Medical Report of Huaihua Red Cross Hospital

Name: Cidalia                     Birth Place: Portugal

Sex: female                       Occupation: retired    

Age: 61

Marital status: widow 

Date of hospitalization: March 2nd, 2007

Date of record: March 3rd, 2007

Narrator: the patient herself.

The main complaint: atrophy and weakness in her left upper-limb for 8 months.

Present illness: two years ago, she started suffering weakness in her both hands in her upper-limbs; till June, 2006, she was processing worse, and she had the symptom of muscular atrophy in her arms. She was diagnosed with ALS by a local MRI examination. She took the medicine Rilutek for a short period. Two months ago, it was stopped because of its side-effect.

Anamnesis: she took the operation of appendectomy at the age of 36. When she was 48, she removed ovariotomy. Two years later, she got fracture in her femur. Seven years ago, she removed a carcinoid in her mandible. She doesn’t have the history of any infectious disease or medical and diet allergy. She had blood transfusion.

Personal history: she was born in Portugal. No habit of smoking or bibulosity, her temperament is gentle and open-minded.

Family history: no history of any special genetic diseases in his family.

Medical examination: T: 36.3℃ P: 64/min　R: 21/min BP: 100/73mmHg

Normal growth of her body and common nutrition level. Clear consciousness and cooperative. No yellow stain of the skin sclera. No edema of the superficial lymph nodes. Normal growth of her head and five sense organs. Sensitive to the light reflection. Symmetrical size of the pupillae. Dry lips. No hyperaemia in the throat. No edema of the tonsil and thyroid gland. Her neck touches naturally soft. Thoracic cage is symmetrical. Normal vocal fremitus. Clear percussion sound. Normal breath sound in the lungs. Spirant of the pleura. The heart rate is 64 times per minute. Normal rhythm of the heart. The abdomen is flat and soft. A scar with the length of 5 cm is visible at her abdomen. No pressing pains and no rebound tenderness. No pressing pains in the region of kidneys. Normal intestinal gurgling sound. No malformation of spinal column and limbs. No pressing pains and no warm sense of the lower limbs.

There is clear atrophy in her left arm. The girth of her left arm up elbow joints 7cm is 2 cm smaller than that of her right arm. The myodynamia of her left hand is level 4; she can lift her left arm horizontally. Her shoulder joints can move about freely.

Accessory examination: it is shown ALS by her local electromyography and MRI examinations.

Primary diagnosis: TCM flaccidity syndrome.

Symptoms diagnosis: spleen vacuity, liver-kidney depletion.

Treatment strategy: fortify the spleen and boost qi; enrich liver and supplement kidney; settle tetany and extinguish wind. Acupuncture combined with massage one time a day.

March 3^rd, 2007 9:00 am

Her complexion is the chronic ailing one. The girth of her left arm up elbow joints 7cm is 2 cm smaller than that of her right arm. The myodynamia of her left hand is level 4, the atrophy in the bicipital muscle of her left arm is visible.

March 4^th, 2007 9:00 am

Today she didn’t tell us any discomfort feeling. She has good spirit. Her bowel movement and urination are normal. She can sleep well in the night. The results of her blood routine examination, urine routine examination and liver function examination are normal. The B-ultrasonic examination shows the size of her liver, gall bladder, spleen, and pancreas are normal. Her pulse is deep and thin.

March 5^th, 2007 9:00 am

Today her spirit is good, her bowel movement and urination are normal, sleep well in the night. Her condition is stable. The pulse is deep and thin. The tongue coating is thin with dark tongue body.

March 9^th, 2007 9:00 am

Her condition is stable, her spirit is good, and her bowel movement and urination are normal, sleep well in the night. Today we checked her grip of the both hands; the left one is 5.3kg, the right hand 13.6kg, which is better than that of last examination, which the results of the left hand was 4.6kg and right hand was 9.3kg.

March 13^rd, 2007 9:00am

Today her spirit is good, her bowel movement and urination are normal, sleep well in the night. Her condition is stable. The pulse is deep and thin, the tongue coating is thin, dark tongue body.

March 18^th, 2007 9:00am

This morning she said she felt spasm in her lower limbs. Her spirit is good, her bowel movement and urination are normal, sleep well in the night. Her attending doctor analyzed that her spasm in the lower limbs was related to the release of calcium which is common in the old-aged people. So we offer her calcium tablets and Vitamin E.

March 22^nd, 2007 9:00 am

Her condition is stable, her spirit is good, and her bowel movement and urination are normal, sleep well in the night. Today we checked her grip of the both hands; the left one is 10.3kg, the right hand 15kg, which is better than that of last examination, which the results of the left hand was 5.3kg and right hand was 13.6kg. 

March 26^th, 2007 9:00 am

Today her spirit is good, her bowel movement and urination are normal, sleep well in the night. Her condition is stable. The pulse is deep and thin, the tongue coating is thin, dark tongue body.