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Records
of Hospitalization
Name:
Jose Sex: Male
Age:
57 Profession: Office
Clerk
Nationality: Portugal
Marital status: Married
Onset
Season: Summer
Date of Admission: Sept. 13th 2007
Complainer: The patient
himself Reliability: Reliable
¡¡
Major
complaint: The patient has
suffered from weakness of the lower limbs along with muscular atrophy for 3
years, and has been aggravated by disability of walking for one year.
Present
illness: In June 2004, the
patient began to feel weakness of the lower 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. Three months later, the
patient began to suffer from muscular atrophy, but he still took no treatment.
In Aug. 2005, the patient went to a local hospital for a diagnosis. After the
EMG examination, he was diagnosed with
amyotrophic lateral sclerosis
(ALS). The patient was told that
there may be some unpleasantness to happen in the future. In Oct. 2005, the
patient began to take Rilutek up to now. From Mar. 2006 to Mar. 2007, the
patient received the treatment of acupuncture and massage for twice a week in a
local hospital, but he got no obvious improvement. In the second half of 2006,
the patient¡¯s condition aggravated and even was not able to walk. Therefore, his
movement had to be supported by a wheelchair. To seek for a further
comprehensive treatment, he hospitalized in our hospital on Sept. 13th
2007. Since he got the disease, his spirit was poor, but his appetite was
normal. His sleep was sound. His urination was normal, and his bowel movement
was hard.
Disease history:
No history of typhoid, tuberculosis, hepatitis, malaria or other infectious
disease. No allergic history of medicine or food. No history of blood
transfusion. No history of preventive vaccination provided. In 1975, he had a
trauma due to a car accident which resulted in his left tibia fracture, and then
he received the treatment of Compression Plate Fixation. In 1997, he received
the resection on his appendicitis in a local hospital, and now he recovered
completely.
Personal
history: he was born in
Portugal. 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. Now he has three daughters. His wife and children have been healthy all the
time.
Family
history: His parents were
both healthy. No family history of special disease.
Physical
examination:
T 36.3¡æ£¬P:
74bpm, R: 20bpm, BP: 140/80 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 abnormity of skull and five organs. No enlargement of his tonsils.
With soft neck and trachea placed in the middle. No enlargement
of the thyroid gland. No turgor 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
74 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. His upper limbs were in free movement, but his lower
limbs were weak, accompanied with difficulty in movement and disability of
walking. Besides, both lower limbs¡¯ movement of flexion and extension
completely paralyzed. Both gastrocnemius and soleus of his lower limbs were
serious atrophic, and muscles of his feet were also obviously atrophic. The
muscles of all over his body beat uncontrollably and frequently. His lower limbs
were Grade
¢ó
with lower muscle hyperthyroidism. The examinations to the anus and pudendum
were both normal. His physiological reflex has not been elicited. His tongue was
red with slightly yellow tongue coating, and there were cracks in the middle
with teeth-marks at the edge of the tongue. His pulse was fine and weak.
Diagnostic
examination: Not provided.
First
diagnosis:
TCM
diagnosis: Wei-syndrome (flaccidity syndrome)
Symptom
diagnosis: liver-kidneys yin vacuity.
WM
diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
First
Medical Record
July 18th 2007
Jose, a
57-year-old male, has suffered from weakness of the lower limbs along with
muscular atrophy for 3 years, and has been aggravated by disability of walking
for one year. 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 Sept. 13th
2007.
Essentials
for diagnosis:
1. The
patient has suffered from weakness of the lower limbs along with muscular
atrophy for 3 years, and has been aggravated by disability of walking for one
year.
2. In June
2004, the patient began to feel weakness of the lower 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. Three months
later, the patient began to suffer from muscular atrophy, but he still took no
treatment. In Aug. 2005, the patient went to a local hospital for a diagnosis.
After the EMG examination, he was diagnosed with
amyotrophic lateral sclerosis
(ALS). The patient was told that
there may be some unpleasantness to happen in the future. In Oct. 2005, the
patient began to take Rilutek up to now. From Mar. 2006 to Mar. 2007, the
patient received the treatment of acupuncture and massage for twice a week in a
local hospital, but he got no obvious improvement. In the second half of 2006,
the patient¡¯s condition aggravated and even was not able to walk. Therefore, his
movement had to be supported by a wheelchair. To seek for a further
comprehensive treatment, he hospitalized in our hospital on Sept. 13th
2007. Since he got the disease, his spirit was poor, but his appetite was
normal. His sleep was sound. His urination was normal, and his bowel movement
was hard.
