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
