Records of Hospitalization
Name:
Moni Sex:
Male
Age:
42
Profession: Businessman
Nationality:
Kosovo Marital
status:
Married
Onset
Season:
Summer
Date of Admission:
Mar.25th, 2007
Complainer of history:
The patient himself Date
of Admission:
Mar.25th, 2007
Chief
complaint:
The patient has suffered from four limbs amyotrophy progressively 13 years
accompanied by unable to walk three years.
Present illness:
On March 1994, the patient began to have four limbs weakness without any obvious
cause. He had not done any examination or treatment about it due to ignorance,
it obviously progressively grew worse and his four limbs started to atrophy
after half a year. He then took a MRI scan in a local hospital (not in detail).
The accurate diagnosis for him is amyotrophic lateral sclerosis (ALS) by the MRI
scan. The doctors in the hospital told him that there was no therapeutic
schedule for his disease and he could not be cured. They gave the patient
vitamin C and vitamin E to orally taken for trophic nerve. The patient¡¯s
condition progressively grew worse. On February 2004, the patient began to
unable to walk and needed to use wheelchair, but he did not do any treatment on
it. He came to hospitalize in our Traditional Chinese Medicine (TCM) Department
today. His spirit, appetite and sleep are bad since he has gotten this disease;
his bowel movement and urination are normal.
Past
history:
He was quite health before. No history of typhoid, tuberculosis, diarrhea and
hepatitis or other history of communicable disease. No history of traumatism or
operation. No history of medicine or food allergy. No history of transfusion.
No history of preventive vaccination provided.
Personal history:
He was born in Kosovo. No contact history of schistosomiasis. No addiction to
alcohol or smoke. No addiction to special food. He is gentle and open minded.
Marital history:
He married at 23 and has three sons. His wife
and children are all healthy.
Family
history:
His parents are both healthy. No family history of special disease.
Physical examination
T: 36.6¡æ£¬P:
91bpm, R: 23bpm, BP: 180/123mmHg
He is
mid-nourished and normally developed. His mind is clear, chronic face mirroring
difficult condition and languor expression. He is in a positive position and
cooperative in examination. His skin is moist. No jaundice in the sclera. No
superficial lymph-node enlargement. Bilateral pupils are round and equal in size
and sensitive to light. No thoracic deformity. Sound of breath is bilaterally
normal on auscultation. No respiratory rales or pleural friction rubs. Heart
border is normal. Heart beat 80bpm. Cardiac rhythm is regular. No pathological
murmurs of heart on auscultation. Abdomen
is flat and soft without tenderness
or rebound tenderness. No percussion pain on renal region. Bowel sound is
normal. No Spinal and pelvic deformity or tenderness. Four limbs will see in
special examination. The development of the anus or pudendum is normal.
He has physiological reflex, but the pathological features are not elicited out.
Special
examination:
Obvious bilateral atrophia on his supraspinous muscle and infraspinous muscle.
His musculus biceps brachii and musculus triceps brachii are nearly disappeared
due to atrophia on bilateral upper arms. The atrophia on his forearms obviously
presents as flat paten and the muscles are basically disappeared. Both of his
hands presents like the hand of apes. It is very hard for him to move his
fingers. He can not carry things. The myodynamia of his lower limbs are grade
two and myatonia. The diameters are 15cm measured on his left and right
forearms; the diameters are 19cm on his left and right upper arms. His muscles
are obviously atrophied. It is very difficult for him to move his lower limbs.
The experiments of straighten-and-risen-up are 10
degree (+)
on his left and right legs.
The jerk reflex is weakened on his knee and his tendon reflex is basically
disappeared. Karyotype (£),
babinski (£).
The myodynamia are grade
II
and myatonia on his lower limbs.
Accessory examination:
It is vacant
at the moment.
First
diagnosis:
TCM diagnosis:
Wei-syndrome (flaccidity syndrome)
Symptom diagnosis:
Weakness of
the liver and spleen; phlegm-heat brewing internally.
WM
diagnosis:
Amyotrophic
lateral sclerosis (ALS).
