Record of
Hospitalization
Name: Daa
Sex: Female
Age:
47 Marital
Status: Married
Nationality:
Slovene Date of Admission:
April 9, 2011
Companion:
Family
First Medical
Record
Date: Apr. 10,
2011 Time: 10:00 am
This 47-year-old lady had suffered from weak
and powerless limbs for two and half years, developing into
difficult walking for 10 months. The patient was hospitalized in
our hospital for TCM treatment at 19 pm on April 9, 2011.
Essential for Diagnosis:
1. The patient had been suffering from weak
and powerless limbs for two and half years, developing into
difficult walking for 10 months.
2. The patient complained of weakness and
pains over her left upper limb without any evident causes on
October, 2008. Fingers of her left hand were also weak, disabled
to fix the fasteners on the clothes. She did not go to hospital
for any examinations. In November, 2009, her left little finger
was out of movement; left lower limb began to be weak; there
were pains over her right wrist and muscle jumpings over her
whole general body. In June, 2010, the above mentioned symptoms
became severe, and the movement of dorsiflexion of her left foot
was reduced. The report of EMG presented that she was attacked
by motor neuron disease (MND), and according to the clinical
symptoms of her condition, her condition was diagnosed as ALS.
The hospital only gave her some medicine supplements for oral
use, instead of any specific treatment.
3. When the patient hospitalized in our
hospital, she felt weak and strength-less over her whole general
body, particularly over her left-side body. There were muscle
jumpings over her whole body. She also had shortness of breath,
much phlegm and saliva, unclear speech, as well as pains over
her shoulders and neck. She was easy to be fatigued. Spirit and
sleep were good. She could sleep for around 8 hours every night.
Urine was yellowish and stool was dry. Because of a fall 2
months ago, phalanx of her left food was broken; therefore, when
walking, she suffered few pains. She could only walk for about
300 meters. Walking balance was not good.
4. T: 36.5¡ãC R: 20 times/minute P: 80
times/minute BP: 120/70 mmHg
5. She had a natural facial expression. Her
spirit activities were normal. She grew normally. The patient
had walking problem. She showed active position. Grasping power:
right hand, 9.5kg, left hand 6.1kg. Her tongue was pale with
thin and white coating. Her pulse was weak and thready.
Diagnostic Basis:
TCM: The
patient had been suffering from weak and powerless limbs for 2
and half years, developing into difficult walking problems for
10 months. The lungs dominate respiration and control qi
throughout the body. Shortness of breath was due to deficiency
of the lungs. The spleen governs the muscles and the four limbs.
The deficiency of spleen and lungs led to improper transmitting
of water and essence to the whole body, so muscle atrophy
appeared. Yin deficiency of the liver and kidneys leads to loss
of nourishment of the vessels and channels as well as muscles,
therefore, muscle jumpings over her whole body and night
sweating appeared. From the principle of TCM, deficiency of the
lungs and spleen as well as yin deficiency of the liver and
kidneys were the characters of atrophy disease.
Western Medicine:
The patient suffered from weak and powerless limbs for two and
half years, developing into difficult walking for 10 months,
accompanied by muscle jumpings and muscle atrophy. Meanwhile,
according to examination results of EMG and her clinical
symptoms, she should have suffered from ALS.
Diagnostic Differentiation:
TCM: Atrophy
diseases are usually differentiated with Bi syndrome or
impediment pattern. Atrophy diseases have such characteristics
as atrophy of the limbs¡¯ muscles, the weakness of the limbs and
the uselessness of the thin feet. The muscular atrophy and
muscle jumpings are the main symptoms of atrophy diseases. The
impediment patterns are reflected by the pains or tense pains on
the body joints. So it is easy to differentiate them.
Western Medicine diagnosis:
ALS should be differentiated with
myasthenia gravis. Myasthenia gravis would be aggravated after
exercises and it would be reduced after some rest. Almost no
muscle atrophy and muscle jumpings. But ALS is caused by lesions
of the central nervous system, accompanied by muscular atrophy
and muscle jumpings. Therefore, there is no difficulty to
differentiate them.
First Diagnosis:
TCM: atrophy disease
Symptom identification: deficiency of the
lungs and spleen as well as yin deficiency of the liver and
kidneys.
