Records of Hospitalization
Name: Thanasis
Sex: Male
Age:
57 Profession: Office
Clerk
Nationality: Greece
Marital status: Married
Onset Season: Summer
Date of Admission: July 21st 2007
Complainer: The patient
himself Reliability: Reliable
Major complaint: The
patient has suffered from difficulties in speaking and swallowing for two years,
accompanied with weakness of his left fingers for nine months.
Present illness: In July
of 2005, the patient began to feel unclearness and disfluency of his speaking
with some difficulty in swallowing without any obvious causes. He coughed when
he drank water. But at that time, the patient paid no attention to it, and did
no treatment about it. Therefore, the disease was developing progressively. In
Oct. of 2006, the patient began to feel weakness of his left fingers, and then
went to a local hospital for a diagnosis. After the EMG examination, the patient
was diagnosed with
amyotrophic
lateral sclerosis (ALS).
The patient was told that his disease was incurable, and then he got no
treatment. In Feb. of 2007,
the patient went to another local hospital for a further diagnosis, and he was
prescribed by some western medicine for oral taking until now. He was picked up
by our staff in Zhijiang Airport and arrived in Huaihua Red Cross Hospital for
further treatment at 19: 00 on July 21st 2007. Since he got the
disease, his sleep and appetite were both poor. His spirit was good. His bowel
movement and urination were both normal.
Disease history: No
history of typhoid, tuberculosis, hepatitis, malaria or other infectious
disease. No allergic history of medicine or food. No trauma history. No history
of blood transfusion. History of preventive vaccination not provided. In 1977,
he got an operation for his hernia. But now, it is cured. In 1997, he suffered
from diabetes. Since then, he has been taken the medicine for it until now.
Personal history: he was
born in Greece. No contact history of schistosomiasis. No addiction to smoking,
alcohol or special food. He was mild-tempered and open-minded.
Marital history: he got
married at 29. He had one son. His wife and child have been healthy all the
time.
Family history: His
parents were both healthy. No family history of special disease.
Physical examination:
T 36.5¡æ£¬P:
80bpm, R: 18bpm, BP: 130/85 mmHg, W: 98 kg
He was
mid-nourished and normally developed. His mind was clear. He had an expression
of chronic illness and languidness. He was in a positive position and
cooperative in examination. His skin was moist. No jaundice in the sclera. No
superficial lymph-node enlargement. Bilateral pupils were round and equal in
size and sensitive to light.
No deformity of skull and the five
sense organs.
No swollen tonsil. With soft neck
and trachea placed in the middle. No enlargement
of the thyroid gland. No congestion of the jugular vein.
No thoracic deformity. Sound of
breath was bilaterally normal on auscultation. No respiratory rales or pleural
friction rubs. Heart border was normal. Heart beat 80 times/min. Cardiac rhythm
was regular. No pathological murmurs on
auscultation. Abdomen touched flat and soft without tenderness or rebound
tenderness. Liver and spleen were not palpable. No percussion pain in renal
region. Bowel sound was normal. No spinal and pelvic deformity or tenderness.
Flexible movement. He was suffering from unclearness and disfluency of speaking,
accompanied by swallowing difficulty, poor movement of his tongue and coughing
as drinking. His tongue was
rugged with atrophic tongue
muscles.
His fingers
were suffered from weakness so that he had difficulty in holding any objects.
The muscles of his hands were
atrophic.
The experiment on his hands
was (+).There was uncontrollable and frequent muscles¡¯ trembling on his upper
limbs, chest and back. The
muscle strength of his upper
limbs was Grade
¢ó
with low muscle hyperthyroidism. His lower limbs were weak in free movement
without any tenderness or deformity. The examinations to the anus and pudendum
were both normal. His physiological reflex exists. The pathological symptoms
have not been elicited. His tongue was red with white and slightly heavy-greasy
tongue coating. His pulse was slippery, fine and weak.
Diagnostic examination: Not provided.