Dr. Zhang
Xiukui/ Dr. Dai Lei
First Medical Record
Moni, a
42-year-old male, has suffered from four limbs amyotrophy progressively 13 years
accompanied by unable to walk three years. He was met by our workers in Zhijiang
Airport and arrived in Huaihua Red Cross Hospital at 18: 30, March 24th,
2007.
Essentials for diagnosis:
1. The patient
has suffered from four limbs amyotrophy progressively 13 years accompanied by
unable to walk three years.
2. On March
1994, the patient began to have four limbs weakness without any obvious cause.
He had not done any examination or treatment about it due to ignorance, it
obviously progressively grew worse and his four limbs started to atrophy after
half a year. He then took a MRI scan in a local hospital (not in detail). The
accurate diagnosis for him is amyotrophic lateral sclerosis (ALS) by the MRI
scan. The doctors in the hospital told him that there was no therapeutic
schedule for his disease and he could not be cured. They gave the patient
vitamin C and vitamin E to orally taken for trophic nerve. The patient¡¯s
condition progressively grew worse. On February 2004, the patient began to
unable to walk and needed to use wheelchair, but he did not do any treatment on
it. He came to hospitalize in our Traditional Chinese Medicine (TCM) Department
today. His spirit, appetite and sleep are bad since he has gotten this disease;
his bowel movement and urination are normal.
3. T: 36.6¡æ£¬P:
91bpm, R: 23bpm, BP: 180/123mmHg
4. He is
mid-nourished and normally developed. His mind is clear, chronic face mirroring
difficult condition and languor expression. He is in a positive position and
cooperative in examination.
5. He has
obvious bilateral atrophia on his
supraspinous muscle and infraspinous muscle. His musculus biceps brachii and
musculus triceps brachii are nearly disappeared due to atrophia on bilateral
upper arms. The atrophia on his forearms obviously presents as a ¡°flat paten¡±
and the muscles are basically disappeared. Both of his hands presents as the
hands of apes. It is very hard for him to move his fingers. He can not carry
things. His myodynamia is grade II
and myatonia. The diameters are 15cm measured on his left and right forearms;
the diameters are 19cm on his left and right upper arms. His muscles are
obviously atrophied at this part. It is very difficult for him to move his lower
limbs. The experiments of straighten-and-risen-up are 10
degree (+)
on his left and right legs.
The jerk reflex is weakened on his knee and his tendon reflex is basically
disappeared. Karyotype (£),
babinski (£).
The myodynamia are grade
II
and myatonia on his lower limbs. He got polypnea sometimes, especially during
the evening.
6. No thoracic
deformity. Chest percussion notes resonance. Sound of breath is bilaterally
clear on auscultation. No pleural friction rubs.
7. Accessory
examination: Not provided yet.
Diagnostic basis
TCM:
The
patient has suffered from four limbs amyotrophy progressively 13 years
accompanied by unable to walk three years. His four limbs are limp wilting; his
body sinews and vessels are atonicity. He has
obvious bilateral atrophia on his
supraspinous muscle and infraspinous muscle on his limbs. It is very hard for
him to move or to exhale and inhale, especially during the night time. The
symptoms all above are pertained to Wei-syndrome.
Western medicine:
The patient has suffered from four limbs amyotrophy progressively 13 years
accompanied by unable to walk three years. He has
obvious bilateral atrophia on his
supraspinous muscle and infraspinous muscle. His musculus biceps brachii and
musculus triceps brachii are nearly disappeared due to atrophia on bilateral
upper arms. The atrophia on his forearms obviously presents as a ¡°flat paten¡±
and the muscles are basically disappeared. Both of his hands presents as the
hands of apes. It is very hard for him to move his fingers. He can not carry
things. His myodynamia is grade II
and myatonia. The diameters are 15cm measured on his left and right forearms;
the diameters are 19cm on his left and right upper arms. His muscles are
obviously atrophied at this part. It is very difficult for him to move his lower
limbs. The experiments of straighten-and-risen-up are 10
degree (+)
on his left and right legs.
