Nationality: the
Netherlands Marital status: Married
Onset Season: Summer
Date of Admission: Nov. 10th 2007
Complainer: The patient
himself Reliability: Reliable
First Medical Record
Nov.
10th 2007
Peter,
a 41-year-old male, has suffered from weakness of upper limbs, along with
difficulty in flexibility of finger joints for two years, and has aggravated for
one year. He was picked up by our staff in Zhijiang Airport and arrived in
Huaihua Red Cross Hospital for further treatment at 20: 10p.m on Nov. 11th
2007.
Essentials for diagnosis:
1. The
patient has suffered from weakness of upper limbs, along with difficulty in
flexibility of finger joints for two years, and has aggravated for one year.
2. In
the beginning of Nov. 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 examination or treatment about it. Therefore, the disease was
developing progressively. Three months later, the patient had difficulty in the
movement of fingers of both hands. The finger joints were not able to do any
flexible movement. But he still took no examination or treatment. In Oct. 2006,
the patient went to a local hospital for a diagnosis. After the MRI examination,
he was diagnosed with amyotrophic lateral sclerosis (ALS). The hospital prescribed him
Rilutek capsule. After
one-month medicine taking, he stopped taking it due to some discomfort. Then he
did no other treatment. In
Nov. 2006, the patient¡¯s condition aggravated, appearing weakness of the lower
limbs, the delay of his movement, and difficulty in speaking. 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 normal.
His sleep was slightly poor. His bowel movement and urination were both normal.
3. T
36.3¡æ£¬P:
83bpm, R: 20bpm, BP: 130/80 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 has suffered from weakness of
upper limbs and slightly muscular atrophy of double arms. There were obvious
atrophy on the muscles of
thenar eminence and hypothenar of his double hands. His fingers of double hands
had difficulty in flexible movement with poor fine movement. The experiment to his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hyperthyroidism. His lower limbs were weak, stiff with
difficulty in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hyperthyroidism. The muscles all over his limbs beat
uncontrollably and frequently. He was with the symptoms of short of breath,
weakness, as well as with difficulty in speaking. His tongue surface was uneven,
and there were teeth marks at the edge 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
weakness of upper limbs, along with difficulty in flexibility of finger joints
for two years, and has aggravated for one year. His limbs were atrophic
and weak with languid spirit and pale face. He had
difficulty in speaking. His tongue was red with thin and white tongue coating.
His pulse was string-like. 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 kidneys, which lead to
deficiency of yin. Then it gradually resulted in flaccidity.
Western medicine: The patient has suffered from weakness of upper limbs, along
with difficulty in flexibility of finger joints for two years, and has
aggravated for one year. His upper limbs were weak with slightly muscular
atrophy of his arms. There were obvious atrophy on the muscles of thenar eminence and hypothenar of
his double hands. His fingers of double hands had difficulty in flexible
movement with poor fine movement. The experiment to his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hyperthyroidism. His lower limbs were weak, stiff with
difficulty in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hyperthyroidism. The muscles all over his limbs beat
uncontrollably and frequently. He was with the symptoms of short of breath,
weakness, as well as with difficulty in speaking. His tongue surface was uneven,
and there were teeth marks at the edge of his tongue. In Oct. 2006, he went to a
local hospital for a MRI examination, and 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 who has 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, 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.
1. On
routine care of traditional Chinese internal medicine
2. On
grade II care
3.
Under care of a companion
4.
high-protein diet
5.
Herbal tea (to nourish the lung and supplement the kidneys, soften the liver and
extinguish the wind): 5 dosages in total. One dosage a day and drink twice
Main
herbs used in the herbal tea: Huangqi (Astragalus root), Taizishen (Pseudostellaria
root), Danshen (Salvia root), etc.
6.
Acupuncture and massage: once a day
7.
Have more medical examinations if necessary
Date:
Nov. 13th 2007 Time: 10:00 a.m.
After
the examinations of ECG, B-ultrasomotonographyand Chest radiography, the
patient was found no abnormality. The three regular examinations and the
examinations to the functions of his liver and kidneys as well as the
examination of E4A were all normal. According to the above information,
the doctor advised him to continue to take herbal tea of the former
prescription.
Date:
Nov. 22nd 2007 Time: 10:00 a.m.
