Records of Hospitalization
Name:
Joern Sex:
Male
Age:
60 years
Profession: Travel
Director
Nationality:
Denmark Marital
status:
Married
Onset
Season:
Summer
Date of
Admission:
Jan. 6th, 2006
Complainer:
The patient himself Reliability:
Reliable
Major
complaint:
The patient has suffered from weakness and amyotrophy of the left lower limbs
for 2 years with six-month walking lamely condition.
Present illness:
In January of 2006, the patient began to have weakness of the left lower limbs
without any obvious cause. At that time, the patient didn¡¯t pay enough attention
to nor do anything about it. In June of 2006, he began to have muscular spasm
and atrophy in his left lower limbs, walking lamely; however, he had no
treatment for those symptoms. In Sep. 2006, he was diagnosed as ALS by EMG and
affection of Borelin by LP in the local hospital, where he got three-month oral
medication called Runterk which was to be proved effectless. And in Dec. 2006 he
took twenty-day herbal tea posted to him from our hospital, after which he felt
certain symptomatic improved. So he came to our hospital for further treatment.
Since he had the disease, his spirit, appetite and sleep had been good,
and his urination and defecation normal.
Past history:
No history of typhoid, tuberculosis, malaria and hepatitis. No allergic history
of medicine or food. No operation history. No history of preventive vaccination
provided. In May of 2005 he had plastic operation meniscus.
Personal history:
He was born in Denmark. No contact history of schistosomiasis. No addiction to
smoking, alcohol or special food. And he was even-tempered and optimistic.
Marital history:
He was married at 25 and had given birth to a
son and a daughter. His wife and children have been healthy all the time.
Family
history:
Her parents were both healthy. No history of special disease.
Physical examination
T 36.5¡æ£¬P
78 bpm, R 20bpm, BP 130/80mmHg, W 86kg
He is
mid-nourished and normally developed. His mind is clear. He has an expression of
chronic illness and languidness. He is in a positive position and cooperative in
examination. His skin is moist. No jaundice in the sclera. No superficial
lymph-node enlargement. Bilateral pupils are round and equal in size and
sensitive to light. No chest deformity. Sound of breath is bilaterally normal on
auscultation. No respiratory rales or pleural friction rubs. Heart border is
normal. Heart beat 78/min. Cardiac rhythm is regular. No pathological murmurs on
auscultation. Abdomen touches flat and soft
without tenderness or rebound tenderness. Liver and spleen are not palpable. No
percussion pain in renal region. Bowel sound is normal. No spinal and pelvic
deformity or tenderness. No deformity or inflexibility of the right lower
extremity or upper ones. The condition of the left lower extremity will be
discussed in the next paragraph. The development of his anus or pudendum
is normal. His tongue body is dull red with thin and white coating, and his
pulse deep, thread-like and loose.
Left
lower limbs:
weakness and mild amyotrophy. The circumference of the right thigh measured 12cm
above the knee joint is 42cm, while that of the left one is 44cm. Measured
around 14cm below the knee joint, the circumference of the left leg is 34cm,
while that of the right one is 36cm. Muscular strength is normal but muscular
tension is weakerl. There are obvious muscular jumps in his left thigh and right
leg.
Diagnostic examination:
In Sep. 2006, he was diagnosed as ALS by EMG in a local hospital.
First
diagnosis:
TCM diagnosis:
Wei-syndrome (flaccidity syndrome)
Symptom
diagnosis: liver and kidney deficiency; spleen and stomach qi-asthenia.
WM diagnosis:
ALS
First
Medical Record
Jan. 6th 2007
Joern, a
60-year male, the patient has suffered from weakness and amyotrophy of left
lower extremity for 2 years with six-month condition of walking lamely. He came
to the TCM Dep. of Huaihua Red Cross Hospital on Jan. 6th 2007.
Essentials for diagnosis:
1. Weakness
and amyotrophy of the left lower extremity for two years; walking lamely for
half a year.
2. In Jan.
2006, the patient began to have weakness of left lower extremity without any
obvious cause. At that time, the patient didn¡¯t pay enough attention to nor do
anything about it. In Jun. 2006, he began to have muscular spasm and atrophy in
his left lower limb, walking lamely; however, he had no treatment for those
symptoms. In Sep. 2006, he was diagnosed as ALS by EMG and affection of Borelin
by LP in a local hospital, where he got three-month oral medication called
Runterk which was of no effect. And in Dec. 2006 he took twenty-day herbal tea
posted by our hospital, after which he felt certain symptomatic improvement. So
he came to our hospital for TCM treatment. Since he had the disease, his spirit,
appetite and sleep were good, and his urination and
defecation were normal.
3. T 36.5¡æ£¬P
78bpm, R 20bpm, BP 130/80mmHg, W 86kg
4. He is
mid-nourished and normally developed. His mind is clear. He has an expression of
chronic illness and languidness. He is in a positive position and cooperative in
examination.