First
diagnosis:
TCM
diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom diagnosis: Spleen-kidney lung vacuity
WM
diagnosis:
Amyotrophic
Lateral Sclerosis (ALS)
First
Medical Record
July
18th 2007
Thanasis, a 57-year-old male, has suffered from difficulties in speaking and
swallowing for two years, accompanied with weakness of his left fingers for nine
months. He was picked up by our staff in Zhijiang Airport and arrived in Huaihua
Red Cross Hospital for further treatment at 19: 00p.m on July 21st
2007.
Essentials for diagnosis:
1. The
patient has suffered from difficulties in speaking and swallowing for two years,
accompanied with weakness of his left fingers for nine months.
2. In
July of 2005, the patient began to feel unclearness and disfluency of his
speaking with some difficulties in swallowing without any obvious causes. He
coughed when he drank water. But at that time, the patient paid no attention to
it, and did no treatment about it. Therefore, the disease was developing
progressively. In Oct. of 2006, the patient began to feel weakness of his left
fingers, and then went to a local hospital for a diagnosis. After the EMG
examination, the patient was diagnosed with
amyotrophic
lateral sclerosis (ALS).
The patient was told that his disease was incurable, and then he got no
treatment. In Feb. of 2007,
the patient went to another local hospital for a further diagnosis, and he was
prescribed by some western medicine for oral taking until now. He was picked up
by our staff in Zhijiang Airport and arrived in Huaihua Red Cross Hospital for
further treatment at 19: 00 on July 21st 2007. Since he got the
disease, his sleep and appetite were both poor. His spirit was good. His bowel
movement and urination were both normal.
3. T
36.5¡æ£¬P:
80bpm, R: 18bpm, BP: 130/85 mmHg, W: 98 kg
4. He
was mid-nourished and normally developed. His mind was clear. He had an
expression of chronic illness and languidness. He was in a positive position and
cooperative in examination.
5.
He was suffering from unclearness and
disfluency of speaking, accompanied by difficulty in swallowing, poor movement
of his tongue and coughing as drinking. His tongue was
rugged with atrophic tongue
muscles.
His fingers
were suffered from weakness so that he had difficulty in holding any object.
The muscles of his hands were
atrophic.
The experiment on his hands
was (+). There was uncontrollable and frequent muscles¡¯ trembling on his upper
limbs, chest and back. The
muscle strength of his upper
limbs was Grade
¢ó
with low muscle hyperthyroidism. His lower limbs were weak in free movement
without any tenderness or deformity. His tongue was red with white and slightly
heavy-greasy tongue coating. His pulse was slippery, fine and weak.
6. No
thoracic deformity. Chest percussion noted clearly Sound of breath is
bilaterally clear on auscultation. No sound of pleural friction.
7.
Diagnostic examination: Not provided
Diagnostic basis
TCM:
The patient has suffered from difficulties in speaking and swallowing for two
years, accompanied with weakness of his left fingers for nine months. The
muscles of his upper limbs were atrophic and weak, accompanied with languid
spirit and pale faces. His speaking was neither clear nor frequent, with
difficulty in swallowing, poor movement of
his tongue and coughing as drinking. His tongue was
rugged with atrophic tongue
muscles. His tongue was red
with white and slightly heavy-greasy tongue coating. His pulse was slippery,
fine and weak. Because of the insufficiency of the liquids, abnormality of the
qi and blood, and lung heat scoring the lobes, his limbs lose the nutrition. He
was with the deficiency of spleen and stomach, so the essence-blood could not
nourish his sinews and vessels. Then it leads to the malnutrition of the
muscles, and gradually it resulted in flaccidity.
Western medicine: The patient has suffered from difficulties in speaking and
swallowing for two years, accompanied with weakness of his left fingers for nine
months. He was suffering from unclearness
and disfluency of speaking, accompanied by difficulty in swallowing, poor
movement of his tongue and coughing as drinking. His tongue was
rugged with atrophic tongue
muscles.
His fingers
were suffered from weakness so that he had difficulty in holding any object.
The muscles of his hands were
atrophic.
The experiment on his hands
was (+).There was uncontrollable and frequent muscles¡¯ trembling on his upper
limbs, chest and back. The
muscle strength of his upper
limbs was Grade
¢ó
with low muscle hyperthyroidism. In Oct. of 2006, after the EMG examination, he
was diagnosed with
amyotrophic
lateral sclerosis (ALS).
