|
Records of
Hospitalization
Name:
Tor Sex:
Male
Age:
43 Profession: Businessman
Nationality:
Norway Marital status: Married
Onset Season:
Winter Date of Admission: Jan. 24th
2008
Complainer:
The patient
himself Reliability: Reliable
Major complaint:
The
patient has suffered from difficulties in swallowing and speaking, accompanied
with weakness of his limbs for 4 months.
Present illness:
In Sept 2007, without any obvious causes, the patient began to appear the
symptoms of difficulties in swallowing and speaking, accompanied with the
weakness of his limbs. At that time, the patient paid no attention to it, and
did no treatment about it. Therefore, the disease was aggravating progressively.
In Dec 2007, the patient went to a local hospital for a diagnosis. After the EMG
examination, the patient was diagnosed with
amyotrophic lateral
sclerosis
(ALS).
The doctor prescribed him Rilutek for oral taking without any other treatment.
To his disappointment, there was no obvious improvement.
To seek for a further
comprehensive treatment, he hospitalized in our hospital on Jan. 24th
2008. Since he got the disease, he has kept normal spirit, appetite and sleep.
His bowel movement and urination were both normal.
Disease history:
No history of typhoid, tuberculosis, hepatitis, malaria or other infectious
disease. No allergic history of medicine or food. No history of trauma or
operation. No history of blood transfusion. History of preventive vaccination
not provided.
Personal history:
he was born in Norway, living in a dry environment. No contact history of
schistosomiasis. No addiction to smoking, alcohol or special food. He was
mild-tempered and open-minded.
Marital history:
he got
married at 36. So far, he has two sons. His wife and sons have been healthy all
the time.
Family history:
His
parents are both healthy. No family history of special inherited disease.
Physical examination:
T 36.6¡æ£¬P:
81bpm, R: 22bpm, BP: 110/70 mmHg, W: 80 kg
He was mid-nourished
and normally developed. His mind was clear. He had an expression of chronic
illness and languidness. He was in a positive position and cooperative in
examination. His skin was moist. No jaundice in the sclera. No superficial
lymph-node enlargement. Bilateral pupils were round and equal in size and
sensitive to light.
No deformity of skull
and the five sense organs.
No congestion
in throat. No swollen tonsil. With soft neck and trachea placed in the middle.
No enlargement of the thyroid
gland. No congestion of the jugular vein.
No thoracic deformity. Clear
percussion sound.
Breath sound
was bilaterally normal on auscultation. No
pleural friction
sound. Heart
border was normal. Heart beat 81/min. Cardiac rhythm was regular. No
pathological murmurs on auscultation.
Abdomen touched flat and soft without tenderness or rebound tenderness. Liver
and spleen were not palpable. No percussion pain over renal region. Bowel sound
was normal. No spinal and pelvic deformity or tenderness. Weakness of
upper limbs. In the experiment, the grip of his left hand was 22.6 kg, and that
of the right hand was 33.9kg. The muscular strength of his upper limbs was Grade
¢ó
with normal muscle hyperthyroidism. His lower limbs were also weak, and the
muscular strength of them was also Grade
¢ó
with normal muscle hyperthyroidism. He had the difficulties in swallowing and
speaking, and his speech was neither clear nor fluent. His anus and pudendum
were unchecked. His physiological reflex exists. The pathological symptoms have
not been elicited. His tongue was dark red with thin and white tongue coating.
His pulse was slightly string-like and weak.
Diagnostic
examination: Not provided.
First diagnosis:
TCM diagnosis: Wei-syndrome
(flaccidity syndrome)
Symptom diagnosis:
insufficiency of liver and kidneys, accompanied with deficiency of lung- Spleen
and qi
WM diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
First Medical Record
Date: Jan. 24th
2008 Time: 22:00
Tor, a 43-year-old
male, has suffered from difficulties in swallowing and speaking, accompanied
with weakness of his limbs for 4 months. He was picked up by our staff in
Zhijiang Airport and arrived in Huaihua Red Cross Hospital for further treatment
at 21: 30p.m on Jan. 24th 2008.
