Records of Hospitalization
Name: Sinar
Sex: Male
Age:
39 Profession: Office
Clerk
Nationality: Indonesia
Marital status: Married
Onset Season: Summer
Date of Admission: July 18th 2007
Complainer: The patient
himself Reliability: Reliable
Major complaint: The
patient has suffered from muscular weakness and atrophy of the upper limbs for 2
years, accompanied with disability of speaking for half a year.
Present illness: In July
of 2005, the patient began to feel weakness of the upper limbs without any
obvious causes. At that time, the patient paid no attention to it, and did no
treatment about it. Therefore, the disease was developing progressively, and he
still took no examination or treatment. In May of 2006, the patient went to a
local hospital for a diagnosis. After the examination, the patient was diagnosed
with hyperosteogeny, and was
done an operation on the back of the patient.
Three months later, the patient¡¯s condition aggravated markedly. Then the
patient went to another local hospital for an examination of
EMG,
and he was diagnosed with
amyotrophic
lateral sclerosis (ALS).
The hospital prescribed some western medicine for him. A month later, his
disease got no improvement. In Nov. of 2006, the patient felt disability of
speaking with unclear words, accompanied by difficulties in swallowing and the
movement of his tongue. Then he got the contact with our hospital and had taken
our herbal tea for a month. He felt some improvement on his upper limbs, and the
movement of his tongue was better than before. To seek for a further
comprehensive treatment, he arrived in our hospital at 19: 30 on July 18th
2007. Since he got the disease, his spirit and appetite were both poor.
His sleep 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.
Personal history: he was
born in Indonesia. 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 27. He had two sons. His wife and children have been healthy all the
time.
Family history: Her
parents were both healthy. No family history of special disease.
Physical examination:
T 36.7¡æ£¬P:
79bpm, R: 18bpm, BP: 140/90 mmHg, W: 60 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 congestion in throat. 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 78/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. He was suffering from weakness of upper limbs,
so that he could not hold any heavy objects. The muscles of his upper hands were
atrophic
completely. He was
poor in fine movement and was disability of writing. The experiment to his hands
was (+). The muscles of all over his body fluctuate uncontrollably and
frequently. His upper limbs were Grade
¢ó
with weak muscle hyperthyroidism. The grip of his left hand was 0 kg, and that
of the right hand was 2.4kg. His speaking was neither clear nor fluent,
accompanied by difficulty in swallowing and poor movement of his tongue. The
examinations for the anus and pudendum were both normal. His physiological
reflex exists. The pathological symptoms have not been elicited. His tongue was
red with yellow tongue coating. His pulse was fine and rapid.
Diagnostic examination: Not provided.
First
diagnosis:
TCM
diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom diagnosis: Spleen-kidney qi vacuity, accompanied with lung- liver yin
vacuity.
WM
diagnosis:
Amyotrophic
Lateral Sclerosis (ALS)
First
Medical Record
July 18th 2007
Sinar,
a 39-year-old male, has suffered from muscular weakness and atrophy of the upper
limbs for 2 years, accompanied with disability of speaking for half a year. He
was picked up by our staff in Zhijiang Airport and arrived in Huaihua Red Cross
Hospital for further treatment at 19: 30p.m on July 18th 2007.
Essentials for diagnosis:
1. The
patient has suffered from muscular weakness and atrophy of the upper limbs for 2
years, accompanied with disability of speaking for half a year.
2. In
July of 2005, the patient began to feel weakness of the upper limbs without any
obvious causes. At that time, the patient paid no attention to it, and did no
treatment about it. Therefore, the disease was developing progressively, and he
still took no examination or treatment. In May of 2006, the patient went to a
local hospital for a diagnosis. After the examination, the patient was diagnosed
with hyperosteogeny, and was
done an operation to the back of the patient.
Three months later, the patient¡¯s condition aggravated markedly. Then the
patient went to another local hospital for an examination of
EMG,
and he was diagnosed with
amyotrophic
lateral sclerosis (ALS).