Diagnostic differentiation
TCM:
The patient¡¯s Wei-syndrome should be differentiated from Bi-syndrome. Wei-syndrome
is characterized by limp, weak, and emaciated limbs with muscular atrophy. A
patient suffered from Wei-syndrome may even become unable to hold any objects or
to stand without any 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 by aching pain, fixed heaviness and
inflexibility of sinews and bones, muscles and joints, with occasional numbness
or swelling, though, no paralytic manifestations. They are not difficult to be
distinguished in clinics.
WM: Wei-syndrome should
be differentiated from myasthenia gravis, which is an acquired autoimmune
disease with the transferring obstacles of nerve-muscles, and is caused by the
autoimmune reaction resulting from the acetylcholine receptor (AchR) of the
striated muscle. It can occur at any age and there are about 60 percent people
stricken before 30 years old. Women are more often affected than men are. The
most obvious characteristic of MG is rapid fatigability of the skeletal muscles
affected, improved with rest or medicines that inhibits the activity of
cholinesterase. It can involve cardiac muscle and smooth muscle. MG patients of
different ages often have different clinical manifestations and courses, which
are different from those of Wei-syndrome patients.
First
diagnosis:
TCM
diagnosis: Wei-zheng (Flaccidity syndrome)
Symptom diagnosis: Spleen-kidney lung vacuity
WM
diagnosis:
Amyotrophic
Lateral Sclerosis (ALS)
Plan
for 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 boost qi and fortify the spleen, to supplement the kidneys and
boost the lung): taking five dosages herbal tea and one dosage a day and drink
twice
Prescription: Variable in Fortifying-Spleen and Supplementing-Kidneys Decoction
Main
herbs used in the herbal tea: Baisheng (White Ginseng), Huangqi (Astragalus
root), Baishu (Ovate Atractylodes root), etc.
6.
Acupuncture and massage: once a day
7.
Take more exercise on the tongue and the suffering parts.
8.
Have more medical examinations if necessary
Date:
July 22nd 2007 Time: 10:00 a.m.
The
patient has suffered from difficulties in speaking and swallowing for two years,
accompanied with weakness of his left fingers for nine months. The patient began
to suffer from unclearness speaking, accompanied with difficulty in swallowing,
coughing as drinking two years ago, and his condition was getting worse day by
day. Nine months ago, he began feel the weakness of his left fingers with
difficulty in holding any objects. His fingers,
back of his hands and palms
were both suffering from muscular atrophy. He suffered muscular trembling of the
upper body. Poor food intake
and fatigue. Sometimes he felt some phlegm in his throat. His lower limbs were
weak. His tongue coating was
whitish and slightly heavy-greasy with rugged
lingual surface. The muscles of his
tongue were atrophic and trembling. There were tooth-marks on the edges of the
tongue. The movement of his tongue was poor. His pulse was slippery, fine and
weak.
TCM
diagnosis: Wei-zheng (Flaccidity syndrome)
Symptom diagnosis: Spleen-kidney lung vacuity
WM
diagnosis:
Amyotrophic
Lateral Sclerosis (ALS)
Principle of TCM treatment:
boosting qi and fortifying the
spleen, supplementing the kidneys and boosting the lung.
Doctor¡¯s requirement: take four dosages herbal tea of the same prescription.
Date:
July 25th 2007 Time: 10:00 a.m.
The
patient felt that his swallowing difficulty got some improvement.
Doctor¡¯s requirement:
He would continue to take five
dosages herbal tea of the former prescription.
Date:
July 30th 2007 Time: 9:00 a.m.
His
swallowing and movement of his tongue was getting better. His sleep was bad with
nightmare. The doctor advised him to add Poria, Spiny Jujube kernel and Polygala
root decocted into the former prescription.
Date:
July 31st 2007 Time: 9:00 a.m.
Today
the patient said that his swallowing, the movement of his tongue and the
muscular fibrillation all
over his body all achieved some improvement. His sleep was still poor, while his
diet was normal. The TCM strategy was to boost qi and fortify spleen, supplement
the kidneys and boost the lung, soften the liver and extinguish the wind. He
would continue to take four dosages herbal tea of the former prescription.