Essentials for
diagnosis:
1. The patient has
suffered from difficulties in swallowing and speaking, accompanied with weakness
of his limbs for 4 months.
2. In Sept 2007,
without any obvious causes, the patient began to appear the symptoms of
difficulties in swallowing and speaking, accompanied with the weakness of his
limbs. At that time, the patient paid no attention to it, and did no treatment
about it. Therefore, the disease was aggravating progressively. In Dec 2007, the
patient went to a local hospital for a diagnosis. After the EMG examination, the
patient was diagnosed with
amyotrophic lateral
sclerosis
(ALS).
The doctor prescribed him Rilutek for oral taking without any other treatment.
To his disappointment, there was no obvious improvement.
To seek for a further
comprehensive treatment, he hospitalized in our hospital on Jan. 24th
2008. Since he got the disease, he has kept normal spirit, appetite and sleep.
His bowel movement and urination were both normal.
3. T 36.6¡æ£¬P:
81bpm, R: 22bpm, BP: 110/70 mmHg, W: 80 kg
4. He was
mid-nourished and normally developed. His mind was clear. He had an expression
of chronic illness and languidness. He was in a positive position and
cooperative in examination.
5. He had the
difficulties in swallowing and speaking, and his speaking was neither clear nor
fluent. He has suffered from weakness of all limbs. The muscular strength of his
upper limbs was Grade
¢ó
with normal muscle hyperthyroidism. In the experiment, the grip of his left hand
was 22.6 kg, and that of the right hand was 33.9kg. The muscular strength of
them was also Grade
¢ó
with normal muscle hyperthyroidism.
6. No thoracic
deformity. Chest percussion noted resonance. Sound of breath is bilaterally
clear on auscultation. No sound of pleural friction.
7. Diagnostic
examination: Not provided
Diagnostic basis
TCM: The patient has
suffered from difficulties in swallowing and speaking, accompanied with weakness
of his limbs for 4 months. Because of deficiency of liver and kidneys, his
essence-blood could not nourish his sinews and vessels, and gradually it
resulted in flaccidity. He has suffered from weakness of all limbs, with an
expression of chronic illness and languidness. He also had difficulty in
speaking. Due to insufficiency of the liquids, abnormality of qi and blood, and
lung heat scoring the lobes, his limbs lose the nourishment. With the weakness
of spleen and stomach, the essence-blood could not nourish his muscles. His
tongue was dark red with thin and white tongue coating. His pulse was slightly
string-like and weak. All the symptoms belong to the scope of flaccidity.
Western medicine: The
patient has suffered from difficulties in swallowing and speaking, accompanied
with weakness of his limbs for 4 months. His speech was neither clear nor
fluent. He has suffered from weakness of all limbs. The muscular strength of his
upper limbs was Grade
¢ó
with normal muscle hyperthyroidism. In the experiment, the grip of his left hand
was 22.6 kg, and that of the right hand was 33.9kg. The muscular strength of
lower limbs was also Grade
¢ó
with normal muscle hyperthyroidism. In Dec.2007, after EMG examination in a
local hospital, he was diagnosed with
amyotrophic lateral
sclerosis
(ALS).
Diagnostic
differentiation
TCM: The patient¡¯s
Wei-syndrome should be differentiated from Bi-syndrome. Wei-syndrome is
characterized by limp, weak, and emaciated limbs with muscular atrophy. A
patient who has suffered from Wei-syndrome may even become unable to hold an
object or to stand without any 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 by aching pain, fixed heaviness
and inflexibility of sinews and bones, muscles and joints, with occasional
numbness or swelling, though, no paralytic manifestations. They are not
difficult to be distinguished in clinics.