The hospital prescribed some western medicine for him. A month later, his
disease got no improvement. In Nov. of 2006, the patient felt disability of
speaking with unclear words, accompanied by difficulties in swallowing and the
movement of his tongue. Then he got the contact with our hospital and had taken
our herbal tea for a month. He felt some improvement on his upper limbs, and the
movement of his tongue was better than before. To seek for a further
comprehensive treatment, he arrived in our hospital at 19: 30 on July 18th
2007. Since he got the disease, his spirit and appetite were both poor.
His sleep was good. His bowel movement and urination were both normal.
3. T
36.7¡æ£¬P:
79bpm, R: 19bpm, BP: 140/90 mmHg, W: 60 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 weakness of
upper limbs, so that he could not hold any heavy objects. The muscles of his
upper hands were
atrophic
completely. He was
poor in fine movement and was disability of writing. The experiment to his hands
was (+). The muscles of all over his body fluctuated uncontrollably and
frequently. His upper limbs were Grade
¢ó
with muscle weak hyperthyroidism. The grip of his left hand was 0 kg, and that
of the right hand was 2.4 kg. His speaking was neither clear nor fluent,
accompanied by difficulty in swallowing and poor movement of his tongue.
6. No
thoracic deformity. Chest percussion noted resonance. 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 muscular weakness and atrophy of the upper limbs
for 2 years, accompanied with disability of speaking for half a year. The
muscles of his upper limbs were atrophic and weak, accompanied with languid
spirit and pale faces. His speaking was neither clear nor frequent. His tongue
was red with yellow tongue coating. His pulse was fine and rapid. Because of the
insufficiency of the liquids, abnormality of the qi and blood, and lung heat
scoring the lobes, his limbs lose the nourishment. 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 muscular weakness and atrophy of
the upper limbs for 2 years, accompanied with disability of speaking for half a
year. He was suffering from weakness
of upper limbs, so that he could not hold any heavy objects. The muscles of his
upper hands were
atrophic
completely. He was
poor in fine movement and was disability of writing. The experiment to his hands
was (+). The muscles of all over his body fluctuated uncontrollably and
frequently. His upper limbs were Grade
¢ó
with muscle weak hyperthyroidism. The grip of his left hand was 0 kg, and that
of the right hand was 2.4 kg. His speaking was neither clear nor fluent,
accompanied by difficulty in swallowing and poor movement of his tongue. In Aug.
of 2006, 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 an object 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 grave 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 qi vacuity, accompanied with lung- liver yin
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.
Regular diet
5.
Herbal tea (to enrich the spleen and to boost the lung, to enrich the spleen and
nourish the liver): one dosage a day and drink by twice
Prescription: Variable in Supplementing-Lung and Enriching-Liver Decoction
Main
herbs used in the herbal tea: Gouqi (Lycium), Shudi (Cooked Rehmannia root),
Zaopi (Cornus fruit), etc.
6.
Acupuncture and massage: once a day
7.
Have more medical examinations if necessary
Date:
July 19th 2007 Time: 10:00 a.m.
The
patient complained to Dr. Yang that he was suffering from muscular weakness and
atrophy of the upper limbs, accompanied with disability of speaking and
difficulty in swallowing. The muscles all over the body fluctuate frequently.
The results of the three major
routine
examinations
are all normal. The
examination to hepatitis B is normal, and the examinations to the function of
his liver and kidney are both normal.
Examination: T 36.7¡æ£¬P:
79bpm, R: 19bpm, BP: 140/90 mmHg, W: 60 kg.
His
heart and lung were normal, and his abdomen was soft and flat.
Dr.
Yang¡¯s analysis:
1. The
patient has suffered from muscular weakness and atrophy of the upper limbs for 2
years, accompanied with disability of speaking for half a year.
2.
He was suffering from weakness of
upper limbs, so that he could not hold any heavy objects. The muscles of his
upper hands were
atrophic
completely. He was
poor in fine movement and was disability of writing. The experiment to his hands
was (+). The muscles of all over his body fluctuated uncontrollably and
frequently. His upper limbs were Grade
¢ó
with weak muscle hyperthyroidism. The grip of his left hand was 0 kg, and that
of the right hand was 2.4 kg. His speaking was neither clear nor fluent,
accompanied by difficulty in swallowing and poor movement of his tongue.
3.
National examination: In
Aug. of 2006, he was diagnosed with
amyotrophic
lateral sclerosis (ALS)
in a local hospital.
