Brief Summary:
On Sep.11, 2009, Shafali from
Sri Lanka,
who had had difficulty in speaking, swallowing and walking for
two years, was hospitalized in our hospital. She was diagnosed
as ALS in March of 2008. However, she has achieved good
improvement after 89 days TCM treatment here.
Records of
Hospitalization
Name:
Shafali
Birthplace:
Sri Lanka
Sex:
Female Age:
53
Religion:
Muslim
Date of Admission: Sep.11,
2009
Marital Status:
Married Date of Record:
Sep.11, 2009
Onset Season:
White Dew Complainer:
The patient herself
First Medical Record
Date: Sep.11,
2009 Time: 20: 00 p. m.
Shafali, a 53-year-old female, who had had difficulty in
speaking, swallowing and walking for two years, was hospitalized
in our hospital on Sep.11,
2009.
Essentials for Diagnosis:
1. The patient has
suffered from ALS, accompanied with the difficult walking and
loss of her balance of the two lower limbs for two years.
Besides, she had difficulty in speaking and swallowing.
2. Two years ago,
the patient began to have difficulty in walking. But she did not
pay much attention to it. Then the condition became worse
gradually. At the same time, she had difficulty in speaking and
swallowing. In March of 2008, she was diagnosed as ALS by MRI in
her local hospital.
3. T 36℃,
P 80 times/minute, R 20 times/minute, BP 120/80mmHg.
4. She grew
normally with medium-level nutrition. Her mind was clear. She
had an expression of chronic illness and tiredness. Her body was
cooperative with his mind.
5. No thoracic
deformity. The sound of breath was bilaterally normal on
auscultation. No sound of pleural friction. The heart border was
not enlarged. The heart beat was 80 times/minute. The cardiac
rhythm was regular. No pathological murmurs on auscultation.
6. The knee joint
of her left leg was swollen as well as her both acrotarsium.
Besides, her pulse was weak.
7.
Accessory examinations: Absent.
Diagnostic Basis:
TCM:
The patient's two lower limbs were inactive. Besides, she had
had difficulty in speaking and swallowing for 2 years. She was
easy to feel tired.
It was due to qi vacuity of the spleen and lungs, insufficiency
of the qi and blood. Qi and blood could not supplement the body,
sinews and the network vessels, so there was weakness of the
body. Her tongue body was dark red. Her tongue coating was thin
and white. Her pulses were wiry and weak. According to the
symptoms of the tongue and pulse, she was diagnosed with wilting
pattern.
Western Medicine:
The patient's two lower limbs are inactive. Besides, she had had
difficulty in speaking and swallowing for 2 years. Besides,
the knee joint of her left leg was swollen as well as her
both acrotarsium. In March of 2008, she was diagnosed as ALS by
MRI in her local hospital.
Diagnostic Differentiation:
TCM:
The patient's wilting pattern should be differentiated from
impediment pattern. Wilting pattern is mainly characterized by
limp, weak, and emaciated limbs with the numbness of the
muscles. But the patient usually has no joint pains. On the
contrary, impediment pattern is generally characterized by the
joint pains. So they are not difficult to be distinguished.
Western Medicine: ALS should be differentiated from progressive
muscular dystrophy, which is characterized by obvious muscular
dystrophy in the legs. But there is no muscular trembling in the
fascicle. The disease can be diagnosed clearly by the
examination of MRI.
First Diagnosis:
TCM diagnosis: Wilting pattern
Symptom identification: vacuity of the
liver and the kidneys,
obstruction of phlegm-damp in the network vessels.
Western Medicine diagnosis: ALS
Plans for treatment strategy and nursing:
1. Routine care of
traditional Chinese internal medicine.
2. Grade II care.
3. Accompanied by
assistants.
4. Low-fat and
high-protein diet.
5. TCM treatment
strategy: Fortify the liver and boost the kidneys, move qi and
supplement the blood.
6. Herbal tea: one
dosage a day and drink twice.（180ml
once）
7. Acupuncture and
massage: once a day.
8. Supplement each
examination for admission.
Date: Sep.12, 2009 Time:
10: 00 a. m.
Two years ago, the
patient began to have difficulty in walking. But she did not pay
much attention to it. Then the condition became worse gradually.
At the same time, she had difficulty in speaking and swallowing.
In March of 2008, she was diagnosed as ALS by MRI in her local
hospital. Presently the patient had weakness of the lower limbs
and she could not walk by herself. So she had to sit in the
wheelchair. Her urine and stool were regular. The spasms of the
four limbs were obvious. According to the symptoms of the tongue
and pulses, Professor Zhang believed that the patient had
suffered from wilting pattern. So our treatment strategy for her
was to fortify the liver and boost the kidneys, move qi and
quicken the blood.