WM: Wei-syndrome
should be differentiated from myasthenia gravis, which is an acquired autoimmune
disease with the transferring obstacles of nerve-muscles, and is caused by the
autoimmune reaction resulting from the acetylcholine receptor (AchR) of the
striated muscle. It can occur at any age and there are about 60 percent people
stricken before 30 years old. Women are more often affected than men are. The
most obvious characteristic of MG is rapid fatigability of the skeletal muscles
affected, improved with rest or medicines that inhibits the activity of
cholinesterase. They are different from those of Wei-syndrome patients.
First diagnosis:
TCM diagnosis: Wei-syndrome
(Flaccidity syndrome)
Symptom diagnosis:
Insufficiency of liver and kidneys, accompanied with deficiency of lung- Spleen
and qi
WM diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
Plan for treatment
strategy and nursing
1. On routine care of
traditional Chinese internal medicine
2. On grade II care
3. Under care of a
companion
4. Regular diet
5. Herbal tea (to
enrich and supplement the liver and kidneys, to supplement the spleen and boost
the lung): one dosage a day and drink by twice
Main herbs used in
the herbal tea: Baisheng (White Ginseng), Baishu (Ovate Atractylodes Root),
Shanyao (Dioscorea), etc.
6. Acupuncture and
massage: once a day
7. Have more medical
examinations if necessary
Date: Jan. 25th
2008 Time: 9:00 a.m.
Today the patient
said to Dr. Yang that he had suffered from difficulties in swallowing and
speaking, along with the weakness of all his limbs. His speech was neither clear
nor fluent.
Examination: T 36.6¡æ£¬P:
81bpm, R: 22bpm, BP: 110/70 mmHg, W: 80 kg
His heart and lung
were normal, and his abdomen was soft and flat.
Dr. Yang¡¯s analysis:
1. The patient has
suffered from difficulties in swallowing and speaking, accompanied with weakness
of his limbs for 4 months.
2. He has suffered
from weakness of upper limbs. In the experiment, the grip of his left hand was
22.6 kg, and that of the right hand was 33.9kg. The muscular strength of his
upper limbs was Grade
¢ó
with normal muscle hyperthyroidism. He has also suffered from weakness of the
lower limbs, and the muscular strength of them was also Grade
¢ó
with normal muscle hyperthyroidism. He had difficulties both in swallowing and
speaking, and his speaking was neither clear nor fluent.
3. National
examination: In
Dec. 2007, after EMG examination, he was diagnosed with
amyotrophic lateral sclerosis
(ALS) in a local
hospital.
According to the
above information, TCM considered it as Wei-syndrome (flaccidity syndrome). Wei-syndrome
is characterized by limp, weak, and emaciated limbs with muscular atrophy.
Because of the insufficiency of the liquids and abnormality of the qi and blood,
his limbs lose the nourishment. With the deficiency of spleen and stomach, and
lung heat scoring the lobes, the essence-blood could not nourish his sinews and
vessels. Then it leads to the malnutrition of the muscles, and gradually it
resulted in flaccidity. Dr. Yang¡¯s analyzed it was insufficiency of liver and
kidneys, accompanied with deficiency of lung- Spleen and qi.
Principle of TCM
treatment:
enriching and
supplementing liver and kidneys, supplementing the spleen and boosting the Lung.
Herbal tea prescribed for four days including Baisheng (White Ginseng), Baishu
(Ovate Atractylodes Root), Shanyao (Dioscorea), etc. One dosage a day and drink
twice.
Doctor¡¯s requirement:
take four
dosages herbal tea of the same formula.
Acupuncture and
massage for once a day. The patient will have more medical examinations if
necessary.
Date: Jan. 26th
2008 Time: 9:00 a.m.
The patient said that
he had difficulties in swallowing and speaking, and that his speaking was
neither clear nor fluent. Besides, He has suffered from weakness of all the
limbs. His
heart and lung were normal, and his abdomen was soft and flat. The physical
examination was the same as before. He has been keeping normal spirit, appetite
and sleep. His bowel movement and urination were both normal. His tongue was red
with thin and white tongue coating. The pulse was string-like. Since the weather
has turned to be terrible these days, especially freezing weather, the doctor
advised him to put on more clothes to avoid cold.