The
patient¡¯s diet has increased. The weakness of his lower limbs has got some
improvement, and the incontrollable beating of the muscles all over his body
lessened. At night, there were some paroxysmal spasms on his limbs. His sleep
was poor with dreaminess. His tongue body was thin, atrophic and tender. The
surface of his tongue was uneven and trembling with teeth marks at the edge of
the tongue. The patient would continue to take the same herbal tea.
Date:
Dec. 5th 2007 Time: 10:00 a.m.
The
stiffness and weakness of his lower limbs, and difficulty in walking have been
improved altogether. The incontrollable beating of the muscles all over his body
and paroxysmal spasms on his limbs lessened. Besides, the difficulties in
speaking and breathing have become better. The doctor advised him that the
herbal tea should be followed by the former prescription.
Summary stage
Dec. 9th
2007 Time: 9:00 a.m.
Peter, a 41-year-old
male, has suffered from
weakness of upper limbs, along with difficulty in flexibility of finger joints
for two years, and has aggravated for one year. The
patient was hospitalized in our Red Cross Hospital at 20:10 p.m. on Nov.11th
2007. He has been hospitalizing for 30 days.
Condition of
admission:
T 36.3¡æ£¬P:
80bpm, R: 20bpm, BP: 130/80 mmHg.
His heart and lung were
normal, and his abdomen was soft and flat. He has
suffered from weakness of
upper limbs and slightly muscular atrophy of double arms. There were obvious
atrophy on the muscles of
thenar eminence and hypothenar of his double hands. His fingers of double hands
had difficulty in flexible movement with poor fine movement. The experiment to his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hyperthyroidism. His lower limbs were weak, stiff with
difficulty in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hyperthyroidism. The muscles all over his limbs fluctuated
uncontrollably and frequently. He was with the symptoms of short of breath,
weakness, as well as with difficulty in speaking. His tongue was uneven, and
there were teeth marks at the edge of his tongue. His
spirit, appetite and sleep were all poor. Both of his bowel movement and
urination were normal.
Since the patient was
hospitalized, he was prescribed herbal tea
to nourish the lung and supplement the kidneys, soften the liver and extinguish
the wind. One dosage 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 36.3¡æ£¬P:
80bpm, R: 20bpm, BP: 130/80 mmHg.
.His heart and lung were normal, and his abdomen was soft and flat.
The difficulties in his speaking, breathing and walking have got some
improvement, so have the weakness and stiffness of lower limbs and the
incontrollable beating of
the muscles all over his body. There is no obvious improvement in the weakness
and tightness of his upper limbs. His spirit, appetite and sleep were all
normal. Both of his bowel movement and urination were normal.
The
incontrollable beating of the muscles all over his body and paroxysmal spasms on
his limbs lessened a lot. His sleep was normal, sometimes with a drumming in the
ears. He continued to take the herbal tea of the same prescription.
Date:
Dec. 20th 2007 Time: 9:00 a.m.
The
thin and tender tongue body became better, so did the uneven and trembling
surface of his tongue. Besides, his tongue coating was white. His general
strength has increased with pleasant spirit. What¡¯s more, the difficulty in
walking has been improved. He would continue to take the former formulation.
Date:
Dec. 30th 2007 Time: 9:00 a.m.
Today
the patient said that he had difficulty in speaking with unclear and influent
speech. Besides, he felt difficulty in breathing with the symptoms of short of
breath and weakness. His stiffness and weakness in the lower limbs, the
difficulty in walking and the muscular beating all over the body all have got
some improvement. There was no improvement in the tight and weak upper limbs. In
the examination, his heart and lung were normal, and his abdomen was flat and
soft. His spirit, appetite and sleep were all normal. His bowel movement and
urination were both normal too. His tongue was red with thin and white tongue
coating. His pulse was fine and weak. The herbal tea would keep the same as
before.
Summary stage
Jan. 9th
2007 Time: 9:00 a.m.
Peter, a 41-year-old
male, has suffered from
weakness of upper limbs, along with difficulty in flexibility of finger joints
for two years, and has aggravated for one year. The
patient was hospitalized in our Red Cross Hospital at 20:10 p.m. on Nov.11th2007. He has been hospitalizing for 60 days.
Condition of
admission:
T 36.5¡æ£¬P:
80bpm, R: 20bpm, BP: 130/80 mmHg.
