Brief Summary: On Aug. 27, 2008, Lucky, from Indonesia, who has suffered from difficulties in swallowing and speaking for 3 years, was hospitalized in our hospital. He has achieved significant improvement after only 20-day TCM treatment here.

Name: Lucky                                                                                                        Sex: Male

Age: 45                                                                                                                Profession:  Employee of the service sector

Nationality: Indonesia                                                                                          Marital Status: Married

Onset Season: Heavy snow                                                                                 Date of Admission: Aug. 27, 2008  

Complainer: The patient¡¯s himself           

First Medical Record

Date: Aug. 27, 2008                     Time: 19:00 p.m.

Lucky, a 45-year-old male, has suffered from difficulties in swallowing and speaking for 3 years. He was hospitalized in our hospital for further treatment at 19: 00 p.m. on Aug. 27, 2008.

Essentials for Diagnosis:

1. The patient has suffered from difficulties in swallowing and speaking for 3 years.

2. Three years ago, the patient began to feel that his speech was unclear. Gradually, he found that he had difficulties in swallowing and speaking. Then he was diagnosed with ALS after the MRI examination in a local hospital. He had ever taken rilutek for the treatment, but there was no obvious improvement. His present condition was as follows: he had difficulties in swallowing and speaking, especially his unclear speech. He sometimes felt short of breath with difficulty in breathing. Besides he felt there were pains on the back and neck. He has lost weight about 20 kg over the past three years, and he felt weakness of all the limbs with poor walking. Sometimes he felt his limbs were numb with a phenomenon of muscular beating. His spirit was poor, but his food intake was normal. His bowel movement and urination were both normal.   

3. T 36.2¡æ£¬P 82 beats/minute, R 20 times/minute, BP 120/80 mmHg.

4. He grew normally with common nutrition. His mind was clear. He had an expression of chronic illness and languidness. His body was in a positive posture and he was cooperative with clear mind.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No sound of pleural friction. Heart border was normal. Heart beat was 80 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The muscles all over the body were slightly atrophic. The muscular strength of all the limbs was normal. The gripping power of the left hand was 30.2 kg, and that of the right hand was 28.8 kg. The body of his tongue was red with cracks in the middle. Besides, there were tooth-marks at the edge of the tongue. His tongue coating was slightly yellow, thick and lack of liquid. His pulse was deep, thready and weak.

7. Diagnostic examination: The MRI shows ¡°ALS¡±.

Diagnostic Basis:

TCM: The patient has suffered from difficulties in swallowing and speaking for 3 years. His present condition was as follows: he had difficulties in swallowing and speaking. Besides, his speech was unclear, sometimes he felt short of breath with difficulty in breathing. He has lost weight about 20 kg over the past 3 years, and he felt weakness of all the limbs with poor walking. The muscles all over the body were slightly atrophic. The body of his tongue was red with cracks in the middle, as well as tooth-marks at the edge of the tongue. His tongue coating was yellow, thick and lack of liquid. His pulse was deep, thready and weak. According to the symptoms of his tongue and pulse, it is shown that due to vacuity of the spleen and lungs, deficiency of the liver and kidneys, the patient was diagnosed with wilting. He is mainly characterized by functions decreasing of limbs and organs.

Western Medicine: The patient has suffered from difficulties in swallowing and speaking for 3 years. Sometimes he felt short of breath with difficulty in breathing. Besides, he felt weakness of all the limbs with poor walking. He has lost weight about 20 kg over the past 3 years. The muscles all over the body were slightly atrophic. The gripping power of the left hand was 30.2 kg, and that of the right hand was 28.8 kg. The MRI examination showed ¡°ALS¡±.

Diagnostic Differentiation:

TCM (Traditional Chinese Medicine): The patient¡¯s wilting syndrome should be differentiated from impediment syndrome. Wilting syndrome is characterized by limp, weak, and emaciated limbs with muscular atrophy. A patient suffered from wilting syndrome seriously may even become unable to hold an object or to stand without any support. Besides, the patient usually has no joint pains. On the contrary, impediment syndrome is generally characterized by aching pains, fixed heaviness and inflexibility of sinews and bones, muscles and joints, with occasional numbness or swelling, though, no paralytic manifestations exist. They are not difficult to be distinguished in clinics.

Western Medicine: Wilting syndrome should be differentiated from myasthenia gravis (MG), which is an acquired autoimmune disease with the transferring obstacles owing to the reduced acetylcholine receptor in the site of neuromuscular junction. It can occur at any age. The most obvious characteristic of MG in clinics is rapid fatigability during the movement of the skeletal muscles, which will be improved by rest or cholinesterase. They are not difficult to be distinguished in clinics.

First Diagnosis: 

TCM (Traditional Chinese Medicine) diagnosis: Wilting syndrome

Symptom identification: Qi vacuity of the lungs and spleen, yin vacuity of the liver and kidneys.

Western Medicine diagnosis: ALS

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Under the care of a companion.

4. Low-fat and high-protein diet.

5. Herbal tea (to fortify the spleen and boost the lungs, supplement the liver and kidneys): one dosage a day and drink twice.

Main herbs used in the herbal tea: baisheng (white ginseng), zaopi (cornus fruit), fuling (poria), etc.

6. Acupuncture and massage: once a day.

7. Have more medical examinations if necessary.

Date: Aug. 28, 2008                               Time: 9:00 a.m.

The patient has suffered from difficulties in swallowing and speaking for 3 years. His speech was unclear. Besides, he felt short of breath with choking when drinking water. His neck was stiff accompanied with pains and weakness. So was his back. He felt the numbness all over the body. When he felt stiff, there was muscles¡¯ beating. His food intake was poor. All the limbs were weak. He felt bitter taste in the mouth with dry throat and mouth-watering. His tongue coating was yellow, thick and lack of liquid. His tongue was red with cracks in the middle and tooth-marks at the edge of the tongue. His tongue was deep, thready and weak.

TCM diagnosis: Wilting.

Symptom identification: Qi vacuity of the lungs and spleen, yin vacuity of the liver and kidneys.

Western Medicine diagnosis: ALS

The TCM treatment strategy is to fortify the spleen and boost the lungs, supplement the liver and kidneys. His prescription was as follows: baisheng (white ginseng), zaopi (cornus fruit), fuling (poria), etc. 4 dosages in total.

Date: Aug. 29, 2008                               Time: 9:00 a.m.

The patient felt that his throat was dry and his voice was hoarse. Besides, he felt discomfort on his throat with feelings of tightness. The body of his tongue was atrophic. His three routine examinations and the functions of the liver and kidneys were all normal, so was his chest radiography. It is considered as bronchitis. There was no other abnormal discovery. His prescription was kept the same.

Date: Aug. 31, 2008                               Time: 9:00 a.m.

The patient felt that his neck and shoulders had got some improvement. The doctor then changed his prescription a little. 5 dosages in total.

Date: Sept. 5, 2008                               Time: 9:00 a.m.

His dry throat, bitter taste in the mouth and the hoarse voice all got much improvement. His prescription was changed a little again. 5 dosages in total.

Date: Sept. 10, 2008                               Time: 9:00 a.m.

After the treatment of the herbal tea, acupuncture and massage, his hoarse voice, difficulty in swallowing as well as discomfortable neck have got significant improvement. He kept a sound sleep and improved his food intake. In recent days, he has not felt any stiffness on the limbs or any phenomena of muscles beating. He would continue the former prescription. 4 dosages in total.

Date: Sept. 13, 2008                               Time: 9:00 a.m.

The patient had something to do with at home, so he had to leave the hospital tomorrow.

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