Date:
Aug. 2nd 2007 Time: 9:00 a.m.
His
fingers of both hands were weak with difficulty in flexible movement of joints.
The doctor advised him to take four dosages herbal tea to soak his hands. The
main herbs in the herbal tea for external use are Cinnamon twig, Ground Pine,
Millettia root and stem, etc.
Date:
Aug. 4th 2007 Time: 9:00 a.m.
Today
the patient said that his swallowing, the movement of his tongue and the
muscular fibrillation all
over his body all achieved some improvement. His sleeping was better than
before. Sometimes he felt some pains in his arms.
Doctor¡¯s requirement: take five
dosages herbal tea of the same formulation.
Date:
Aug. 9th 2007 Time: 9:00 a.m.
The
muscular fibrillation all
over his body lessened. He spoke very slowly with inflexible movement of his
tongue. Dry mouth. His lingual surface was tugged with its muscular atrophy. His
tongue coating was white with less liquid. The treatment strategy was to boost
qi and fortify spleen, supplement the kidneys and boost the lung, and extinguish
the wind. He would continue to take five dosages herbal tea of the former
prescription.
Date:
Aug. 11th 2007 Time: 9:00 a.m.
His
fingers of the hands were with muscular atrophy and poor movement of the
fingers. The oral taking herbal tea should combine with five dosages herbal tea
for the external use. The main herbs in the herbal tea for external use are
Cinnamon twig, Ground Pine, Millettia root and stem, etc.
Date:
Aug. 14th 2007 Time: 9:30 a.m.
The
patient¡¯s difficulty in swallowing and the muscular
fibrillation all over his body both
achieved obvious improvement. His difficulty in speaking was also getting
better. The strength of the limbs increased. He could raise his thumb to praise
something good. He also complained that he felt numbness of his fingers and
lips. Dryness of his mouth at night, sometimes accompanied with
tinnitus.
Doctor¡¯s requirement: take five
dosages herbal tea of the same prescription.
Date:
Aug. 19th 2007 Time: 9:00 a.m.
The
patient¡¯s diet was poor. His dry month was getting better. His tongue coating
was slightly greasy. He would continue to take five dosages of herbal tea of the
same prescription, adding Tangerine peel into it.
Date:
Aug. 24th 2007 Time: 9:00 a.m.
The
patient said that his difficulties in speaking and swallowing achieved
significant improvement. The upper limbs were painful, and he was with poor
diet. Doctor¡¯s requirement: take four dosages of herbal tea of the same
prescription.
Date:
Aug. 28th 2007 Time: 9:00 a.m.
The
patient felt that the strength of his left fingers increased. The muscular
trembling lessened. There was small quality of
phlegm.
Doctor¡¯s requirement: take three
dosages of herbal tea of the same prescription.
Date:
Aug. 31st 2007 Time: 9:00 a.m.
These
days the patient has suffered from diarrhea with water-like stool. He had no
abdominal pains or distention. He was with poor absorption and coughing.
Doctor¡¯s requirement: take five dosages of herbal tea of the same prescription.
Date:
Sep. 1st 2007 Time: 9:00 a.m.
The
patient was suffering from diarrhea with water-like stool 3 to 4 times a day. He
felt poor spirit with tired body during taking the self-prepared medicine for
his diarrhea. He was given the injection 1000ml with 10% of potassium chloride
10ml and Caloric agent. He
took herbal tea orally to boost qi and fortify spleen and help to digest. The
doctor advised him to avoid the cold food or oily food.
Date:
Sep. 4th 2007 Time: 9:00 a.m.
The
patient still suffered from diarrhea, 2 to 3 times a day. After using the
Huoxiang Zhengqi
Pills, his diarrhea
was getting better. This morning, had only one bowel movement and his stools
returned to normal. The doctor still advised him to take the herbal tea.
Date:
Sep. 5th 2007 Time: 9:00 a.m.
The patient suffered from diarrhea
several days ago with poor food intake and weakness body. He had history of
diabetes, so could not give injection with some medicine containing any sugar or
amino acid. He got an examination for his blood sugar, which showed 6.1. The
doctor advised him to stop antidiabetic medicines, and he should take them again
after he returned his function of diet and digestion of
intestinal tract. The herbal tea is
to fortify spleen, transform the food, soften the liver and extinguish the wind.