Date: Jan. 27th
2008 Time: 9:00 a.m.
The patient said that
he had difficulties in swallowing and speaking, and his speech was neither clear
nor fluent. Besides, He has suffered from weakness of all the limbs.
His heart and lung
were normal, and his abdomen was soft and flat. The physical examination was the
same as before. He has been keeping normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was red with thin and white
tongue coating. His pulse was string-like.
The herbal tea is
followed by the former prescription.
Date: Feb 1st
2008 Time: 9:00 a.m.
The patient said that
he had difficulties in swallowing and speaking, and his speech was neither clear
nor fluent. Besides, He has suffered from weakness of all the limbs.
His heart and lung
were normal, and his abdomen was soft and flat. The physical examination was the
same as before. He has been keeping normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was red with thin and white
tongue coating, his pulse was string-like and week.
The herbal tea is
followed by the former prescription.
Date: Feb 6th
2008 Time: 9:00 a.m.
The patient said that
he had difficulties in swallowing and speaking, and his speech was neither clear
nor fluent. Besides, He has suffered from weakness of all the limbs.
His heart and lung
were normal, and his abdomen was soft and flat. The physical examination was the
same as before. He has been keeping normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was red with thin and white
tongue coating, his pulse was string-like and week.
The herbal tea is
followed by the former prescription.
Date: Feb 11th
2008 Time: 9:00 a.m.
The patient said that
he had difficulties in swallowing and speaking, and that his speaking was
neither clear nor fluent. Besides, He has suffered from weakness of all the
limbs. His
heart and lung were normal, and his abdomen was soft and flat. The physical
examination was the same as before. He has been keeping normal spirit, appetite
and sleep. His bowel movement and urination were both normal. His tongue was red
with thin and white tongue coating. His pulse was string-like and week.
The herbal tea is
followed by the former prescription.
Date: Feb 16th
2008 Time: 9:00 a.m.
Today the patient
said that his difficulties in swallowing and speaking, along with his unclear
and influent speaking all have become better, so has the weakness of all his
limbs. His
heart and lung were normal, and his abdomen was soft and flat. The physical
examination was the same as before. He has been keeping normal spirit, appetite
and sleep. His bowel movement and urination were both normal. His tongue was red
with thin and white tongue coating, and his pulse was string-like and weak.
The herbal tea
is followed by the former prescription.
Date: Feb 21st
2008 Time: 9:00 a.m.
His difficulties in
swallowing and speaking, along with his unclear and influent speaking all have
got some improvement, so has the weakness of all his limbs.
His heart and lung
were normal, and his abdomen was soft and flat. The physical examination was the
same as before. He has been keeping normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was red with thin and white
tongue coating, and his pulse was string-like and weak.
The herbal tea is
followed by the former prescription.
Summary
stage
Date: Feb. 25th
2008 Time: 9:30 a.m.
Tor, a 43-year-old
male, has suffered from difficulties in swallowing and speaking, accompanied
with weakness of his limbs for 4 months. He hospitalized in Huaihua Red Cross
Hospital for TCM treatment at 21: 30 p.m. on Jan. 24th 2008. So far,
he has been hospitalizing for 30 days.
Admitting Condition:
T 36.6¡æ£¬P:
81bpm, R: 22bpm, BP: 110/70 mmHg, W: 81 kg
His heart and lung
were normal, and his abdomen was soft and flat.
He had difficulties
both in swallowing and speaking, and
his speaking was
neither clear nor fluent. He has also suffered from weakness of all the limbs.
