|
Records
of Hospitalization
Name:
Felix
Sex: Male
Age:
27
Profession: Office
Clerk
Nationality: China
Birthplace:
The United States
Marital
status: Unmarried
Onset Season: Summer
Date of
Admission: Oct.14th
2007
Complainer: The patient
himself
Major
complaint: The patient has
suffered from weakness of all the limbs and has progressively aggravated for one
and a half years, accompanied with difficulties in speaking and swallowing for
10 months.
Present
illness: In Apr. 2006, the
patient fell down to the ground carelessly when walking. At that time, the
patient didn¡¯t feel any discomfort. A week later, the patient appeared stiffness
of his left ankle joints, but he paid no attention to it. Several days later,
the patient fell down to the ground again when he tried to pick up some objects.
After that, he appeared stiffness of both ankle joints, accompanied with
discomfort of his left hip and weakness of his arms. He did no examination or
treatment about it. Therefore, the condition was aggravating progressively. In
Dec. 2006, the patient appeared difficulties in speaking and swallowing along
with choking when drinking water. He still took no examination or treatment.
Until May 2007, the patient went to a local hospital for a diagnosis. After the
EMG examination, the patient was diagnosed with
amyotrophic lateral sclerosis
(ALS). The doctor told the
patient it was incurable and prescribed him Rilutek Capsule for one-month oral
taking. He got no obvious improvement. In Aug. 2007, the patient again went to a
local hospital for another examination, and he was diagnosed with
amyotrophic lateral sclerosis
(ALS). To seek for a comprehensive treatment, he arrived in our
hospital on Oct.14th 2007. Since he got the disease, his spirit and
appetite were both slightly poor, especially poor in sleep. 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 the
United States. No contact history of schistosomiasis. No addiction to smoking,
alcohol or special food. He was mild-tempered and open-minded.
Marital
history: Unmarried.
Family
history: his parents are both
healthy. No family history of special disease.
Physical
examination:
T 36.4¡æ£¬P:
80bpm, R: 20bpm, BP: 120/80 mmHg
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/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 suffered from weakness of upper limbs with
declining grip of both hands. In the examination, the grip of his left hand was
12.5 kg, and that of the right hand was 11.4kg. The extorsion of double forearms
was limited. His upper limbs were Grade
¢ó
with normal muscle hyperthyroidism. Both of his lower limbs
were weak with mild stiffness of double ankle joints. His movement was
inflexible. His lower limbs were Grade
¢ó
with normal muscle hyperthyroidism. His speaking was neither clear nor fluent,
accompanied by difficulty in swallowing and choking while drinking. The
examinations for the anus and pudendum were both normal. His physiological
reflex exists. The pathological symptoms have not been elicited. His tongue was
slightly red with white and thin tongue coating. His pulse was weak.
Diagnostic
examination: Not provided.
First
diagnosis:
TCM
diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom
diagnosis: Lung-Spleen qi vacuity, accompanied with deficiency of liver and
kidneys.
WM
diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
First
Medical Record
Oct.14th 2007
Felix, a
27-year-old male, has suffered from weakness of all the limbs and has
progressively aggravated for one and a half years, accompanied with difficulties
in speaking and swallowing for 10 months. He was picked up by our staff in
Huaihua railway station and arrived in Huaihua Red Cross Hospital for further
treatment at 9: 00 a.m. on Oct.14th 2007.
Essentials
for diagnosis:
1. The
patient has suffered from weakness of all the limbs and has progressively
aggravated for one and a half years, accompanied with difficulties in speaking
and swallowing for 10 months
2. In Apr.
2006, the patient fell down to the ground carelessly when walking. At that time,
the patient didn¡¯t feel any discomfort. A week later, the patient appeared
stiffness of his left ankle joints, but he paid no attention to it. Several days
later, the patient fell down to the ground again when he tried to pick up some
objects. After that, he appeared stiffness of both ankle joints, accompanied
with discomfort of his left hip and weakness of his arms. He did no examination
or treatment about it. Therefore, the condition was aggravating progressively.
In Dec. 2006, the patient appeared difficulties in speaking and swallowing along
with choking when drinking water. He still took no examination or treatment. In
May 2007, the patient went to a local hospital for a diagnosis. After the EMG
examination, the patient was diagnosed with
amyotrophic lateral sclerosis
(ALS). The doctor told the
patient it was incurable and prescribed him Rilutek Capsule for one-month oral
taking. He got no obvious improvement. In Aug. 2007, the patient again went to a
local hospital for another examination, and he was diagnosed with
amyotrophic lateral sclerosis
(ALS). To seek for a comprehensive treatment, he arrived in our
hospital on Oct.14th 2007. Since he got the disease, his spirit and
appetite were both slightly poor, especially poor in sleep. His bowel movement
and urination were both normal.