3. T 36.3¡æ£¬P:
74bpm, R: 20bpm, BP: 140/80 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.
His lower limbs were weak, accompanied with
difficulty in movement and disability of walking. Both gastrocnemius and
soleus of his lower limbs were serious atrophic, and muscles of his feet were
also obviously atrophic. Both lower limbs were completely paralyzed. Below the
ankle-joints, there were apparently swelling. The muscles of all over his body
beat uncontrollably and frequently. His lower limbs were Grade
¢ó
with lower muscle hyperthyroidism.
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 the lower limbs along with muscular atrophy for 3 years, and has
been aggravated by disability of walking for one year. It belongs to vacuity of
liver-kidneys and blood-essence, so it could not nourish the sinews and vessels.
Therefore, it gradually results in flaccidity. With the withered marrow and dry
vessels, the fat on his legs became thinner, and so he kept a decadent spirit.
The kidneys are in charge of bone-marrow. Due to lack of the essence, his
waist-ridge was wilting with difficulty in movement. His tongue was red with
slightly yellow tongue coating, and there were cracks in the middle with
teeth-marks at the edge of the tongue. His pulse was fine and weak. All above
symptoms belong to the scope of liver-kidneys Yin vacuity.
Western
medicine: The patient has suffered from weakness of the lower limbs along with
muscular atrophy for 3 years, and has been aggravated by disability of walking
for one year. His lower limbs were weak,
accompanied with difficulty in movement and disability of walking. He could
neither raise nor sway his lower limbs, and also could not do any flexible
movement. Both of his lower limbs were completely paralyzed. Both
gastrocnemius and soleus of his lower limbs were serious atrophic, and muscles
of his feet were also obviously atrophic. The muscles of all over his body beat
uncontrollably and frequently. His lower limbs were Grade
¢ó
with lower muscle hyperthyroidism. After the EMG examination in Aug. 2005, 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. In the late
period of Bi-syndrome, the patient was not able to do any movement due to the
aching pain of the limb joints. With apraxic
limbs for a long time, the muscles were limp and atrophic, which is similar to
Wei-syndrome, but it is mainly characterized by aching pain on the limb joints.
While Wei-syndrome is characterized by limp and weak, in general, there was no
aching pain on the limb joints. 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 in clinics is rapid fatigability of the
skeletal muscles affected, improved with rest or medicines that inhibits the
activity of cholinesterase. They are not difficult to be distinguished in
clinics.
First
diagnosis:
TCM
diagnosis: Wei-zheng (Flaccidity syndrome)
Symptom
diagnosis: liver-kidneys 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.
High-protein diet
5. Herbal
tea (to enrich yin and supplement the kidneys, to soften the liver and
extinguish the wind): one dosage a day and drink twice
Prescription: Variable in Supplementing-Kidneys and Softening-Liver Decoction
Main herbs
used in the herbal tea: Baishao (White Peony), Shudi (Cooked Rehmannia root),
Chuanwu (Aconite main tuber), etc.
6.
Acupuncture and massage: once a day
7. Have
more medical examinations if necessary
Date: Sept.
14th 2007 Time: 10:00 a.m.
The patient
complained that he has suffered from weakness of the lower limbs along with
muscular atrophy for 3 years, and has been aggravated by disability of walking
for over one year. His lower limbs were weak with seriously atrophic, so he
could neither stand nor walk. His lower limbs paralyzed completely, so he even
could not do any flexible movement. There were swellings below the ankle joints.
His strength of his arms lessened. He felt languid and weak. There were muscles
beating with feeling of tightening on all over the body. He suffered from fuzzy
eyes, wilt waist and distending stomach duct. He kept a normal diet with dry
month dying to drink. His stool was dry and hard. His tongue was red with light
yellow tongue coating. There were cracks in the middle of the tongue along with
teeth marks at the edge of the tongue. His pulse was fine, rapid and weak. TCM
diagnosed it as Flaccidity Syndrome because of the Liver-Stomach yin vacuity.
Western medicine diagnosed it as
Amyotrophic Lateral Sclerosis
(ALS). The treatment strategy is
to enrich yin and supplement the kidneys, to soften the liver and extinguish the
wind.
Main herbs
used in the herbal tea: Baishao (White Peony), Shudi (Cooked Rehmannia root),
Chuanwu (Aconite main tuber), etc. three dosages in total. One dosage a day and
drink twice
Date: Sept.
16th 2007 Time: 9:00 a.m.