Western medicine diagnosis: ALS
Treatment strategy and nursing:
1. Routine care of traditional Chinese
internal medicine.
2. Grade
¢ò
care.
3. Companion.
4. Common diet.
5. Pathogenesis: deficiency of the lungs and
spleen as well as yin deficiency of the liver and kidneys.
6. TCM strategy:
nourish the spleen and benefit the lungs, nourish the liver and
kidneys as well as nourish blood and soften the tendons.
7. Herbal tea: one dosage a day and drink
twice
8. Acupuncture and massage: once a day
9. Have more medical examination if
necessary.
Date: Apr. 11,
2011 Time: 10:30 am
Professor Yang, paid a visit to the patient.
The patient felt weak and strength-less over her whole general
body, particularly over her left-side body. There were muscle
jumpings over her whole body. She also had shortness of breath,
much phlegm and saliva, unclear speech, as well as pains over
her shoulders and neck. She was easy to be fatigued. Spirit and
sleep were good. Her stool was dry and urine yellowish. She
complained of pains over the back of her feet when walking. She
could only walk for around 300 meters, with bad balance.
Physical check: The functions of her heart and lungs were
normal. There was muscle atrophy over tucks muscles of her both
hands, finger muscles and her left supraspinatus muscles.
Grasping power: right hand, 9.5kg, left hand 6.1kg. Her tongue
was pale with thin and white coating. Her pulse was weak and
thready. Professor Yang thought from the TCM principle that the
patient suffered from atrophy disease, which was due to
deficiency of the lungs and spleen as well as yin deficiency of
the liver and kidneys. The therapeutic methods for the atrophy
disease are to nourish the spleen and benefit the lungs, nourish
the liver and kidneys as well as nourish blood and soften the
tendons.
Date: Apr. 12,
2011 Time: 10:30 am
Feedback of examinations: Blood routine,
urine routine as well as the functions of the liver and kidneys
were normal.
Date: Apr. 13,
2011 Time: 10:00 am
The patient said muscle jumpings over her
whole general body were reduced. She was no longer that easy to
be fatigued even after some exercise. Sleep was good.
Date: Apr. 17,
2011 Time: 10:00 am
The patient said symptoms of her whole body
were changing better. Other conditions were good except of much
saliva in her mouth.
Date: Apr. 21,
2011 Time: 10:00 am
There was no special improvement in the
patient¡¯s conditions. Saliva was reduced somewhat. There was
sweating over her chest. Urine was yellowish. Pains over her
left foot back were reduced slightly when walking.
Date: Apr. 25,
2011 Time: 9:30 am
The patient felt sever pains over her left
foot back, since they had a tour of mountain climbing. There was
sweating over the front part of her chest. Strength over her
whole body was increasing. Muscle jumpings were reduced
evidently. Saliva was reduced.
Date: Apr. 30,
2011 Time: 9:15 am
The patient said strength of her four limbs
was increasing some bit. Grasping power: right hand, 10.6 kg,
left hand 6.4 kg. Now she could walk for around 400 meters.
There were slight edema and pains over her left foot back. She
had chest oppression, shortness of breath, sweating over her
chest and occasional restless. Her tongue was red with thin
tongue coating. Her pulse was wiry.
Date: May 6,
2011 Time: 9:15 am
The patient¡¯s conditions were stable. She had
good spirit and good sleep. Her appetite was normal. Bowel
movement and urine were normal. Her tongue was red with thin
coating. Her pulse was wiry.
Date: Mar. 10, 2011
Time: 10:00 am
After one month TCM treatment, the patient
requested to leave hospital today. After treatment in our
hospital, the patient¡¯s conditions were much better than before.
Weakness and powerlessness of her four limbs were changing
better. Chest oppression and shortness of breath were reduced.
Muscle jumpings over her whole body and pains over her neck and
shoulders were basically improved. Pains over her left foot back
were reduced when walking. Sleep, appetite and sleep were good.
She felt muscle-increasing on the tuck muscles of her left hand.
Grasping power: right hand 10.8 kg, left hand 6.8 kg.
Doctor¡¯s advice after leaving hospital:
1. Maintain good moods and be careful with
the cold.
2. Take herbal medicine back for continuing
treatment.