According to the above information, TCM considered it as Wei-syndrome
(flaccidity syndrome). Wei-syndrome is characterized by limp, weak, and
emaciated limbs with muscular atrophy. Because of the insufficiency of the
liquids and abnormality of the qi and blood, his limbs lose the nourishment. He
was with the deficiency of spleen and stomach, and lung heat scoring the lobes,
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. Dr.
Yang¡¯s analyzed it was lung-spleen qi vacuity, accompanied with lung- kidney yin
vacuity.
Principle of TCM treatment:
tonifying the spleen and boosting
the lung, nourishing lung and kidney: Herbal tea prescribed for three days
including Gouqi (Lycium), Shudi (Cooked Rehmannia root), Zaopi (Cornus fruit),
etc. One dosage a day and drink twice.
Prescription: Variable in Supplementing-Lung and Enriching-Liver Decoction
Doctor¡¯s requirement:
take three dosages herbal tea of the same prescription. Acupuncture and massage
for once a day. The patient will have more medical examinations if necessary.
Date:
July 20th 2007 Time: 10:00 a.m.
The
patient did not complain about any other special discomfort. The examination to
sternum is normal. The ECG examination is also normal.
The B-ultrasomotonography
examination to liver,
gallbladder, pancreas, spleen and kidneys is normal, too. His heart and lung
were normal, and his abdomen was soft and flat.
He was
suffering from weakness of
upper limbs, so that he could not hold any heavy objects. The muscles of his
upper hands were
atrophic
completely. He was
poor in fine movement and was disability of writing. The experiment to his hands
was (+). The muscles of all over his body fluctuated uncontrollably and
frequently. His upper limbs were Grade
¢ó
with muscle weak hyperthyroidism. The grip of his left hand was 0 kg, and that
of the right hand was 2.4 kg. His speaking was neither clear nor fluent,
accompanied by difficulty in swallowing and poor movement of his tongue. He was
normal both in spirit and appetite, with good sleep. His bowel movement and
urination were both normal. His tongue was red with yellow tongue coating. His
pulse was fine and weak.
Doctor¡¯s requirement: take herbal tea of the same prescription. One dosage a day
and drink twice.
Date:
July 21st 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs was getting better, and the movement of his
hands improved a little. The experiment to his hands was (+).The incontrollable
fluctuation of the muscles of all over his body lessened obviously.
Examination: T 36.7¡æ£¬P:
79bpm, R: 19bpm, BP: 140/90 mmHg, W: 60 kg.
His
heart and lung were normal, and his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. The herbal tea is followed by the former prescription.
Date:
July 24th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs is getting better, and the movement of his
hands improves much. The experiment to his hands was (+).The incontrollable
fluctuation of the muscles of all over his body lessened obviously. His upper
limbs were Grade
¢ó
with increasing muscle hyperthyroidism. The grip of his left hand was 5.1 kg,
and that of the right hand was 7.7 kg.
Examination: T 36.7¡æ£¬P:
79bpm, R: 19bpm, BP: 140/90 mmHg, W: 60 kg.
His
heart and lung were normal, and his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. Since the patient has achieved significant effect, Dr. Yang advised him
to take more exercise on his upper hands. The herbal tea is followed by the
former prescription.
Date:
July 28th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs was getting better, and the movement of his
hands improved a lot. The experiment to his hands was (-).The incontrollable
fluctuation of the muscles of all over his body lessened obviously. His upper
limbs were Grade
¢ó
with increasing muscle hyperthyroidism. The grip of his left hand was 4.0 kg,
and that of the right hand was 9.4 kg. Examination:
His heart and lung were normal, and
his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. Since the patient has achieved significant effect, Dr. Yang advised him
to take more exercise on his upper hands. The herbal tea is followed by the
former prescription.
Date:
Aug. 2nd 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands got better. The experiment to his hands was (-).The incontrollable
fluctuation of the muscles of all over his body lessened obviously. His upper
limbs were Grade
¢ó
with increasing muscle hyperthyroidism. The grip of his left hand was 4.7 kg,
and that of the right hand was12.9 kg. The grip increases significantly.
Examination: His heart and
lung were normal, and his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. The herbal tea is followed by the former prescription.
