Brief Summary: August 15, 2006. Mr.
Hrabina from Czech,
suffering from internationally difficult condition ALS (amyotrophic lateral
sclerosis) for 2 years. After 28 days treatment in our hospital, his weight has
increased 2 kg, speaking and swallowing ability become basically normal, the
spasms all over the body have disappeared. He has achieved 80% improvement.
Medical Record of
Hospitalization
Name:
Hrabina Nationality: Czech
Sex:
Male Profession:
Engineer
Age:
47 Married status: Married
Date of
hospitalization:
August 15th, 2006
Date of
record: August 15th, 2006
Chief
Complaint: The patient has suffered difficult in vocalizing and shrinking of his
tongue for 2 years.
Present
illness:
Two years
ago, without any reasons, his tongue started to be atrophic, combined with
inflexibility of its movement and difficulty in vocalizing. In the local
hospital, he, after the MRI examination, was diagnosed with ALS, which was
difficult to be cured. He did not take any treatment except take Vitamin B12.
Later, he became thinner and felt numb in the limbs, shortness in breathing and
had difficulty in swallowing. His condition was worse and worse. Three months
ago, he tried our herbal tea prescribed by our hospital, gradually, he felt
better and thus he came to our hospital for better comprehensive treatment. The
difficulty in swallowing was reduced a lot. His tongue coating is yellowish and
greasy. The pulse is deep and fine.
Past
Illness:
Generally
normal health status; no history of operation; no allergic history to any
medicine; no infectious disease history of tuberculosis or hepatitis.
Personal
history: he was born in Czech. The living environment is damp. The patient has no
addiction to smoking or drinking and has a peaceful personality.
Marriage
history: he got married at 22 years old; he has one son. Both of his son and his
wife are healthy.
Physical
Examination
Vital signs:
T 37≧,
P 80/min, R 21/min, BP 130/92 mmHg, weight 59kg.
Normal
growth of his body
and good nutrition level.
Clear mind and tired complexion. Cooperative for examination. There are no
swellings of lymph nodes. Normal skin. The lips are red, alveolar ridges normal.
Breast is normal. No abnormal breath sound. No pathologic heart murmur. Heart
rate is 80 times per minute and the rhythm is normal.
Specialized
Examination: His tongue body is obviously shortened and uneven at the both edges
of the tongue. The tongue body is not soft but hard, tongue coating is yellowish
and greasy. The pulse is deep and fine. There is obvious muscular shaking of
his upper limbs, but the shaking of the right lower limbs is clearer than that
of left one. There is also obvious atrophy in his right supraspinous muscle.
Diagnosis:
TCM:
flaccidity Syndrome (Impairment of the liver and kidney, deficiency of spleen
and stomach.)
Western
Medicine: ALS
Differential Diagnosis:
At the last
period of arthralgia-syndrome, the limbs got the symptom of atrophy, because the
limbs can't move flexible and the joints are painful a lot. But there is no pain of the
joints in the symptoms of flaccidity syndrome, and the pain of the joints is a
characteristic of arthralgia-syndrome. The patient does not feel painful in the
joints; he just has the symptoms as shortened tongue-body, unclear voice and
difficulty in speaking, uneven tongue edge, irregular tongue-body, spasms of
the muscle of his four limbs.
Treatment
strategy:
1.
TCM medical department
routine nursing.
2.
Second level nursing.
3.
Accompany nursing.
4.
Half liquid diet.
5.
Herbal tea for
supplementing qi and nourishing yin, tonifying the liver and the kidney, and Zi
Gan Yang Rong Decoction is prescribed for him, twice a day, 200 milliliters each
time.
6.
Acupuncture and massage
once a day.
7.
Increase nutrition;
take a diet with enough protein and try to keep optimistic.
Physical
conditions after our treatments:
After 28
days' treatments here, his tongue gets a clear improvement. It can move more
flexibly like twisting or curving in the mouth, he can speak more clearly, the
right edge of his tongue-body is obviously flatter than before, and the left
edge gets a slight improvement. The muscular spasms all over the whole body
fundamentally disappear. His tongue coating is white and thin; pulse is deep
and fine.