3. T 36.4¡æ£¬P:
80bpm, R: 20bpm, BP: 120/80 mmHg
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 suffered from weakness of all the
limbs with declining grip of both hands. In the examination, the grip of his
left hand was 12.5 kg, and that of the right hand was 11.4kg. The extorsion of
double forearms was limited. His upper limbs were Grade
¢ó
with normal muscle hyperthyroidism. His double ankle joints were in mild
stiffness with slow movement. His lower limbs were Grade
¢ó
with normal muscle hyperthyroidism. His speaking was neither clear nor fluent,
accompanied by difficulty in swallowing and choking while drinking water. His
tongue was slightly red with white and thin tongue coating. His pulse was weak.
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 weakness of all the limbs and has progressively
aggravated for one and a half years, accompanied with difficulties in speaking
and swallowing for 10 months. All his limbs were weak, accompanied with languid
expression on his face. His speaking was neither clear nor frequent, accompanied
with difficulty in swallowing and choking while drinking water. His tongue was
slightly red with white and thin tongue coating. His pulse was weak. Because of
the insufficiency of the liquids, abnormality of the qi and blood, and lung heat
scoring the lobes, his body loses the nourishment. What¡¯s more, due to the
deficiency of spleen and stomach, along with the disability of the
transportation and transformation, and shortage of the source of qi-blood, all
lead to the malnutrition of the muscles, and gradually it results in flaccidity.
Western
medicine: The patient has suffered from weakness of the limbs and has
progressively aggravated for one and a half years, accompanied with difficulties
in speaking and swallowing for 10 months.
He suffered from weakness of all the limbs with declining grip of both
hands. In the examination, the grip of his left hand was 12.5 kg, and that of
the right hand was 11.4kg. The extorsion of double forearms was limited. His
upper limbs were Grade
¢ó
with normal muscle hyperthyroidism. His double ankle joints were in mild
stiffness with slow movement. His lower limbs were Grade
¢ó
with normal muscle hyperthyroidism. His speaking was neither clear nor fluent,
accompanied by difficulty in swallowing and choking while drinking water. In May
of 2007, he was diagnosed with
amyotrophic lateral sclerosis
(ALS) in a local hospital.
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 pains. 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: Lung-Spleen qi vacuity, accompanied with deficiency of liver and
kidneys.
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 supplement the center and boost qi, to enrich and nourish the liver and
kidneys): one dosage a day and drink twice
Main herbs
used in the herbal tea: Baisheng (White Ginseng), Baishu (Ovate Atractylodes
root), Shanyao (Dioscorea), etc.
6.
Acupuncture and massage: once a day
7. Have
more medical examinations if necessary
Date: Oct.
15th 2007 Time: 10:00 a.m.
Today the
patient complained to Dr. Yang that all his limbs felt weak, accompanied with
stiffness of his double ankle joints and inflexible movement. His speaking was
neither clear nor fluent, along with difficulty in swallowing and choking while
drinking water. The results of the three major routine examinations are all
normal. The examination to the six items of hepatitis B is normal, and the
examinations to the function of his liver and kidney are both normal. The result
of Electrolyte turned out to be normal and the examination to sternum is normal,
too. The ECG examination is also normal.
Examination: T 36.4¡æ£¬P:
80bpm, R: 20bpm, BP: 120/80 mmHg
His heart
and lung were normal, and his abdomen was soft and flat.
Dr.
Yang¡¯s analysis:
1. The
patient has suffered from weakness of the limbs and has progressively aggravated
for one and a half years, accompanied with difficulties in speaking and
swallowing for 10 months.
2.
He suffered from weakness of all the
limbs with declining grip of both hands. In the examination, the grip of his
left hand was 12.5 kg, and that of the right hand was 11.4kg. The extorsion of
double forearms was limited. His double ankle joints were in mild stiffness with
inflexible movement. His speaking was neither clear nor fluent, accompanied by
difficulty in swallowing and choking while drinking water. His tongue was
slightly red with white and thin tongue coating. His pulse was weak.
3.
National examination: In May
2007, 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). Because of the insufficiency of the liquids, abnormality of the qi
and blood, and lung heat scoring the lobes, his body loses the nourishment.
What¡¯s more, due to the deficiency of spleen and stomach, along with the
disability of the transportation and transformation, and shortage of the source
of qi-blood, all lead to the malnutrition of the muscles, and gradually it
results in flaccidity. Dr. Yang¡¯s analyzed it was Lung-Spleen qi vacuity,
accompanied with deficiency of liver and kidneys.
Principle of TCM treatment:
supplementing the center and boosting qi, enriching and nourishing the liver and
kidneys
Herbal tea
prescribed for four days including Baisheng (White Ginseng), Baishu (Ovate
Atractylodes root), Shanyao (Dioscorea), etc. One dosage a day and drink twice.