Date:
Aug. 7th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands got better. The experiment to his hands was (-).The incontrollable
fluctuation of the muscles of all over his body almost disappeared. His upper
limbs were Grade
¢ó
with increasing muscle hyperthyroidism. The grip of his left hand was 12.5 kg,
and that of the right hand was 4.8 kg. The grip of his hands increased
significantly. Examination:
His heart and lung were normal, and his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. The herbal tea is followed by the former prescription.
Date:
Aug. 12th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands got better and better. The incontrollable fluctuation of the muscles
of all over his body disappeared. His upper limbs were Grade
¢ó
with increasing muscle hyperthyroidism. The grip of his left hand was 12.5 kg,
and that of the right hand was 4.8 kg. The strength of his hands increased
significantly. Examination:
His heart and lung were normal, and his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. His tongue was slightly red with thin and white tongue coating. His
pulse was deep and fine. The herbal tea is followed by the former prescription.
Date:
Aug. 16th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands got better and better. The incontrollable fluctuation of the muscles
of all over his body disappeared. His upper limbs were Grade
¢ó
with increasing muscle hyperthyroidism. The grip of his left hand was12.5 kg,
and that of the right hand was 10.1 kg. The strength of his hands increased
significantly. Examination:
His heart and lung were normal, and his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. His tongue was slightly red with thin and white tongue coating. His
pulse was deep and fine. The herbal tea is followed by the former prescription.
Date:
Aug. 20th 2007 Time: 9:30 a.m.
The
patient did not complain about any other special discomfort. His condition kept
stable. Examination: His
heart and lung were normal, and his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. His tongue was slightly red with thin and white tongue coating. His
pulse was deep and fine. The herbal tea is followed by the former prescription.
Date:
Aug. 24th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands got better and better. His upper limbs were Grade
¢ó
with stronger muscle hyperthyroidism. The grip of his left hand was 12.5 kg, and
that of the right hand was 10.1 kg. Examination:
His heart and lung were normal, and
his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. His tongue was slightly red with thin and white tongue coating. His
pulse was deep and fine. The herbal tea is followed by the former prescription.
Date:
Aug. 28th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands got better and better. His upper limbs were Grade
¢ó
with stronger muscle hyperthyroidism. The grip of his left hand was12.5 kg, and
that of the right hand was 10.1 kg. Examination:
His heart and lung were normal, and
his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. His tongue was slightly red with thin and white tongue coating. His
pulse was deep and fine. The herbal tea is followed by the former prescription.
Date:
Sep. 1st 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands also improved obviously than before. Examination:
His heart and lung were normal, and
his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. His tongue was slightly red with thin and white tongue coating. His
pulse was deep and fine. The herbal tea is followed by the former prescription.
Date:
Sep. 5th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. His condition kept
stable. All other conditions are normal. His tongue was slightly red with thin
and white tongue coating. His pulse was deep and fine. The herbal tea is
followed by the former prescription.
Date:
Sep. 10th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands also achieved significant improvement than before. Examination:
His heart and lung were normal, and
his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. His tongue was slightly red with thin and white tongue coating. His
pulse was deep and fine. The herbal tea is followed by the former prescription.
Date:
Sep. 15th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands also achieved significant improvement than before. Examination:
His heart and lung were normal, and
his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. His tongue was slightly red with thin and white tongue coating. His
pulse was deep and fine. The herbal tea is followed by the former prescription.
Date:
Sep. 20th 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands also achieved significant improvement. Examination:
His heart and lung were normal, and
his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. His tongue was slightly red with thin and white tongue coating. His
pulse was deep and fine. The herbal tea is followed by the former prescription.
Date:
Sep. 23rd 2007 Time: 9:00 a.m.
The
patient did not complain about any other special discomfort. The patient said
that the weakness of his upper limbs improved significantly, and the movement of
his hands also achieved significant improvement. Examination:
His heart and lung were normal, and
his abdomen was soft and flat.
He had pleasant spirit and
appetite, with sound sleep. His bowel movement and urination were both
normal. His tongue was slightly red with thin and white tongue coating. His
pulse was deep and fine. The patient demanded to leave the hospital today.
