Name: David T. Anderson                                                                                      Sex: Male

Age: 45                                                                                                                  Marital Status: Married

Nationality: American                                                                                            Date of Admission: Jan. 8, 2011

Companion: Alone

First Medical Record

Date: Jan. 8, 2011                                Time: 14:00 pm

This 45-year-old man had suffer from unclear speech for 11 months and muscle atrophy of the right upper limb for 6 months, accompanied by weakness and muscle jumpings all over the body. The patient was hospitalized in our hospital for TCM treatment at 14 pm on January 8, 2011.

Essential for Diagnosis:

1. The patient had suffered from unclear speech for 11 months and muscle atrophy of the right upper limb for 6 months.

2. The patient had complained of speech problem, weak wriggling of the facial and tongue muscles and weak chewing without any obvious cause of disease in March, 2010. Then, he went to local hospital to take MRI examination and EMG check. The report showed that Mr. David indeed had ALS. He took the medicine of Rilutek and vitamins for the treatment of ALS, but the therapeutic effects were not great. In August of the same year, there was evident muscular atrophy of the right upper limb, especially of the thumb web muscles and the muscles of the thenar and hypothenar. He lost weight for 20 pounds, accompanied by weakness and muscle jumpings over the whole body. In November, 2011, he began to take the herbal medicines delivered from our hospital for treatment, and his above-mentioned conditions were reduced somewhat.

3. When the patient hospitalized in our hospital, he had speech difficulty and swallowing problem and sometimes he suffered from coughs. The right upper limb was weak, accompanied by muscle atrophy. He was very easy to be tired and was feeling weak all over the body. Besides, he had muscle jumpings over the general body and occasionally had short breath and chest tightness. The patient felt dry in the mouth and liked hot drinking. Sometimes, he coughed with white and sticky sputum. He felt cold limbs. His spirit was ok. Anyway, He had good appetite and sleep. There was bowel movement one time a day. Urine was of yellow color. The tongue was slightly red with thin and yellow tongue-coating. In the middle of the tongue, there were cracks, and along the tongue edge, there were tooth marks. The surface of the tongue was a little uneven with weak wriggling of the tongue. The pulse was slippery.

4. T: 36.3¡ãC   R: 20 times/minute    P: 60 times/minute   BP: 104/70mmHg

5. He grows normally. The patient¡¯s daily food was of medium nutrition. He had conscious mind and natural facial expression, but the expression was exhausted. He could walk by himself. He cooperated with doctors when did the physical examination.

6. The formation and size of the thorax were normal. The breathing sounds of the lungs were clear, with no pathological murmurs. The heart rate was regular and it was 60 times per minute.

7. Examinations of MRI and EMG in March, 2010 in America showed the patient had been attacked by ALS.

Diagnostic Basis:

TCM: The patient complained of speech problem for 11 months, accompanied by weakness of the right upper limb and muscle atrophy for 6 months. Due to the long time of disease, the qi and blood of the patient had been damaged and it also caused the deficiency of intestines, spleen and qi, and therefore, speech problem, chewing difficulty and weakness over the whole body occurred. Nutrition could not be better digested due to the deficiency of intestines and spleen. And because of that, he suffered from muscle atrophy. Muscle jumpings over the general body were due to insufficiency of the liver and kidney. From the principle of TCM, deficiency of intestines, spleen and qi and liver-kidney yin deficiency were the characters of atrophy disease.

Western Medicine: According to the reports of electromyography and MRI and the symptoms of speech problem and muscle spasms over the general body, he should have suffered from ALS.

Diagnostic Differentiation:

TCM: Atrophy diseases are usually differentiated with Bi syndrome or impediment pattern. Atrophy diseases have such characteristics as atrophy of the limbs¡¯ muscles, the weakness of the limbs and the uselessness of the thin feet. The muscular atrophy and muscle jumpings are the main symptoms of atrophy diseases. The impediment patterns are reflected by the pains or tense pains on the body joints. So it is easy to differentiate them.