Doctor¡¯s
requirement: take four
dosages herbal tea of the above prescription. Acupuncture and massage for once a
day. The patient will have more medical examinations if necessary.
Date: Oct.
16th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He still said that all his
limbs felt weak, accompanied with stiffness of his double ankle joints and
inflexible movement. The extorsion of double forearms was limited. Besides, his
speaking was neither clear nor fluent, along with difficulty in swallowing and
choking while drinking water.
Examination: T 36.4¡æ£¬P:
80bpm, R: 20bpm, BP: 120/80 mmHg
His heart
and lung were normal, and his abdomen was soft and flat. His spirit and appetite
got better, and his sleep was sound. Both of his bowel movement and urination
were normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Oct.
20th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved a lot. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite got better,
and his sleep was sound. Both of his bowel movement and urination were normal.
His tongue was slightly red with white and thin tongue coating. His pulse was
weak. Doctor¡¯s requirement: take herbal tea of the same prescription. One dosage
a day and drink twice.
Date: Oct.
25th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite got better,
and his sleep was sound. Both of his bowel movement and urination were normal.
His tongue was slightly red with white and thin tongue coating. His pulse was
weak. Doctor¡¯s requirement: take herbal tea of the same prescription. One dosage
a day and drink twice.
Date: Oct.
30th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite got better,
and his sleep was sound. Both of his bowel movement and urination were normal.
His tongue was slightly red with white and thin tongue coating. His pulse was
weak. Doctor¡¯s requirement: take herbal tea of the same prescription. One dosage
a day and drink twice.
Date: Nov.
5th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite got better,
and his sleep was sound. Both of his bowel movement and urination were normal.
His tongue was slightly red with white and thin tongue coating. His pulse was
weak. Doctor¡¯s requirement: take herbal tea of the same prescription. One dosage
a day and drink twice.
Date: Nov.
10th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite got better,
and his sleep was sound. Both of his bowel movement and urination were normal.
His tongue was slightly red with white and thin tongue coating. His pulse was
weak. Doctor¡¯s requirement: take five dosages herbal tea of the same
prescription. One dosage a day and drink twice.
Nov. 14th
2007 Time: 9:30 a.m.
Felix, a
27-year-old male, has suffered from weakness of the limbs and has progressively
aggravated for one and a half years, accompanied with difficulties in speaking
and swallowing for 10 months. The patient hospitalized in our Red Cross Hospital
at 9: 00 a.m on Oct.14th 2007. He has hospitalized for 30 days so
far.
Condition
of admission:
T 36.4¡æ£¬P:
80bpm, R: 20bpm, BP: 120/80 mmHg.
His heart
and lung were normal, and his abdomen was soft and flat.
He suffered from
weakness of all the limbs with
declining grip of both hands. In the examination, the grip of his left hand was
12.5 kg, and that of the right hand was 11.4kg. The extorsion of double forearms
was limited. His upper limbs were Grade
¢ó
with normal muscle hyperthyroidism. His double ankle joints were in mild
stiffness with slow movement. His lower limbs were Grade
¢ó
with normal muscle hyperthyroidism. His speaking was neither clear nor fluent,
accompanied by difficulty in swallowing and choking while drinking water. His
tongue was slightly red with white and thin tongue coating. His pulse was weak.
His spirit, appetite and sleep were all poor. Both of his bowel movement and
urination were normal.
Diagnosis
of admission:
TCM
diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom
diagnosis: Lung-Spleen qi vacuity, accompanied with deficiency of liver and
kidneys.
WM
diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
The course
of diagnosis:
Since the
patient hospitalized, he was prescribed herbal tea to supplement the center and
boost qi, to enrich and nourish the liver and kidneys. One dosages a day and
drink twice. 100ml each time, accompanied with acupuncture and massage once a
day for a comprehensive treatment. The patient¡¯s condition got some improvement.
The current
condition:
T 36.4¡æ£¬P:
80bpm, R: 20bpm, BP: 120/80 mmHg.
His heart
and lung were normal, and his abdomen was soft and flat. The weakness of all his
limbs got better. The grip of his double hands increased. In the examination,
the grip of his left hand was 16.0kg, and that of his right hand was 18.1kg. The
limited extorsion of his double forearms got some improvement. His upper limbs
were Grade
¢ó
with normal muscle hyperthyroidism. The stiffness of his double ankle joints
also got better. His lower limbs were Grade
¢ó
with normal muscle hyperthyroidism. His speaking was still unclear and influent,
but the symptom of difficulty in swallowing improved some. Besides, the symptoms
of choking while drinking water almost disappeared. His tongue was red with
white and thin tongue coating. His pulse was weak. His spirit, appetite and
sleep were all normal. Both of his bowel movement and urination were normal.