5. He has
weakness and mild amyotrophy in left lower extremity. The circumference of the
right thigh measured 12cm above the knee joint is 42cm, while that of the left
one was 44cm. Measured around 14cm below the knee joint, the circumference of
the left leg is 34cm, while that of the right one is 36cm. Muscular strength is
normal but muscular tension weaker than normal. And there are obvious muscular
jumps in his left thigh and right leg. His hands are normal.
6. No thoracic
deformity. Chest percussion noted resonance. Sound of breath is bilaterally
clear on auscultation. No sound of pleural friction.
7. Diagnostic
examination: In Sep. 2006, he was diagnosed as ALS by EMG in a local hospital.
Diagnostic basis
TCM:
He has
weakness and mild amyotrophy of left lower extremity for two years with
six-month condition of walking lamely. There exists flaccidity of sinews and
vessels in his left lower extremity. And there are obvious muscular jumps in his
left thigh and right leg.
Western medicine:
He has weakness and mild amyotrophy in left lower extremity. The circumference
of the right thigh measured 12cm above the knee joint is 42cm, while that of the
left one was 44cm. Measured around 14cm below the knee joint, the circumference
of the left leg is 34cm, while that of the right one is 36cm. Muscular strength
is normal but muscular tension weaker than normal. And there are obvious
muscular jumps in his left thigh and right leg.
Diagnostic differentiation
TCM: The
patient¡¯s Wei-syndrome should be differentiated from Bi-syndrome. Although they
both fall into the category of limb disease, they are different in pathogeny,
pathogenesis and clinical manifestations. Wei-syndrome is characterized as limp,
weak and emaciated limbs with shriveled muscles. A patient suffering from Wei-syndrome
may even become unable to hold an object or to stand without support. Besides,
the patient¡¯s lower limbs are more often affected, though he or she usually has
no joint pain. On the contrary, Bi-syndrome is generally characterized as aching
pain, fixed heaviness and inflexibility of sinews and bones, muscles and joints,
with occasional numbness or swelling, though, no paralytic manifestations. The
pathogenesis of Wei-syndrome is that the essence and blood in five-fu organs is
insufficient to travel through the whole body leading to malnourish of the
meridians and collaterals; while that of Bi-syndrome is that the obstruction of
meridians and collaterals by pathogenic qi blocks the circulation of qi and
blood. They are not difficult to be distinguished in clinics.
WM: Wei-syndrome
should be differentiated from myasthenia gravis which can occur at any age and
strikes typically between ages 10 and 35. Women are more often affected than
men. The most obvious characteristic of MG is rapid fatigability of the skeletal
muscles affected, improved with rest in various degrees. The patient¡¯s condition
fluctuates, relatively better in the morning and worse at dusk. The onset is all
of a sudden, often begun with a group of muscles, and as time goes on, the
disease progressively affects other groups. It is most common that the cranial
innervate muscles are often the first group of muscles to be affected evidenced
by the fact that about 90 percent of persons with MG have such initial symptoms
as drooping eyelids (ptosis) and double vision (diplopia). And the bulbar
muscles and girdle muscles are often the second group of muscles to be affected.
MG patients of different ages often have different clinical manifestations and
courses which are different from those of Wei-syndrome paients.
First
diagnosis:
TCM diagnosis:
Weizheng (flaccidity syndrome)
Symptom
diagnosis: liver and kidney deficiency; spleen and stomach qi-asthenia.
WM diagnosis:
ALS
Plan
of treatment strategy and nursing
1. On routine
care of traditional Chinese internal medicine
2. On grade II
care
3. Under care
of a companion
4.
High-protein diet
5. Herbal tea
(to nourish liver and kidney and to invigorate spleen and replenish qi): one
dosage a day and drink by twice
Main herbs
used in the herbal tea: Shudi (Cooked Rehmannia), Baishen (White Ginseng), Tubie
(Wingless cockroach), Zaopi (Cornus), Niuxi (Achyranthes), Ruxiang
(Frankincense), Moyao (Myrrh), Suoyang (Cynomorium), Yimi (Coix), Zhimu (Anemarrhena),
Jixueteng (Millettia), Baizhu (Ovate Atractylodes).
6. Acupuncture
and massage: once a day
7. Have more
medical examinations if necessary
Date:
7th of Jan. 2007
Time: 9:00 a.m.
In today¡¯s
doctor¡¯s rounds, the patient told Dr. Yang that he has weakness of left lower
extremity and difficulty in walking.
Examinations: T 36.5¡æ£¬P
78bpm, R 20bpm, BP 130/80mmHg, W 86kg.
The patient
has weakness in left lower extremity and difficulty in walking. The
circumference of his right thigh measured 12cm above the knee joint is 42cm,
while that of the left one was 44cm. Measured around 14cm below the knee joint,
the circumference of the left leg is 34cm, while that of the right one is 36cm.
Muscular strength is normal but muscular tension weaker than normal. And there
are obvious muscular jumps in his left thigh and right leg. His tongue is dull
red with thin and white coating, and his pulse deep, threadlike and loose. In
Sep. 2006, he was diagnosed as ALS by EMG in a local hospital.