His heart and lung were
normal, and his abdomen was soft and flat. He has
suffered from weakness of
upper limbs and slightly muscular atrophy of double arms. There were obvious
atrophy on the muscles of
thenar eminence and hypothenar of his double hands. His fingers of double hands
had difficulty in flexible movement with poor fine movement. The experiment to his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hyperthyroidism. His lower limbs were weak, stiff with
difficulty in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hyperthyroidism. The muscles all over his limbs fluctuated
uncontrollably and frequently. He was with the symptoms of short of breath,
weakness, as well as with difficulty in speaking. His tongue was uneven, and
there were teeth marks at the edge of his tongue. His
spirit, appetite and sleep were all poor. Both of his bowel movement and
urination were normal.
Since the patient was
hospitalized, he was prescribed herbal tea
to nourish the lung and supplement the kidneys, soften the liver and extinguish
the wind. One dosage 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 36.5¡æ£¬P:
80bpm, R: 20bpm, BP: 130/80 mmHg.
.His heart and lung were normal, and his abdomen was soft and flat.
The strength of his lower limbs has increased, and the incontrollable beating of the muscles all over his
body has
lessened. Besides, there was no obvious improvement in the weakness of his upper
limbs. His speech was unclear and influent. While his
spirit, appetite and sleep were all normal. Both of his bowel movement and
urination were normal. His tongue was red with thin and white tongue coating.
His pulse was string-like.
The
strength of his lower limbs has increased, and the muscular beating all over his
body has lessened. There was no obvious improvement in his upper limbs. Besides,
his speech was still unclear. He kept a normal sleep. The patient said that his
deafness began at his early age.
Date:
Jan. 20th 2008 Time: 9:00 a.m.
The
thinness and tenderness of his tongue body, along with the uneven tongue surface
has been improved markedly. What¡¯s more, the trembling in the tongue body has
lessened significantly, and the strength of his lower limbs has also increased a
lot. There was still no obvious improvement in his upper limbs. He would
continue to take the former herbal tea.
Date:
Jan. 31st 2008 Time: 9:00 a.m.
The
pain of his lower limbs¡¯ joints has almost disappeared. The doctor would make
some changes on the basis of his former herbal tea.
Summary stage
Feb. 9th
2007 Time: 9:00 a.m.
Peter, a 41-year-old
male, has suffered from
weakness of upper limbs, along with difficulty in flexibility of finger joints
for two years, and has aggravated for one year. The
patient was hospitalized in our Red Cross Hospital at 20:10 p.m. on Nov.11th
2007. He has been hospitalizing for 90 days.
Condition of
admission:
T 36.5¡æ£¬P:
80bpm, R: 20bpm, BP: 130/80 mmHg.
His heart and lung were
normal, and his abdomen was soft and flat. He has
suffered from weakness of
upper limbs and slightly muscular atrophy of double arms. There were obvious
atrophy on the muscles of
thenar eminence and hypothenar of his double hands. His fingers of double hands
had difficulty in flexible movement with poor fine movement. The experiment to his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hyperthyroidism. His lower limbs were weak, stiff with
difficulty in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hyperthyroidism. The muscles all over his limbs fluctuated
uncontrollably and frequently. He was with the symptoms of short of breath,
weakness, as well as with difficulty in speaking. His tongue was uneven, and
there were teeth marks at the edge of his tongue. His
spirit, appetite and sleep were all poor. Both of his bowel movement and
urination were normal.
Since the patient was
hospitalized, he was prescribed herbal tea
to nourish the lung and supplement the kidneys, soften the liver and extinguish
the wind. One dosage 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 36.5¡æ£¬P:
80bpm, R: 20bpm, BP: 130/80 mmHg.
.His heart and lung were normal, and his abdomen was soft and flat.
The strength of his lower limbs has increased, and the incontrollable beating of the muscles all over his
body has
lessened. Besides, there was no obvious improvement in the weakness of his upper
limbs. His speech was unclear and influent. While his
spirit, appetite and sleep were all normal. Both of his bowel movement and
urination were normal. His tongue was red with thin and white tongue coating.
His pulse was string-like.
In
recent days, the patient has had a slightly cold. Besides, his pharyngeal itching
and expectoration has
aggravated. The doctor made some changes on the basis of his former herbal tea.
