

Compared with before, his speaking was clearer. The gripping power of the left hand was 12.2 kg and that of the right hand was 9.7 kg. He felt aching pains on his shoulders. His sleep was ok. His urine and stool were normal. Continue to take the same prescription. 5 dosages in total.

 

Date: Jun. 20, 2009                                       Time: 9: 00 a. m.

His condition was stable. There was no obvious change. His sleep was not good due to hot weather in the recent days. His pulse was wiry and thready. His tongue was pale. His tongue coating was thin and yellow. The prescription was the same as before. 4 dosages in total.

 

Date: Jun. 23. 2009                                       Time: 9: 00 a. m.

His condition was stable. His diet and sleep were normal. His pronunciation was clear and resonant. His sleep was ok. His urine and stool were normal. He kept in good mood. His tongue was slight moist, slippery and dark. His tongue coating was thin and yellow. The prescription was as follows: chuanxiong (ligusticum root), danggui (tangkuei), etc. 4 dosages in total.

 

Date: Jun. 30, 2009                                       Time: 9: 30 a. m.

His spirit and sleep were good. His urine and stool were normal. Compared with before, his speaking was obviously clearer. The strength of the hands increased. His tongue was pale with slightly dark. His tongue coating was thin and yellow. Continue to take the same prescription. 5 dosages in total.

 

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

His condition was stable. There was no obvious change. He was easy to sweat. The other condition was normal. The prescription was changed a little. 5 dosages in total.

 

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

The symptom of the weakness all over the body was improved. There was obvious improvement of sweating. His speaking was clear. His sleep was ok. His urine and stool were normal. The prescription was made a little change on the basis of the prescription on Jul. 5. 5 dosages in total.

 

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

His spirit and sleep were good. His urine and stool were normal. The weakness all over the body and pronunciation were improved. The doctor added fuxiaomai (light wheat grain) in the previous prescription. 5 dosages in total.

 

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

The patient said his condition was good. His pronunciation was resonant. There was no weakness all over the body. His sleep was ok. His urine and stool were normal. The prescription was the same as before. 5 dosages in total.

 

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

The patient decided to leave the hospital tomorrow.

 

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