The daily
record is as follows:
August 21st,
2006 9:30 am
He has a
common mood and feels energetic. Normal appetite. There is obvious shaking in
his lower limbs and frequent shaking in the back. He can sleep well. The
urination and bowel movement are normal. The tongue coating is yellowish and
greasy. The pulse is deep and fine.
August 22nd,
2006 9:00 am
He has a
better mood today. The feeling of his tongue is better and its movement is
slightly better. There is still obvious shaking of his four limbs. The atrophy
of his right supraspinous muscle is slightly better. His sleeping is good. The
tongue coating is yellowish and greasy, and the pulse is deep and fine.
August 25th,
2006 10:00 am
Today the
patient feels better of his tongue, it can move more flexibly, and he can feel
the improvement when speaking. The shaking in his back is reduced more, but
there is still obvious shaking in his lower limbs. He feels energetic all over
the body. His appetite and sleeping are good. The bowel movement and urination
are normal. We tell him to do the tongue exercise three times for 30 minutes a
day, relatively at morning, noon, and afternoon. When doing the exercise, we ask
him to swallow the saliva.
August 28th,
2006 9:00 am
He feels
good about the tongue, it can move more, and he can speak clearer and stronger.
The shaking in his back continued to be reduced. But the shaking in his lower
limbs is slightly reduced; the atrophy in his right supraspinous muscle is
fundamentally recovered. His mood and appetite are good, sleep well. The tongue
coating is yellowish and greasy, and pulse is deep and fine.
August 31st,
2006 9:00 am
He feels
that has been better than before. His tongue can move a little bit more. He can
also speak much clearer. The atrophy in his right supraspinous muscle is
recovered. His mood and appetite are good, sleep well. The tongue coating is
yellowish and greasy, and the pulse is deep and fine.
September 3rd,
2006 9:00 am
The patient
tell us that he gets much improvements, he can move his tongue more freely, even
roll his tongue in his mouth, his voice is clearer. The hollowed surface at the
right edge of his tongue is better, and the shakings in his back, shoulder and
lower limbs are slight. He can do sports longer and stronger without tiredness.
His appetite and sleeping are as good as before.
September 6th,
2006 9:00 am
He feels
more improvements, he can move his tongue more flexibly, even roll more his
tongue in his mouth, his voice is much clearer. The hollowed surface at the
right edge of his tongue is flatter, and the spasms in his back, shoulder and
lower limbs have disappeared. His emotional condition is quite good. He can do
exercise longer and stronger without tiredness. His appetite and sleeping are as
good as before. He has normal urination and bowel movement. The tongue fur is
yellowish and fine. Keep on with the same prescription of herbal tea. We ask him
to do more exercise about his tongue functions.
September 9th,
2006 9:00 am
He tells us
that he has gained further improvements. The extent of the movements at his
tongue is increased; he can roll and stretch more his tongue in his mouth, he can
speak more clearly, the edge of his tongue is flat without atrophic surface, and
only a little atrophic at the left edge. The muscular shaking all over his body
disappears. His appetite and sleeping are as good as before. He has normal
urination and bowel movement. The tongue coating is yellowish and thin.
September
12, 2006 9:00 am
He says he
gains further improvements. The extent of the movements in his tongue is
increased; he can roll and stretch more his tongue in his mouth, his voice is
clearer, the edge of his tongue is flat without atrophic surface and only a
little atrophy at the left edge. There is no obvious muscular shaking all
over his body. His appetite and sleeping are as good as before, and he feels
energetic all the time. He has normal urination and bowel movements. The tongue
coating is whitish and thin. The pulse is deep and fine. The weight rises up to
61.5 kg from 59 kg now.
September
14th, 2006 8:00 am
Today is
his last time treatment. In the early morning we give him an earlier routine
treatment because he has to catch the flight. He says the treatment we have
offered him is very successful; he has gained much improvement here. There is no
obvious muscular shaking all over his body. The edge of his tongue is flat
without atrophic surface and only a little atrophy at the left edge of the
tongue. He can
roll and stretch more his tongue in his mouth, his voice is clearer. The tongue
coating is whitish and thin. The pulse is deep and fine.