Western Medicine diagnosis: ALS should be differentiated with myasthenia gravis. Myasthenia gravis would be aggravated after exercises and it would be reduced after some rest. Almost no muscle atrophy and muscle jumpings. But ALS is caused by lesions of the central nervous system, accompanied by muscular atrophy and muscle jumpings. Therefore, there is no difficulty to differentiate them.

First Diagnosis:

TCM: atrophy disease

Symptom identification: liver-spleen qi vacuity and liver-kidney yin deficiency.

Western medicine diagnosis: ALS

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade ¢ò care.

3. Companion.

4. Common diet.

5. Pathogenesis: dampness and heat staying in the channels and joint points, qi vacuity and blood stasis, and deficiency of the livers and lungs.

6. TCM strategy: fortifying spleen, nourishing intestines and nourishing liver and spleen.

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

8. Acupuncture and massage: once a day

9. Have more medical examination if necessary.

Date: Jan. 9, 2011                                          Time: 10:00 am

Professor Zhang, associate chief physician, paid a visit to the patient. The patient complained of disfluency in speech, occasional coughing, swallowing problem, and weakness over the whole body and muscle jumpings. There was evident muscle atrophy on the right upper limb, especially on the thenar and hypothenar eminences and tucks muscles. He was easy to be fatigue after doing some exercise. Occasionally, the patient suffered from short breath and choking sensation in the chest. He felt dry in the mouth and liked warm drinking. He expectorated with white and viscous sputum. The patient always felt cold in the four limbs. He had normal spirit and good appetite and sleep. One time of bowel movement everyday. The tongue was light red with thin and yellow tongue coating. There were cracks in the middle of the tongue, teeth prints on the edge of the tongue and slightly rough and uneven tongue surface. The pulse was slippery. He had the medical history of asthma. Professor Zhang thought from the TCM principle that the patient¡¯s conditions were due to the deficiency of intestines, spleen and qi and the deficiency of liver, spleen and yin.  He suffered from atrophy diseases. The TCM formula should have the functions of invigorating intestines, fortifying spleen and nourishing liver-kidney.

Date: Jan. 10, 2011                                          Time: 10:00 am

The patient said there was slightly reduce in the dry taste in the mouth. No change on other conditions.

Date: Jan. 12, 2011                                          Time: 10:15 am

The patient complained of bad sleep those days and no evident change on the muscle jumpings of the upper limbs and muscles behind the legs of lower limbs. Yesterday, the stool was watery but he did not sugger from diarrhea. Urine was good. Thirst in the mouth was reduced and the saliva was much. The tongue was slightly red with thin and yellow tongue coating. There were cracks in the middle of the tongue, teeth prints on the edge of the tongue and slightly rough and uneyen tongue surface. No obvious change on the creeping motion of the tongue body. The pulse was slippery.

Date: Jan. 16, 2011                                           Time: 10:30 am

The patient said muscle jumpings of the muscles behind the legs were reduced, even though no evident change on the muscles of the two upper limbs and back. There was some improvement in speech problem, dry taste and the quantity of saliva in the mouth. There was some increase of the tucks muscles. The tongue was slightly red with thin tongue coating. The pulse was slippery and weak. His spirit, appetite and sleep were good.

Date: Jan. 20, 2011                                          Time: 10:00 am

The patient complained of bad sleep due to the noise of the air conditioner in recent two days. He felt obvious muscle jumpings during the night. The power of the two hands was increasing. The patient felt slightly dry in the mouth. The quantity of saliva was basically normal. The tongue was slightly red with thin and yellow tongue coating. The pulse was slippery but a little bit powerful.

Date: Jan. 24, 2011                                          Time: 10:00 am

The patient felt better those days. He did not suffer from asthma since being hospitalized in our hospital. Swallowing was good. He sometimes got coughing when drank water too fast. Strength over the whole body was increasing. The power of gripping: right hand, 13.1kg, left hand, 27.4kg. Muscle jumpings were reduced. The patient did not feel too dry in the mouth any more. And the quantity of saliva was basically normal. The tongue was slightly red with thin and yellow tongue coating. The pulse was slippery.