The patient¡¯s examinations of ECG, B-ultrasomotonography
examination and blood were both normal. His urine examination was (+); the Urea
Ammonia was 9.61. Considering there were some errors. The patient would have
more examination if necessary. The patient said that his muscles beating all
over the body lessened. Doctor¡¯s requirement: take four dosages herbal tea of
the same prescription.
Date: Sept.
20th 2007 Time: 9:00 a.m.
The
muscular
tremor
all over the body almost disappeared. His lower limbs still could not do any
movement, and he had to sit all the time. His lower limbs drooped, so the blood
was difficult to flow back to the body, which resulted in swellings below the
knee joints. The doctor advised him to lay his legs straight and do more
exercise for his suffering parts. He would continue to take five dosages herbal
tea of the same prescription.
Date: Sept.
25th 2007 Time: 9:00 a.m.
The
muscular
tremor
s all over the body improved significantly. He still suffered from abdominal
distention with dry and hard stool. His ankle joints were stiff and unable to do
any flexible movement. There were swellings below the ankle joints. The
treatment is to enrich the liver and supplement kidneys, to quicken the blood
and soften the hardness. He would continue to take five dosages herbal tea of
the same prescription.
Date: Sept.
29th 2007 Time: 9:00 a.m.
After the
treatment of herbal tea and massage, the muscular
tremor
all over the body lessened day by day. It has been three days since the muscular
tremor
stopped. The stiff ankle joints and swellings improved obviously. He would
continue to take herbal tea of the same prescription.
Date: Oct.
5th 2007 Time: 9:00 a.m.
Both stiff
ankle joints improved apparently and his toe-joints could do some slightly
flexible movement. There were contracted movements among the muscles of his
legs. The patient was glad to receive such great improvement, so he kept a
pleasant mood. Doctor¡¯s requirement: take herbal tea of the same prescription.
Date: Oct.
10th 2007 Time: 9:00 a.m.
In recent
days, the patient has suffered from vomiting, poor food intake and watery stool
twice a day. No stomachache. The treatment strategy is to warm the center and
dissipate cold, to fortify the spleen and transform food. Doctor¡¯s requirement:
take three dosages herbal tea as following: Baishu (Ovate Atratylodes root),
Fulin (Poria), Dangshen (Codonopsis root), etc.
Date: Oct.
13th 2007 Time: 9:00 a.m.
The patient
said that his food intake was normal without any vomiting. He still suffered
from abdominal distention with once dilute stool a day. Doctor¡¯s requirement:
take herbal tea of the former prescription without Lycium. In recent days, the
patient felt that there were muscular contracted movements among his legs and
calves. He was told he was recovering in a good condition.
Date: Oct.
18th 2007 Time: 10:00 a.m.
The patient
complained about his uncomfortable throat. In the examination, there were
swellings and congestion in the throat. He was considered to have caught a cold.
The doctor added 6g Sichuan Coptis root, etc. to his herbal tea. The patient was
with the symptoms of dry stool and abdominal distention. There were muscular
contracted movements among his legs and calves. His left knee joints can do
flexible movement, and the symptoms of swellings and livor below his ankle
joints lessened, which showed that his condition was improving. There was
stiffness on his ankle joints, especially serious on his left one. The patient
told the doctor that he had had the history of trauma 30 years before.
Date: Oct.
20th 2007 Time: 10:00 a.m.
The
patient¡¯s angina due to a cold has almost recovered. He was in poor spirit with
abdominal distention and dry stool. There were symptoms of swelling below the
ankle joints of his lower limbs, so the doctor advised him to eat more fruit and
vegetables, and he could not only take high-protein food. The main herbs in the
prescription as following: Baishu (Ovate Atratylodes root), Huangqi (Astragalus
root), Dangshen (Codonopsis root), etc.
Date: Oct.
23rd 2007 Time: 10:00 a.m.
In recent days, the patient has caught a
cold along with dieting outside, so he was considered that his diarrhea resulted
from
gastrointestinal disorder.
He suffered from watery stool for
twice a day, accompanied with abdominal distention, poor food intake and
weakness. He was prescribed 1000ml energy mixture with potassium chloride. He
orally took self-prepared medicine for his diarrhea. The TCM treatment strategy
is to boost qi and fortify the spleen. The main herbs in the three dosages
herbal tea as following: Baishen (White Ginseng), Huangqi (Astragalus root),
Caihu (Bupelurum root), etc.
Date: Oct.
24th 2007 Time: 9:00 a.m.