Date:
Feb. 23rd 2008 Time: 9:00 a.m.
Recently, his repeated cold, cough has almost recovered. There still existed
muscular beating in the upper limbs and paroxysmal spasms in his fingers. His
diet and sleep were both normal. The herbal tea keeps the same as before.
Date:
Mar. 5th 2008 Time: 9:00 a.m.
The
patient had too much saliva with poor sleep. His sometimes shoulder pain and
muscular beating have lessened. The herbal tea keeps the same as before.
Summary stage
Mar. 9th
2007 Time: 9:00 a.m.
Peter, a 41-year-old
male, has suffered from
weakness of upper limbs, along with difficulty in flexibility of finger joints
for two years, and has aggravated for one year. The
patient was hospitalized in our Red Cross Hospital at 20:10 p.m. on Nov.11th
2007. He has been hospitalizing for 120 days.
Condition of
admission:
T 36.5¡æ£¬P:
80bpm, R: 20bpm, BP: 130/80 mmHg.
His heart and lung were
normal, and his abdomen was soft and flat. He has
suffered from weakness of
upper limbs and slightly muscular atrophy of double arms. There were obvious
atrophy on the muscles of
thenar eminence and hypothenar of his double hands. His fingers of double hands
had difficulty in flexible movement with poor fine movement. The experiment to his hands was
(+). The muscular strength of his upper limbs was Grade
¢ó
with muscle weak hyperthyroidism. His lower limbs were weak, stiff with
difficulty in walking. The muscular strength of his lower limbs was also Grade
¢ó
with muscle weak hyperthyroidism. The muscles all over his limbs fluctuated
uncontrollably and frequently. He was with the symptoms of short of breath,
weakness, as well as with difficulty in speaking. His tongue was uneven, and
there were teeth marks at the edge of his tongue. His
spirit, appetite and sleep were all poor. Both of his bowel movement and
urination were normal.
Since the patient was
hospitalized, he was prescribed herbal tea
to nourish the lung and supplement the kidneys, soften the liver and extinguish
the wind. One dosage 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 36.5¡æ£¬P:
80bpm, R: 20bpm, BP: 130/80 mmHg.
.His heart and lung were normal, and his abdomen was soft and flat.
The strength of his lower limbs has increased, and the incontrollable beating of the muscles all over his
body has
lessened. Besides, there was no obvious improvement in the weakness of his upper
limbs. His speech was unclear and influent. While his
spirit, appetite and sleep were all normal. Both of his bowel movement and
urination were normal. His tongue was red with thin and white tongue coating.
His pulse was string-like.
The
pain of his shoulder joint and hip joint has lessened, so have the symptoms of
the muscles all over his body and his fingers. He still felt weak in raising his
arms. He has kept a sound sleep as well as pleasant spirit and normal diet. In
the examination, his tongue body has broadened, and the uneven tongue surface
with trembling and the teeth marks at the edge of his tongue have got some
improvement. He would continue the herbal tea.
Date:
Mar. 31st 2008 Time: 9:00 a.m.
The
thin and atrophic tongue body as well as the uneven tongue surface has been
improved significantly, so has the slow and unclear speech. Besides, the
stiffness and weakness of his lower limbs along with the difficulty in walking
has also been improved significantly. His short of breath, poor spirit and sleep
has turned out to be normal. While there were still no obvious changes in some
of his symptoms, such as the muscular atrophy and weakness on his upper limbs,
the difficulty in joints¡¯ flexible movement, and the disability of laying his
arms flat or raising his arms. All the symptoms have kept stable condition.
Date:
Apr. 11th 2008 Time: 9:00 a.m.
The
stiffness and weakness of his lower limbs along with the difficulty in walking
has been improved significantly. Besides, the thin and atrophic tongue body, as
well as the uneven tongue surface and teeth marks at the edge of the tongue also
has got much improvement, so has his slow and unclear speech. What¡¯s more, the
incontrollable beating of the muscles all over his body and paroxysmal spasms on
his lower limbs also lessened significantly. He has recovered with normal sleep
and diet as well as pleasant spirit. He felt no tiredness with a good mood. He
spoke highly of our TCM treatment, especially satisfied with his treatment
results. Today he demanded to leave the hospital with two-month herbal tea for
home taking.
