Medical Report of Huaihua Red
Cross Hospital
General introduction of this
report: Mr. Vladimir, from Czech Republic, took our treatments for one month.
After the doctors¡¯ efforts, he got much improvement. His treatment is
successful.
Name:
Vladimir Birth Place: Czech Republic
Sex:
male Occupation: Book-seller
Marital
status: married
Date of
hospitalization: January 1st, 2007
Date of
record: January 1st, 2007
Narrator:
the patient himself.
The
major complaint: atrophy and weakness in his limbs
for 2 years, being worsening for half a year.
Present
disease: two years ago, without any obvious
inducement, he started suffering weakness in his both hands and atrophy in his
upper limbs; it was difficult for him to lift his arms. But he didn¡¯t pay any
attention. His condition was worse 3 months later, the muscles in his four limbs
and chest started jumpiness. But he didn¡¯t take any treatments. Till the
September of 2005, he was diagnosed as ¡°ALS¡± after the electromyography and MRI
examination at his local hospital. The hospital offered him the medicines such
as, magnesium, lorista verospiron, etc, but he didn¡¯t gain any obvious
improvements.
Anamnesis: he doesn¡¯t have the history of any
infectious disease or medical and diet allergy. No blood transfusion. He took
the operations appendectomy, cholecystectomy and adrenalectomy relatively in the
year of 1955, 1992 and January 18th, 2006.
Personal
history: he was born in Czech Republic, no addiction of smoking or bibulosity,
his temperament is gentle and open-minded.
Family
history: no history of any special genetic
diseases in his family.
Medical
examination:
T: 36.2¡æ
P: 88/min¡¡R:
20/min BP: 120/80mmHg Weight: 64kg
Normal
growth of his 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 his 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. His 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 88 times per minute. Normal rhythm of the heart. The abdomen is flat and
soft. No pressure pains and no rebound tenderness. No pressure 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 his both sides¡¯ supraspinous muscles and infraspinous muscles
and there is also clear muscle atrophy in his both arms. The girth of his right
arm up elbow joints 8cm is 19cm, the left one is the same. The girth of his left
arm down elbow joints 10cm is 19 cm, the left one is the same. Both of his
bicipital muscles and triceps muscles of arm almost disappear, the myodynamia of
his both hands is level 3, strength of his right hand is 5.5kg; strength of his
left hand is 4.2kg. He has difficulties in lifting his hands. He can only lift
the left hand about 5cm, the right hand about 6 cm. there is also clear
jumpiness on his chest, there is a little bit atrophy in his lower limbs.
Accessory examination: it is shown ALS through
electromyography and MRI examinations.
Primary
diagnosis: TCM flaccidity syndrome.
Symptoms
diagnosis: spleen deficiency, 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 once a day.
January 2nd,
2007 9:00 am
Weakness in
his four limbs. He feels fatigue because of his long journey from Czech Republic
to our hospital. He slept well in the night. The results of liver function and
kidney function, blood sugar, and blood fat are all normal.
January 3rd,
2007 9:00 am
He doesn¡¯t
have any other discomfort, no headache, no dizziness. Spirit and appetite are
good. He slept well. Urination and bowel movement are normal. There is no
obvious change in his four limbs. Tongue body is reddish; tongue coating is thin
and white. The pulse is deep and thin.
January 4th,
2007 9:00 am
He doesn¡¯t
have any other discomfort, no headache, no dizziness. Spirit and appetite are
good. He slept well. Urination and bowel movement are normal. There is no clear
change in his four limbs. His tongue body is reddish; tongue coating is thin and
white. The pulse is deep and thin.
January 7th,
2007 9:00 am
He doesn¡¯t
have any other discomfort. The weakness in his four limbs is slightly reduced.
No headache. No dizziness. Spirit and appetite are good. He slept well.
Urination and bowel movement are normal. His tongue body is reddish; tongue
coating is thin and white. The pulse is deep and thin.
January 10th,
2007 9:00am
He doesn¡¯t
have any other discomfort, he feels stronger in his upper limbs. He can lift his
hands more about 5cm than before. No headache. No dizziness. Spirit and appetite
are good. He slept well. Urination and bowel movement are normal. His tongue
body is reddish; tongue coating is thin and white. The pulse is deep and thin.
January 14th,
2007 9:00am
He doesn¡¯t
have any other discomfort, he feels stronger in his upper limbs, he can lift his
hands about 5cm than before. No headache. No dizziness. Spirit and appetite are
good. He slept well. Urination and bowel movement are normal. His tongue body is
reddish; tongue coating is thin and white. The pulse is deep and thin.
January 18th,
2007 9:00 am
He doesn¡¯t
have any other discomfort, he feels stronger in his upper limbs, he can lift his
hands about 5cm than before. No headache and no dizziness. Spirit and appetite
are good. He slept well. Urination and bowel movement are normal. His tongue
body is reddish; tongue coating is thin and white. The pulse is deep and thin.
His attending doctor asks him to do some proper exercise for limbs everyday.
January 22nd,
2007 9:00 am
He doesn¡¯t
have any other discomfort. He doesn¡¯t feel any clear change in the past four
days. No headache and no dizziness. He can lift his hands about 5cm more than
before. No fever sense. No headache and no dizziness. His spirit and appetite
are perfect. His sleeping was good. Normal urination and bowel movements. There
is no clear growth of his supraspinous muscles and infraspinous muscles; we can
see the frequent muscle jumpiness on his back, chest, and four limbs. His tongue
body is reddish; tongue coating is thin and white. The pulse is deep and thin.
His attending doctor asks him to do some proper exercise for his limbs everyday.
January 26th,
2007 9:00 am
Today he
said he didn¡¯t have any special discomfort, he feels obviously stronger in his
four limbs, and he can lift his hands 5cm more than before. No fever sense. No
headache and no dizziness. His spirit and appetite are good. There is no clear
growth of his supraspinous muscles and infraspinous muscles; we can see the
frequent muscle jumpiness on his back, chest, and four limbs. His tongue body is
reddish; tongue coating is thin and white. The pulse is deep and thin.
January 30th,
2007 9:00 am
Today he
said he didn¡¯t have any special discomfort, he feels obviously stronger in his
four limbs, and he can lift his hands 5cm more than before. No fever, no
headache, no dizziness. His spirit and appetite are good. There is no clear
growth of his supraspinous muscles and infraspinous muscles; we can see the
frequent muscle jumpiness on his back, chest, and four limbs. His tongue body is
reddish; tongue coating is thin and white. The pulse is deep and thin.
January 31st,
2007 9:00 am
Today he
didn¡¯t have any discomfort, no fever, no headache, no dizziness. Spirit and
appetite are good, normal urination and bowel movements. We checked his liver
and heart, and the results are the same as before. His tongue body is reddish;
tongue coating is thin and white. The pulse is deep and thin.
More ALS cases that we helped
well:
Case-1
Case-2
Case-3
Case-4 Case-5
Case-6
Case-7
Case-8
Case-9
Case-10
Case-11 Case-12