The patient
said that his spirit got better. No abdominal distention or diarrhea. The doctor
advised him that he¡¯d rather go on a light diet than a greasy or high-protein
diet. He should avoid the spicy or cold food.
Date: Oct.
26th 2007 Time: 9:00 a.m.
The
patient¡¯s condition was normal. He did not feel any other special discomfort.
His diet increased. He was with slight abdominal distention. No diarrhea. He
kept a normal spirit. The main herbs in another three dosages herbal tea:
Baishen (White Ginseng), Huangqi (Astragalus root), Caihu (Bupelurum root), etc.
Date: Oct.
29th 2007 Time: 14:00 p.m.
In recent
two days, the patient has eaten some fruits, which resulted in diarrhea,
accompanied with rectal tenesmus. He suffered with poor food intake and
weakness. The patient took self-prepared medicine for his diarrhea, and he was
prescribed by 1000ml + gentamicin 240,000 U and energy mixture. The patient felt
no special discomfort. He continued to take two dosages herbal tea of the former
formulation.
Date: Oct.
31st 2007 Time: 10:00 a.m.
The patient
diarrhea recovered completely. His stool was dry with blood in it. Today the
invited surgeon professor Yu examined him, and found that there were several
hemorrhoids among some hard and dry stool of his anal canal. There was no other
abnormality. It was considered that the patient had taken too much self-prepared
medicine for diarrhea. Therefore, he was prescribed by Glycerine Enema (Kaisailu)
for external use. The doctor advised him to eat more fruit and take the herbal
tea for further examination. The TCM treatment strategy is to fortify the spleen
and supplement the kidneys. The main herbs in the three dosages herbal tea as
following: Baishen (White Ginseng), Huangqi (Astragalus root), Caihu (Bupelurum
root), etc.
Date: Nov.
3rd 2007 Time: 9:00 a.m.
The
patient¡¯s stool was constipated and dry. After the Glycerine Enema (Kaisailu)
for external use twice, he had excluded a lot of stool. His diet got better
significantly, and he kept a normal spirit with good mood. The patient continued
to take the herbal tea to fortify the spleen and supplement the kidneys.
Doctor¡¯s requirements: take four dosages herbal tea of the same formulation.
Date: Nov.
7th 2007 Time: 9:00 a.m.
In recent
days, the patient has had slightly muscular beatings. His other condition was
normal. Doctor¡¯s requirements: take five dosages herbal tea of the following
formulation: Baishen (White Ginseng), Huangqi (Astragalus root), Baishu (Ovate
Atratylodes root),, etc.
Date: Nov.
12th 2007 Time: 9:00 a.m.
The
patient¡¯s muscular beatings disappeared. The swellings below his ankle joints of
his lower limbs lessened. The contracted strength of his lower limbs¡¯ muscles
increased. His bowel movement and urination were both normal. He kept a normal
diet and steady mood. There was no other abnormality. The doctor added Tangkuei
to another five dosages herbal tea.
Date: Nov.
17th 2007 Time: 9:00 a.m.
The
stiffness of his lower limbs¡¯ ankle joints lessened significantly. His skin was
in purple. There was blood block due to his tiredness after travel. Another
three dosages herbal tea was invariable as following: Baishen (White Ginseng),
Huangqi (Astragalus root), Baishu (Ovate Atratylodes root), etc.
Date: Nov.
20th 2007 Time: 9:00 a.m.
The
stiffness of his lower limbs¡¯ ankle joints lessened significantly. Doctor¡¯s
requirements: take four dosages herbal tea of the foremer formulation.
Date: Nov.
25th 2007 Time: 9:00 a.m.
The
swellings of his lower limbs¡¯ ankle joints lessened further. There were slight
swelling on his feet and back. His skin was in purple and dark. He kept a normal
diet and sleep. His bowel movement and urination were both normal. Doctor¡¯s
requirements: take four dosages herbal tea of the same formulation. Doctor¡¯s
requirements: take six dosages herbal tea of the former formulation.
Date: Nov.
30th 2007 Time: 9:00 a.m.
The patient
kept a steady condition. Doctor¡¯s requirements: take four dosages herbal tea of
the former formulation.
Date: Dec.
4th 2007 Time: 9:00 a.m.
The
muscular beatings all over his body disappeared completely. The swellings on his
lower limbs almost recovered. The stiffness on his ankle joints improved
significantly. The blood circulation of his lower limbs improved. He kept a
normal diet, sleep and digestion. The patient took 30 dosages herbal tea of the
former formulation and demanded to leave hospital.
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