The jerk reflex is weakened on his knee and his tendon reflex is basically
disappeared. Karyotype (£),
babinski (£).
The myodynamia are grade
II
and myatonia on his lower limbs. He got polypnea sometimes, especially mush
worse during the night times. On September 1994, he took MRI scan in a
local hospital (not in detail) and got the accurate diagnosis which was
amyotrophic lateral sclerosis (ALS).
Diagnostic differentiation
TCM:
The patient¡¯s Wei-syndrome should be differentiated from Bi-syndrome. Although
they both fall into the category of limb disease, they are different in
pathogeny, pathogenesis and clinical manifestations. Wei-syndrome is
characterized as limp, weak and emaciated limbs with shriveled muscles. A
patient suffering from Wei-syndrome may even become unable to hold an object or
to stand without support. Besides, the patient¡¯s lower limbs are more often
affected, though he or she usually has no joint pain. On the contrary,
Bi-syndrome is generally characterized as aching pain, fixed heaviness and
inflexibility of sinews and bones, muscles and joints, with occasional numbness
or swelling, though, no paralytic manifestations. The pathogenesis of Wei-syndrome
is that the essence and blood in five-fu organs is insufficient to travel
through the whole body leading to malnourish of the meridians and collaterals;
while that of Bi-syndrome is that the obstruction of meridians and collaterals
by pathogenic qi blocks the circulation of qi and blood. So it is not hard to
differentiate Wei-syndrome from Bi-syndrome in clinical manifestations.
WM: The
patient¡¯s ALS (amyotrophic lateral sclerosis) should be differentiated from
myasthenia gravis pseudoparalytica which occurs to any aged people, mostly
between 10 to 35 years old and more female suffered from it than male do, and
the proportion is about 2-4.5:1. The typical characteristic is that the using
skeletal muscles are very easily fatigability, but it would be more or less
better after some rest; fluctuate of patients¡¯ condition, and it is much worse
in the evening time, many illnesses onset secretly. Usually it onset from one
group of muscle to other groups, and involved in cranial innervations first be
put into trouble which is mostly common to see. It should be differentiated that
different aged myasthenia patients, their clinical manifestation or course of
disease are differenced from each other.
First
diagnosis:
TCM diagnosis:
Wei-syndrome (flaccidity syndrome)
Symptom diagnosis:
Weakness of
the liver and spleen; phlegm-heat brewing internally.
WM
diagnosis:
Amyotrophic lateral sclerosis (ALS)
Plan
of treatment and care
1. On routine
care of traditional Chinese internal medicine
2. On grade II
care
3. Nurse
4. High
protein diet
5. Herbal tea:
boost qi and fortify the spleen, enrich the liver and kidney, clear heat and
transform phlegm. Prescription: belamcanda (Shegan), astragalus (Huangqi),
moutan (Danpi), etc. Four days, one dosage a day and drink by twice.
6. Massage and
acupuncture: once a day
7. Some proper
functional training.
8. Have more
medical examinations if necessary
Date:
27th of March, 2007
Time: 2 p.m.
The patient
complains to Dr. Zhang that his appetite is better and can take in more food. He
says that there is no throat pain, less expectoration. He has a good sleep and
his spirit is good. His bowel movement and urination are normal. He has general
muscular atrophy, especially on his forearms. His wrist joints and figure joints
neither can not do flexion and extension movement nor hold in fists. He can not
carry chopsticks nor hold subjects. He needs some one to feed him. His limbs are
weak. He can not rise up his feet nor walk by himself. His ankle joints and
digital joints can not do flexion and extension movement. His pharyngeal portion
gets inflammation and swollen. Slimy and pale yellow coating tongue fur,
red-purple tongue, slippery and forceless pulse. The doctor gives him herbal
medicine to boost qi and fortify the spleen, clear heat and transform phlegm,
enrich the liver and kidney. The prescription is belamcanda (Shegan), astragalus
(Huangqi), moutan (Danpi), etc. One dosage a day and drink by twice, four days.