Diagnosis
of admission:
TCM
diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom
diagnosis: Lung-Spleen qi vacuity, accompanied with deficiency of liver and
kidneys.
WM
diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
Plan for
treatment strategy
1. Continue
to take the herbal tea
2.
Acupuncture and massage for once a day
3. Keep a
pleasant mood and open-minded spirit.
Date: Nov.
16th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Nov.
20th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Nov.
25th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Nov.
30th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Dec.
5th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Dec.
10th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Dec.
10th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Dec. 14th
2007 Time: 9:00 a.m.
Felix, a
27-year-old male, has suffered from weakness of the limbs and has progressively
aggravated for one and a half years, accompanied with difficulties in speaking
and swallowing for 10 months. The patient hospitalized in our Red Cross Hospital
at 9: 00 a.m on Oct.14th 2007. He has hospitalized for 60 days so
far.
Condition
of admission:
T 36.4¡æ£¬P:
80bpm, R: 20bpm, BP: 120/80 mmHg.
His heart
and lung were normal, and his abdomen was soft and flat.
He suffered from
weakness of all the limbs with
declining grip of both hands. In the examination, the grip of his left hand was
12.5 kg, and that of the right hand was 11.4kg. The extorsion of double forearms
was limited. His upper limbs were Grade
¢ó
with normal muscle hyperthyroidism. His double ankle joints were in mild
stiffness with slow movement. His lower limbs were Grade
¢ó
with normal muscle hyperthyroidism. His speaking was neither clear nor fluent,
accompanied by difficulty in swallowing and choking while drinking water. His
tongue was slightly red with white and thin tongue coating. His pulse was weak.
His spirit, appetite and sleep were all poor. Both of his bowel movement and
urination were normal.
Diagnosis
of admission:
TCM
diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom
diagnosis: Lung-Spleen qi vacuity, accompanied with deficiency of liver and
kidneys.
WM
diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
The course
of diagnosis:
Since the
patient hospitalized, he was prescribed herbal tea to supplement the center and
boost qi, to enrich and nourish the liver and kidneys. One dosages a day and
drink twice. 100ml each time, accompanied with acupuncture and massage once a
day for a comprehensive treatment. The patient¡¯s condition got some improvement.
The current
condition:
T 36.4¡æ£¬P:
80bpm, R: 20bpm, BP: 120/80 mmHg. His heart and lung were normal, and his
abdomen was soft and flat. The weakness of all his limbs got better. The grip of
his double hands increased. In the examination, the grip of his left hand was
16.0kg, and that of his right hand was 18.1kg. The limited extorsion of his
double forearms got some improvement. His upper limbs were Grade
¢ó
with normal muscle hyperthyroidism. The stiffness of his double ankle joints
also got better. His lower limbs were Grade
¢ó
with normal muscle hyperthyroidism. His speaking was still unclear and influent,
but the symptom of difficulty in swallowing improved some. Besides, the symptoms
of choking while drinking water almost disappeared. His tongue was red with
white and thin tongue coating. His pulse was weak. His spirit, appetite and
sleep were all normal. Both of his bowel movement and urination were normal.
Diagnosis
of admission:
TCM
diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom
diagnosis: Lung-Spleen qi vacuity, accompanied with deficiency of liver and
kidneys.
WM
diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
Plan for
treatment strategy
1. Continue
to take the herbal tea
2.
Acupuncture and massage for once a day
3. Keep a
pleasant mood and open-minded spirit.
Date: Dec.
16th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Dec.
20th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Dec.
25th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Dec.
30th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms were getting
better. He also felt the stiffness of his double ankle joints and inflexible
movement got some improvement. Besides, he still had difficulty in speaking with
unclear and influent speaking, but the symptom of difficulty in choking while
drinking water improved obviously. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Jan.
5th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms got much better.
He also felt the stiffness of his double ankle joints and inflexible movement
got much improvement. Besides, he still had difficulty in speaking with unclear
and influent speaking, but the symptom of difficulty in choking while drinking
water improved significantly. In the examination, his heart and lung were
normal, and his abdomen was soft and flat. His spirit and appetite were both
normal, and his sleep was sound. Both of his bowel movement and urination were
normal. His tongue was slightly red with white and thin tongue coating. His
pulse was weak. Doctor¡¯s requirement: take herbal tea of the same prescription.
One dosage a day and drink twice.
Date: Jan.
8th 2007 Time: 9:00 a.m.
The patient
did not complain about any other special discomfort. He said that the weakness
of all his limbs and the limited extorsion of double forearms got much better.
He also felt the stiffness of his double ankle joints and inflexible movement
got much improvement. Besides, he still had difficulty in speaking with unclear
and influent speaking, but the symptom of difficulty in choking while drinking
water improved significantly. The patient demanded to leave hospital today. |