Dr. Yang¡¯s
analysis:
1. According
to those manifestations, the patient¡¯s disease falls into the category of
Wei-syndrome (flaccidity syndrome)
which
refers to the flaccidity and weakness of extremities leading to inability to
move freely. In clinics, amyotrophy and weakness of lower extremities are
eminent. The cause of the disease can be external or internal. The external
cause is the long-term infiltration of splenic and gastric fluid by exogenous
pathologic factors such as warmth, heat, toxin, and damp heat. While the
internal causes are always impaired function of the zang-fu organs due to
factors such as irregular diet, chronic illness, or overstrain, etc., leading to
the asthenia of spleen and stomach and consumption of liver and kidney. The
condition of chronic wei-syndrome patients will become critical if the splenic
and renal essence and qi are severely exhausted.
2. Symptom
diagnosis: liver and kidney deficiency; spleen and stomach qi-asthenia.
3. Principle
of TCM treatment: to nourish liver and kidney and to invigorate spleen and
replenish qi. Main herbs used in the herbal tea for six days: Shudi (Cooked
Rehmannia), Baishen (White Ginseng), Tubie (Wingless cockroach), Zaopi (Cornus),
Niuxi (Achyranthes), Ruxiang (Frankincense), Moyao (Myrrh), Suoyang (Cynomorium),
Yimi (Coix), Zhimu (Anemarrhena), Jixueteng (Millettia), Baizhu (Ovate
Atractylodes). A daily dosage should be decocted twice.
4. Other
treatments or examinations: daily acupuncture and massage; have more medical
examinations if necessary.
Date:
8th of Jan. 2007 Time:
9:00 a.m.
Today the
patient has no discomforts such as headache, dizziness, nausea, vomit, fever or
aversion to cold, except weakness in left lower extremity and difficulty in
walking. He has no problem with spirit and appetite, and he has had a good
sleep. His bowel movement and urination are normal. His heart and lungs are
normal. His abdomen is flat and soft. The condition of his left lower limb
remains the same. His tongue is dull red with thin and white coating. His pulse
is deep, threadlike and loose. Doctor¡¯s request: the herbal tea should follow
the original formulation.
Date:
9th of Jan. 2007
Time: 9:00 a.m.
Today the
patient has no discomforts such as headache, dizziness, nausea, vomit, fever or
aversion to cold, except weakness in left lower extremity and difficulty in
walking manifested as walking lamely. He has no problem in spirit and appetite,
and he has had a good sleep. His bowel movement and urination are normal. He has
had routine blood, urine and stool test, liver function test, hepatitis-B test,
kidney function tests, blood sugar test, blood fat test, of which the results
are all normal. He also has had ECG and X-ray of hip joints of which the results
are both normal. And he has had ultrasonic examination of his spleen, kidney and
gall bladder, of which the results are all normal. However, he has liver
enlargement. His tongue is dull red with thin and white coating. His pulse is
deep, threadlike and loose. Doctor¡¯s request: the herbal tea should follow the
original formulation.
Date:
12th of Jan. 2007
Time: 9:00 a.m.
Today the
patient has no discomforts such as headache, dizziness, nausea, vomit, fever or
aversion to cold, except weakness in left lower extremity and difficulty in
walking. He has no problem with spirit and appetite, and he has had a good
sleep. His bowel movement and urination are normal. His heart and lungs are
normal. His abdomen is flat and soft. Unlike before, his right toes are able to
flex and extend again. His tongue is dull red with thin and white coating. His
pulse is deep, threadlike and loose. Doctor¡¯s request: the patient should have
confidence in fight against the disease and be cooperate in the treatment.
Date:
16th of Jan. 2007
Time: 9:00 a.m.
Today the
patient has no discomforts such as headache, dizziness, nausea, vomit, fever or
aversion to cold, except weakness in left lower extremity and difficulty in
walking manifested as walking lamely. He has no problem in spirit and appetite,
and he has had a good sleep. His bowel movement and urination are normal. His
heart and lungs are normal. His abdomen is flat. His tongue is dull red with
thin and white coating. His pulse is deep, threadlike and loose. Doctor¡¯s
request: the herbal tea should follow the original formulation.
Date:
19th of Jan. 2007
Time: 9:00 a.m.
Today the patient has no discomforts such as
headache, dizziness, nausea, vomit, fever or aversion to cold, except weakness
in left lower extremity and difficulty in walking manifested as walking lamely.
He has no problem in spirit and appetite, and he has had a good sleep. His bowel
movement and urination are normal. His heart and lungs are normal. His abdomen
is flat. His tongue is dull red with thin and white coating. His pulse is deep,
thread-like and loose. Doctor¡¯s advice: the herbal tea should follow the
original formulation.
Based upon our very successful help
to many ALS patients, ALS is now one of the significant focuses of our hospital.
More ALS cases that we helped
well:
Case-1
Case-2
Case-3
Case-4 Case-5
Case-6
Case-7
Case-8
Case-9
Case-10
Case-11
Case-12
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