Date: Jan. 28, 2011                                          Time: 9:00 am

The patient had nasal obstruction, dry feeling in the throat and mouth and weak sensation over the general body due to catching a cold recently. He did not cough. Sleep was not so good. Speech was better. There was no evident change on muscle jumpings.

Date: Jan. 31, 2011                                          Time: 9:00 am

The patient said he had recovered from cold.

Date: Feb. 5, 2011                                           Time: 10:00 am

The patient felt less muscle jumpings these days, especially during the night. Other conditions were stable. The tongue was a little bit red with white and thick tongue coating. The pulse was slippery.

Date: Fed. 9, 2011                                           Time: 11:00 am

Muscle jumpings were reduced, but there were still some jumpings on the muscles of the upper limbs, shoulders and back. He did not feel dry in the mouth and throat any more. Swallowing was good. The strength of the four limbs was increasing and the motion of the two hands was better than before. The tongue was a little bit red with white and thick tongue coating. The pulse was slippery.

Date: Feb. 12, 2011                                         Time: 11:10 am

The patient¡¯s conditions were stable recently. The mouth was a little dry. Appetite and sleep were good.

Date: Feb. 16, 2011                                            Time: 9:30 am

The patient said the strength over the whole body was increasing. It was easy for him to do some exercise. The muscle jumpings over the general body were reduced to around 60%. There was a sense of sore pains on the region of the right cheek bone, but it was much better than 3 days ago. Speech was better. Swallowing was good. He felt dry in the mouth during the night. When he lied on his side, he liked to breathe with his mouth open. The motion of the tongue was more flexible than before. There was some improvement in the uneven tongue surface. The tongue was red with white and slightly yellow tongue coating. The pulse was slippery.

Date: Feb. 21, 2011                                            Time: 9:00 am

Conditions of the patient were keeping better. Appetite and sleep were good. He felt weak when spoke with slow tempo.

Date: Feb. 25, 2011                                            Time: 9:00 am

The patient said his conditions were better. Appetite, sleep and swallowing were good. He did not feel dry in the mouth any more. Muscle jumpings on the right upper limb were a little obvious. The weak sense of the speaking was turning better. The tongue was red with thin tongue coating. The pulse was thin and slippery.

Date: Feb. 28, 2011                                            Time: 10:00 am

The patient complained of no special change on his conditions in recent 3 days. He felt dry in the mouth. Sleep was not so good. The tongue was red with thin and yellow tongue coating.  

Date: Mar. 4, 2011                                            Time: 10:00 am

The patient said his conditions were turning better. The strength over the whole body was increasing. Dry taste in the mouth dispelled. He could sleep around 7 hours. Except that muscle jumpings on the right upper limb were still evident, muscle jumpings on other parts were reduced. The phlegm in the throat was gone.

Date: Mar. 8s, 2011                                            Time: 10:00 am

The patient complained that the weak sense of speaking sometimes was good but sometimes was bad. The tempo of speech was slow. Other conditions were turning better and better.

Date: Mar. 12, 2011                                            Time: 10:00 am

The conditions of the patient were stable those days.

Date: Mar. 18, 2011                                            Time: 9:30 am

The patient said his conditions were better. And he asked to leave the hospital tomorrow.

Date: Mar. 19, 2011                                            Time: 10:00 am

After more than 2 months TCM treatment, the patient requested to leave hospital today. After treatment in our hospital, the patient¡¯s conditions were much better than before. He did not suffer from choking, swallowing problem, the peristaltic facial muscles, dryness in the mouth, short breathing, chest tightness and cold limbs any more. There were some evident improvements on speech problem, chewing weakness, weak sense of the general body and muscle jumpings. Since he was hospitalized in our hospital, his asthma had been controlled without any recurrence.

Doctor¡¯s advice after leaving hospital:

1. Maintain good moods.

2. Take 30 days herbal medicine back for continuing treatment.

3. Avoid wind-cold and be careful with the cold.