TCM China:  

Record of Herbal Treatment Of Grebenikova from Russia Improvement Of ALS
 

　　

　

　

 

   

　

　

　

Brief Summary: On November 18, 2013, Grebenikova, from Russia, who had suffered from difficult swallowing for one year, developing into weight losing and muscle jumping for 6 months, was hospitalized in our hospital. Her condition was diagnosed as ALS. She achieved some great improvement after 86 days TCM treatment.

 

Record of Hospitalization

Name: Grebenikova                                                     Sex: Female

Age: 69                                                                       Marital Status: Married

Nationality: Russian                                                    Date of Admission: November 18, 2013

Companion: Her Granddaughter

 

First Medical Record

Date: Nov. 19, 2013                                Time: 09:30 a.m.

This 69-year-old lady had suffered from difficulty swallowing and talk for one year, developing into weight losing and muscle jumping for 6 months. The patient was hospitalized in our hospital for TCM treatment at 12:30 p.m. on November 18, 2013.

　

Essential for Diagnosis:

1. The patient had been suffering from difficulty swallowing and talk for one year, developing into weight losing and muscle jumping for 6 months. She had no allergy history of any food or medicine.

2. When the patient hospitalized in our hospital, she felt difficulty in swallowing and speaking. She felt dryness in her mouth. She drank much water. In recent 6 months, her voice became lower and then she suffered speaking problem. Appetite was poorer than before. The sense of hunger was not that stronger than before. No night sweat or night heat over the body. She suffered frequent night urination, sometimes 2 times, while sometimes 3-4 times. The night urination problem had been lasted for ten years. She also suffered headache for many years. She felt dizziness in recent 4 months. The color of urine was yellowish. The stool was hard. She lost weight in recent months, but no change over her power, right hand: 19.6 kilos; left hand 15.2 kilos. Sometimes she suffered muscle jumpings and muscle spasms. Shortness of breath was not obvious. Her pulse was slippery and rapid. Her tongue was red with yellowish coating.

3. T: 36.4＜C   R: 20 times/minute    P: 80 times/minute   BP: 170/90 mmHg

4. She had a chronic sick facial expression. Her spirit activities were normal. She grew normally. There was no yellow skin or yellow sclera over her whole body. Rhythm of her heart was 80 times per minute. Heart rate was regular with no murmurs. Sound of breathing in the lungs was clear, without any rhonchi. Her abdomen was soft with no pressing pains and rebound tenderness. There were few muscle jumpings over her four limbs, but there was no obvious muscle atrophy over them.

 

Diagnostic Base:

TCM:

The patient was old. Her kidneys were in a deficient state. The deficiency of kidney-yang led to the deficiency of liver-yang. Wind-yang attacked upwards the mind, which caused change of emotion. Liver stagnation led to qi stagnation. The patient suffered painful menstruation often when she was young. Floating yang got up, which caused dizziness and headache. The stomach meridian goes through the neck. Over heat caused dryness in the mouth. Wind-yang disturbed inside, which caused muscle jumping. Therefore, her condition should be deficiency of the kidneys and liver-yang hyperactivity as well as wind-fire attacking upwards the mind. The treatment should be nourishing the kidneys and tonifying the spleen.

 

Western Medicine diagnosis:

1. Chronic ill occurrence.

2. Symptoms: Swallowing and speaking difficulty, muscle jumpings

3. Lab examination report.

 

First Diagnosis:

TCM: atrophy disease

Symptom identification: deficiency of the kidneys and liver-yang hyperactivity as well as wind-fire attacking upwards the mind.

Western medicine diagnosis: ALS

　

Treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade Å care.

3. Companion.

4. Common diet.  

5. Pathogenesis: deficiency of the kidneys and liver-yang hyperactivity as well as wind-fire attacking upwards the mind.

6. TCM strategy: nourish water and clear liver as well as soothe and free the meridians and channels

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: Nov. 20, 2013                                Time: 10:00 a.m.

Dr. Ming, doctor-in-charge, paid a visit to the patient this morning. The patient had difficulty in swallowing and speaking for almost one year. She felt muscle jumpings in recent 1 month. She also had thyroiditis and severe painful menstruation when she was young. In recent six months, she suffered dizziness. The patient used to suffered kidney deficiency. Kidney deficiency led to the deficiency of kidney-yin. Kidney-yang attacked upwards. Neck is the passageway of the kidney meridian. The deficiency of kidney water led to dryness in the mouth and throat. Kidney deficiency affected the function of liver, and wind-yang attacked upwards, which caused muscle jumping. The treatment should focus on the liver.

 

Date: Nov. 21, 2013                                Time: 10:00 a.m.

Till now, the patient did not feel any obvious change. The tongue and pulse were the same. Sleep was normal.

 

Date: Nov. 22, 2013                                Time: 10:00 a.m. 

The patient felt some improvement in dryness of her mouth. Stool was easier to be defecated than before, but the stool was still a little hard.