Date:
Sep. 6th 2007 Time: 11:40 a.m.
The
patient complained that he had suffered diarrhea again with 4 to 5 times stools
last night. He felt weak with low spirit, poor appetite and poor sleep. The
herbal tea Poria and Ovate Atractylodes Powder was to prescribe for his
diarrhea. The doctor gave him three dosages herbal tea, one dosage a day and
drink twice. The western medicine was the injection with 10% glucose 500ml +
vitamin C 2.0 + 10% potassium chloride 10ml + amino acid 250 ml to supplement
enough energy. Since the patient had the history of diabetes, he was give 8 ml
insulin instead of 500 ml glucose, so as to prevent the patient¡¯ s blood sugar
increasing. The patient was given the careful treatment and would continue to
take the examination when necessary.
Date:
Sep. 12th 2007 Time: 9:00 a.m.
The
patient had 3 times bowel movements yesterday morning since he had eaten eggs.
After examination, the patient was considered to be with poor digestion. The
doctor advised him not to take any eggs or oily food at this time. The patient¡¯s
former herbal tea should add Blast-fried Ginger 7g, Aconite accessory tuber 12g,
and Mume fruit 20g.
Date:
Sep. 13th 2007 Time: 9:00 a.m.
The
patient¡¯s diarrhea recovered by taking the medicine to warm and supplement
spleen, and he had only once bowel movement today. His appetite increased and
his spirit was getting better. The herbal tea prescription is the same as the
former.
Date:
Sep. 16th 2007 Time: 9:00 a.m.
The
patient¡¯s stools were normal, his appetite increased, and his spirit was getting
better. His muscular trembling lessened. His tongue was still numb, and he had
difficulty in swallowing. His month was slightly dry. The herbal tea
prescription is the same as the former.
Date:
Sep. 19th 2007 Time: 9:00 a.m.
The
patient¡¯s stools were normal, his appetite increased obviously and he could
swallow food. His muscular trembling lessened day by day. He was still weak and
tired since he had suffered from diarrhea before. No dry month. Doctor¡¯s
requirement: take four dosages herbal tea of the same prescription as Sep. 16th.
Date:
Sep. 23rd 2007 Time: 9:00 a.m.
The
patient¡¯s condition was normal. His lower limbs were with some slight pains.
Doctor¡¯s requirement: take five dosages herbal tea of the same prescription.
Date:
Sep. 25th 2007 Time: 10:00 a.m.
After
hospitalization in our hospital and the treatment of our herbal tea accompanied
by acupuncture and massage and some exercise, the ALS patient¡¯s swallowing and
speaking difficulties, and his muscular trembling all achieved significant
improvement. Today, he demanded to leave the hospital with 3-month herbal tea
for home taking.
The
main herbs such as White Ginseng, Astragalus root, Salvia root, etc are
contained in the 90 days herbal tea.
The
main herbs such as White Ginseng, Astragalus root, Ovate Atractylodes root, etc
are contained in the 5-day honey pills.
Date:
Sep. 28th 2007 Time: 9:00 a.m.
The
patient had diarrhea last night again with twice
sloppy stools. He also felt some
abdominal pain.
The doctor prescribed him the
herbal tea decocted with Agastache,
Aconite accessory
tuber, and Mume fruit. This morning he still had diarrhea with some bellyache.
His other condition was good without dry month. Doctor¡¯s requirement: take two
dosages herbal tea of the same prescription.
Date:
Sep. 30th 2007 Time: 9:00 a.m.
After
hospitalization in our hospital and the treatment of our herbal tea accompanied
by acupuncture and massage and some exercise, the ALS patient¡¯s difficulties in
swallowing and speaking, and his muscular trembling all achieved significant
improvement. His poor food intake, weak and tired body also improved obviously.
Now he has no diarrhea, and the strength of his limbs increased a lot. He kept a
good mood. He demanded to leave the hospital with three-month herbal tea and
5-day honey pills for home taking.