The muscular strength of his upper limbs was Grade
¢ó
with normal muscle hyperthyroidism. In the experiment, the grip of his left hand
was 22.6 kg, and that of the right hand was 33.9kg. He has been keeping a normal
spirit, appetite and sleep. His bowel movement and urination were both normal.
Admitting Diagnosis:
TCM diagnosis: Wei-syndrome
(flaccidity syndrome)
Symptom diagnosis:
Insufficiency of liver and kidneys, accompanied with deficiency of lung- Spleen
and qi.
WM diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
The Course of
Diagnosis:
Since the patient
hospitalized here, he has been prescribed herbal tea to enrich and supplement
liver and kidneys, to supplement the spleen and boost the lung.
One dosage a day and
drink twice. 100ml each time, accompanied with acupuncture and massage once a
day for a comprehensive treatment. The patient has got some improvement.
The Current
Condition:
T 36.6¡æ£¬P:
81bpm, R: 22bpm, BP: 110/70 mmHg, W: 81 kg
His heart and lung
are normal, and his abdomen is soft and flat. The difficulties both in
swallowing and speaking has improved obviously, so has
his unclear speaking.
The weakness of all his limbs has also got much better. He has been keeping
normal spirit, appetite and sleep. His bowel movement and urination were both
normal. His tongue was red with thin and white tongue coating. His pulse was
string-like and weak.
The Current
Diagnosis:
TCM diagnosis: Wei-syndrome
(flaccidity syndrome)
Symptom diagnosis:
Insufficiency of liver and kidneys, accompanied with deficiency of lung- Spleen
and qi.
WM diagnosis:
Amyotrophic Lateral Sclerosis
(ALS)
Plan for treatment
strategy
1. Continue to take
the herbal tea
2. Acupuncture and
massage for once a day
3. Keep a pleasant
mood and open-minded spirit.
Date: Feb 26th
2008 Time: 9:00 a.m.
His difficulties in
swallowing and speaking, along with his unclear and influent speaking all have
got some improvement, so has the weakness of all his limbs.
His heart and lung
were normal, and his abdomen was soft and flat. The physical examination was the
same as before. He has been keeping normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was red with thin and white
tongue coating, and his pulse was
string-like
and weak. The
herbal tea is followed by the former prescription.
Date: Mar. 1st
2008 Time: 9:00 a.m.
His difficulties in
swallowing and speaking, along with his unclear and influent speaking all have
got much better, so has the weakness of all his limbs.
His heart and lung
were normal, and his abdomen was soft and flat. He has been keeping normal
spirit, appetite and sleep. His bowel movement and urination were both normal.
His tongue was red with thin and white tongue coating, and his pulse was
string-like
and weak. The
herbal tea is followed by the former prescription.
Date: Mar. 6th
2008 Time: 9:00 a.m.
His difficulties in
swallowing and speaking, along with his unclear and influent speaking all have
been improved a lot, so has the weakness of all his limbs.
His heart and lung
were normal, and his abdomen was soft and flat. The physical examination was the
same as before. He has been keeping normal spirit, appetite and sleep. His bowel
movement and urination were both normal. His tongue was red with thin and white
tongue coating, and his pulse was
string-like
and weak. The
herbal tea is followed by the former prescription.
Date: Mar. 11th
2008 Time: 9:00 a.m.
His difficulties in
swallowing and speaking, along with his unclear and influent speaking all have
been improved a lot, so has the weakness of all his limbs.
He has been keeping a
stable condition. His tongue was red with thin and white tongue coating, and his
pulse was
string-like
and weak. The
herbal tea is followed by the former prescription.
Date: Mar. 13th
2008 Time: 9:00 a.m.
The patient has been keeping a stable condition. His difficulties in swallowing
and speaking, along with his unclear and influent speaking all have been
improved significantly, so has the weakness of all his limbs. In the physical
examination, his heart and lung were normal, and his abdomen was soft and flat.
He has been keeping normal spirit, appetite and sleep. His bowel movement and
urination were both normal. The patient demanded to leave the hospital today. |