 

Date: Nov. 26, 2013                                Time: 10:00 a.m.

The patient felt headache today. Blood pressure was 175/90 mmHg. Her pulse was wiry, without dryness or bitterness in her mouth. The patient had stopped the use of blood pressure medications.

 

Date: Nov. 30, 2013                                Time: 10:00 a.m.

Headache had gone away. BP: 138/80. Headache had some relations with the elevation of blood pressure. Dryness and thirst in her mouth were obviously changed better. She had slight constipation.

 

Date: Dec. 2, 2013                                Time: 10:00 a.m.

The patient did not suffer headache any more. Sleep and appetite were improved. Her pulse was stable. Her tongue was slightly thick and yellowish. Blood pressure was good. No use of blood pressure medication.

 

Date: Dec. 5, 2013                                Time: 10:00 a.m.

The patient¨s conditions were stable recently. She had good spirit and good sleep. Her appetite was normal. Bowel movement and urine were normal. Her blood pressure was normal, too.

 

Date: Dec. 9, 2013                                Time: 10:00 a.m.

The patient¨s blood pressure, bowel movement, urination, sleep and appetite were normal. Her tongue body was moist. Her pulse was stable and slow.

 

Date: Dec. 12, 2013                                Time: 10:00 a.m.

The movement of her lower limbs was better than before. Temperature was better than before. She was afraid of cold before. Muscle jumpings of her lower limbs were almost gone. Muscles over her lower legs grew a little bit. Blood pressure was normal.

 

Date: Dec. 12, 2013                                Time: 10:00 a.m.

The patient felt obvious improvement over her symptoms, except for problems in her throat.

 

Date: Dec. 20, 2013                                Time: 10:00 a.m.

In recent days, her blood pressure was kept stable, at 120-130/80-90 mmHg. There was no obvious discomfort. The treatment for the next stage was for the throat.

 

Date: Dec. 25, 2013                                Time: 10:00 a.m.

The blood pressure of the patient was 130/80 mmHg. She did not feel headache or dizziness. Appetite was much better than before. She had bowel movement once a day.

 

Date: Dec. 30, 2013                                Time: 10:00 a.m.

The patient caught cold yesterday. She suffered runny nose. She did not feel any headache.

 

Date: Jan. 3, 2014                                 Time: 10:00 a.m.

The patient got recovery from cold. She felt slightly dry over her throat. Right pulse was wiry. Spleen and kidney pulse were slightly weak. Her tongue coating was slightly yellowish.

　

Date: Jan. 7, 2014                                 Time: 10:00 a.m.

The patient felt improvement over the dryness of her throat. Muscles were plumper than before. Thyroid nodule was almost gone. Advise her to reduce the use of thyroid medication.

 

Date: Jan. 11, 2014                                 Time: 10:00 a.m.

The patient still had sleep problem. Yesterday, she felt headache over the back of her head. Blood pressure rose up to 150/80 mmHg.

 

Date: Jan. 14, 2014                                 Time: 10:00 a.m.

The patient¨s condition was stable. Blood pressure was 128/74 mmHg. No muscle jumpings. Appetite was normal. Bowel movement and urination were normal.

 

Date: Jan. 17, 2014                                 Time: 10:00 a.m.

The patient still felt slightly dryness in her mouth during the night, but her mouth was moist.

 

Date: Jan. 20, 2014                                 Time: 10:00 a.m.

The patient felt slight headache.

 

Date: Jan. 23, 2014                                 Time: 10:00 a.m.

Recently, blood pressure of the patient was stable. She did not feel headache or dizziness. BP: 130-120/80-70 mmHg. Swallowing was better. Breathing was stable. Appetite was better. Weight was increased.

 

Date: Jan. 26, 2014                                 Time: 10:00 a.m.

Blood pressure was stable. She did not feel any discomfort. She did not use the blood pressure medications for more than 2 months. Muscles over her arm were plumper than before. No more obviously thirsty feeling. Tongue coating was greasier than before.

 

Date: Jan. 31, 2014                                 Time: 10:00 a.m.

Today, the blood pressure of the patient was slightly high. It was 138-140/86-90 mmHg. When the pressure was high, she felt heavy sense over her head.

 

Date: Feb. 5, 2014                                  Time: 10:00 a.m.

The weight of the patient did not lose during those three months. She did not feel headache or dizziness. Bowel movement and urination were normal. Appetite was normal.

　

Date: Feb. 10, 2014                                  Time: 10:00 a.m.

The patient decided to leave our hospital today. She stopped the use of blood pressure medication for 2.5 months. Blood pressure was normal, at about 130/90 mmHg. No loss of her weight during these days. Muscle jumping went away. No more night urination. Appetite was improved. No more headache or dizziness.

 

Doctor¨s advice after leaving hospital:

1. Maintain good moods and be careful with the cold.

2. Take herbal medicine back for continuing treatment.

3. Keep doing exercise of the limbs.

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