Dr. Zhang
Xiukui
Date:
31st of March, 2007
Time: 3 p.m.
The patient
complains to Dr. Zhang that his appetite is basically normal. He says he has
polypnea and sense of obstruction in his throat. He feels like phlegm inside,
but he does not have expectoration. Slight-slimy and pale yellow coating tongue
fur, red-purple tongue and slippery pulse. The doctor tells the patient to take
more nutrition food, increase exercise and functional training. The doctor gives
him herbal medicine to fortify the spleen and transform phlegm, boost qi and
quicken the blood, enrich the liver and kidney. The prescription is zhebei (zhejiang
fritillaria), danpi (cortex moutan), chenpi (dried orange peel), etc. One dosage
a day and drink by twice, three days.
Dr. Zhang
Xiukui
Date:
3rd of April, 2007
Time: 9 a.m.
Generally the
patient¡¯s condition is good. Continue given him the former prescription, but
take shegan (belam canda) out and add 20g of maohuang (lanaurin).One dosage a
day and drink by twice, three days. Continue combining supply a bottle of 10%
klinitamin and energy. Keep observing the patient¡¯s condition.
Dr. Zhang
Xiukui
Date:
6th of April, 2007
Time: 9 a.m.
The patient
says his apatite is very good today. He feels much better about the block sense
of phlegm in his throat. His sleep is normal. He feels his body condition is
becomes better and better day after day. He very seldom had polypnea and short
breathe last night. It last very short and then disappeared. The back side of
this throat is a little red and slight swollen. Slimy and pale yellow coating
tongue fur, and slippery pulse. The prescription for him is maohuang (lanaurin),
zhebei (zhejiang fritillaria), astragalus (Huangqi), etc. One dosage a day and
drink by twice, four days.
Dr. Zhang
Xiukui
Date:
10th of April, 2007
Time: 10 a.m.
The patient
complains that he had slight chest tightness, polypnea and feels thirsty last
night. He does not have expectoration. His lower limbs are cold, but heat in the
center feet. His sleep is good and his diet is normal. The doctor found the back
of his throat is slightly red and swollen. His bilateral upper limbs, wrist
joints and figure joints all can not do flexion and extension movement. His
ankle joints and digital joints also can not do flexion and extension movement.
Besides given him herbal tea, acupuncture and massage, the doctor also gives him
medicine of warm the channels and free the network vessels to marinate and
external wash once a day in order to observe. Since the patient admitted in the
hospital, his weight increased 3 kg in half a month. The prescription for orally
taken is Baishen (white ginseng), maohuang (lanaurin), danpi (cortex moutan),
etc. One dosage a day and drink by twice, four days. The prescription for
external using is aiye (Artemisia leaf), yimucao (leonurus), kuqin (scutellaria),
etc. Decoct the medicine in water for external using in the afflicted part, six
days.
Dr. Zhang
Xiukui
Date:
14th of April, 2007
Time: 10 a.m.
The patient
presents a good spirit. His diet and sleep are normal. He very seldom has chest
tightness or the sense of obstruction in his throat. The doctor finds his throat
is slight red and swollen. The doctor considers it is chronic pharyngitis. Slimy
and pale yellow coating tongue fur, fine and weak pulse. The prescription for
him is maohuang (lanaurin), bairenshen (white ginseng), astragalus (Huangqi),
etc. One dosage a day and drink by twice, four days.
Dr. Zhang
Xiukui
Date:
19th of April, 2007
Time: 9 a.m.
The patient
and his wife are going to Hong Kong to renew the visas, so the doctors
temporarily stop all the treatment.
Dr. Zhang
Xiukui
Date:
20th of April, 2007
Time: 10 a.m.
The patient
and his wife have to come back to their country to get new visas, so the
treatment is temporarily stopped.
Dr. Zhang
Xiukui
Date:
20th of April, 2007
Time: 3 p.m.
Because the
patient and his wife did not get the new visa, they have to end the treatment
and admit out the hospital.
Dr. Zhang
Xiukui