The prescription was as follows:
bai shao
(white
peony root),
dang gui (tangkuei), etc. 4 dosages in total.
Date: Sep.15, 2009 Time:
10: 00 a. m.
The feedback of the examination today was as follows: Blood R (－),
Urine R (－).
The function of the liver was normal as well as the kidneys.
Date: Sep.20, 2009 Time:
10: 00 a. m.
The patient’s walking had not got much improvement. She still
felt the weakness of the whole body. Her urine and stool were
regular. Besides, the swallowing had improved to some extent.
Her spasms of the four limbs also had got some improvement.
According to her latest symptoms, our expert prepared a new
formula for her.
Date: Sep.25, 2009 Time:
10: 00 a. m.
The patient had not had headache up to now. The pains of the
joints had become better. However, she said that the speaking
condition became worse and the swallowing still had not got much
improvement. Then
the prescription was changed a little
bit.
Date: Sep.30, 2009 Time:
10: 00 a. m.
The
patient had cough sometimes. Her two lower limbs were stiff.
Then our treatment was to boost qi and enrich yin, fortify the
spleen and harmonize the blood. So our experts change the
formula again according to her latest condition.
Date: Oct.10, 2009 Time:
10: 00 a. m.
The patient’s cough disappeared. She also had no headache.
Besides, the swallowing had got some improvement. Her other
conditions were stable. Then she was told to
use the same formula to consolidate
the result.
Date: Oct.20, 2009 Time:
10: 00 a. m.
The patient said that her health condition did not get much
improvement in recent days. She had not pains. The swelling of
her right food was obvious. Then our experts changed her formula
a little.
Date: Oct.25, 2009 Time:
10: 00 a. m.
The patient felt the weakness of the two lower limbs. The
speaking and swallowing became worse. Her pulses were weak and
her tough body was pale. Then she was told to use the
prescription of Sep.12. And our experts added another two kinds
of herbs to let her get more improvement.
Date: Oct.29, 2009 Time:
10: 00 a. m.
The patient was
hospitalized in our hospital on Sep.11, 2009. She had had
difficult in speaking and swallowing for two years. After 48-day
treatment of fortifying the liver, boosting the kidneys, moving
qi and supplementing the blood, her health condition had not got
obvious improvement. Then our experts prepared a new formula
again according to her condition.
The prescription
was as follows:
bai
ren shen (white ginseng), fu ling (Poria), she gan (belamcandae
root), etc..
Date: Nov.6, 2009 Time:
10: 00 a. m.
The patient’s speaking and swallowing had got some improvement.
Her appetite became better than before. The tongue body was pale
and the pulses were weak. So our experts prescribed a new
formula for the third time to fortify the spleen and boost qi.
Date: Nov.11, 2009 Time:
10: 00 a. m.
The patient's health condition had got some improvement. Her
tongue body was still pale and pulses were weak. Then we added
another kind of herb to the formula.
Date: Nov.16, 2009 Time:
10: 00 a. m.
The patient’s health condition was stable. She continued to use
the same formula to get further improvement.
Date: Nov.21, 2009 Time:
10: 00 a. m.
After 10-day treatment of supplementing the spleen and boosting
the lungs, the patient’s health condition had got obvious
progress. Her appetite was good. Besides, her urine and stool
were regular. At present, the main problem was that her heels
were weakness and still she had difficulty in walking. Then
according to her latest symptoms, our experts changed her
formula to supplement the spleen, boost the kidneys and
strengthen the sinews and bones.
Date: Nov.26, 2009 Time:
10: 00 a. m.
The patient could feel the strength of the four limbs. She could
walk slowly by holding the wheelchair. Her other condition was
stable.
Date: Dec.1, 2009 Time:
10: 00 a. m.
The patient’s condition was stable. The main problem was the
weakness of her left lower limb. Then our strategy was to
continue to supplement the spleen, boost the kidneys and
strengthen the sinews and bones.
Date: Dec.6, 2009 Time:
10: 00 a. m.
The patient still could feel the weakness of her left part of
body. Her other condition was in normal. Then she still used the
same formula.
Date: Dec.9, 2009 Time:
10: 00 a. m.
After 89-day treatment of boosting the lungs, supplementing the
spleen, boosting the kidneys, strengthening the sinews and
bones, and adjusting the treatment according to her symptoms,
together with acupuncture and massage, the patient had got
obvious improvement. The patient
decided to leave the hospital today with 60 dosages of herbal
tea back home for continuous treatment.
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Case-19
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Case-23 Case-24
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Case-31
