¡¡Brief Summary:
On May 28, 2009,
Vladimir from Israel, who has suffered from ALS, accompanied with the symptom of
the weakness of the hands for 1 year, was hospitalized in our hospital. He has
achieved much improvement after 51 days TCM treatment here. Compared with
before, his speaking was clearer and more fluent. The gripping power of his
hands increased. The slight muscular jumping of the arms and
prothorax completely disappeared.
Record of Hospitalization
Name:
Vladimir
Birthplace: Israel
Sex:
Male
Profession: Businessman
Age:
69
Date of Admission: May 28, 2009
Religion:
Muslim
Date of Record: May 28, 2009
Marital Status:
Married
Onset Season: Summer begins
Complainer:
The
patient himself
First Medical
Record
Date: May 28,
2009 Time: 1: 00 a. m.
Vladimir, a
69-year-old male, has suffered from ALS, accompanied with the symptom of the
weakness of the hands for 1 year. He was hospitalized in our hospital at 1: 00
a. m. on May 28, 2009.
Essentials for
Diagnosis:
1. The
patient has suffered from the symptom of the weakness of the hands for 1 year.
2. Last
May, the patient began to feel the weakness of the hands without obvious
reasons, but he didn¡¯t pay much attention to this and hadn¡¯t taken any
examination and treatment. Then the condition gradually became worse. In April
2009, he was given MRI examination in the local hospital and was diagnosed with
ALS. The doctor told him there was no treatment for ALS except for Rilutek
capsules. Besides, he didn¡¯t take any treatment. So he came to our hospital on
May 28, 2009 for further treatment.
3. T
36.3¡æ,
R 20 times/minute, P 80 times/minute, BP 140/80mmHg.
4. He
grew normally with common nutrition. His mind was clear. He had an expression of
chronic illness and tiredness. His body was cooperative with his 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 patient
felt the weakness of the hands, sometimes accompanied with pains. His hands were
delicate and the ability to act was declining. The flexibility of the fingers
was good. The gripping power of the left hand was 10.2 kg and that of the right
hand was 9.2 kg. There was slight muscular jumping of the arms and
prothorax. The function of his speaking declined.
Sometimes he had the symptom of dry cough when drinking water.
7.
Accessory examination: None.
Diagnostic Basis:
TCM: The patient has suffered from the weakness of the hands for 1 year. He
felt the
weakness of the hands, sometimes accompanied with pains. His hands were delicate
and the ability to act was declining. The flexibility of the fingers was good.
The gripping power of the left hand was 10.2 kg and that of the right hand was
9.2 kg. There was slight muscular jumping of the arms and
prothorax. The function of his speaking declined.
Sometimes he had the symptom of dry cough when drinking water. His tongue was
dark. His tongue coating was yellow and slimy. His pulse was wiry, thready and
slippery. The patient was mainly characterized by limp, weak, and
emaciated limb. According to the symptoms of the tongue and pulse, he was
diagnosed with wilting pattern.
Western
Medicine: The patient has suffered from the weakness
of the hands for 1 year. He felt the weakness of the hands, sometimes
accompanied with pains. His hands were delicate and the ability to act was
declining. The gripping power of the left hand was 10.2 kg and that of the right
hand was 9.2 kg. There was slight muscular jumping of the arms and
prothorax. The function of his speaking declined.
Sometimes he had the symptom of dry cough when drinking water. He was
given MRI examination in the local hospital and was diagnosed with ALS in April
2009.
Diagnostic
Differentiation:
TCM: The
patient¡¯s wilting pattern should be differentiated from impediment pattern.
Wilting pattern is characterized by limp, weak, and emaciated limbs with the
numbness of the muscles. But the patient usually has no joint pains. On the
contrary, impediment pattern is generally characterized by joint pains. So they
are not difficult to be distinguished.
Western
Medicine: ALS should be differentiated from tumor of spinal cord, which is
characterized by nerve root pains of the upper limbs, but without extensive
trembling of the muscle bundles. Besides, there is disturbance of sensation and
obstruction of the subarachnoid cavity. The disease can be diagnosed clearly by
the examination of CT or MRI.
First Diagnosis:
TCM diagnosis:
Wilting pattern
Symptom
identification: qi vacuity and blood stasis, damp-heat obstructing the channels
and network vessels.
Western Medicine
diagnosis: 1. ALS
2. Chronic hyperplasia of prostate gland
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.
TCM treatment
strategy: boost qi, quicken the blood circulation, clear heat, dispel dampness
and free the channels and network vessels.
6. Herbal
tea: one dosage a day and drink twice.
7. Acupuncture
and massage: once a day.
8. Have
more medical examinations if necessary.
Date: May 28,
2009 Time: 9: 00 a. m.
The patient has
suffered from the weakness of the hands for 1 year. Last May, he began to feel
the weakness of the hands without obvious reasons and his condition was
gradually worse. In April 2009, he was given MRI examination and was diagnosed
with ALS. Then he took Rilutek capsules for 1 month. Presently the patient felt
the weakness of the hands, sometimes accompanied with pains. His hands were
delicate and the ability to act was declining. The
function of his speaking declined. Sometimes he had the symptom of dry cough
when drinking water. Besides, there was slight cough. He had the history of
chronic obstructive pulmonary disease and hyperplasia of prostate gland.
His mouth was dry and he drank much water. There was slight muscular jumping of
the arms and prothorax. His weight reduced 5-8 kg in
the recent months. He was easy to be tired. His heart was ok. His walking was
normal. His urine was ok, but he had constipation. There was no obvious muscular
atrophy all over the body. His BP was 140/80mmHg. The gripping power of
the left hand was 10.2 kg and that of the right hand was 9.2 kg. His pulse was
wiry, thready and slippery. His tongue was dark. His tongue coating was yellow
and slimy. According to the symptoms of the tongue and pulse, Professor Yang
believed that the patient had suffered from wilting pattern due to qi vacuity
and blood stasis, damp-heat obstructing the channels and network vessels. So the
treatment strategy for him was to boost qi, quicken the blood circulation, clear
heat, dispel dampness and free the channels and network vessels. The
prescription was as follows: baizhu (ovate
atractylodes root), chuanxiong (ligusticum root), etc. 5 dosages in total.
Date: May 29, 2009 Time: 9: 00 a. m.
The feedback of the examination was as follows: Blood R (£),
Urine R (£),
Stool R (£).
The function of the liver and kidneys as well as blood fat was normal. The
examination of
type-B
ultrasonic showed that the echo of liver parenchyma became thick. Doctor
considered it as fatty liver. Besides, he had cyst in the left kidney.
Date: May 31,
2009 Time: 9: 00 a. m.
There was slight
improvement of the weakness of the hands. But there was no obvious change of the
muscular jumping. His sleep was ok. His urine and stool were normal. His tongue
was pale red. His tongue coating was thin and yellow. His pulse was thready and
slippery. The former prescription was changed a little. 5 dosages in total.
Date: Jun. 1,
2009 Time: 10: 00 a. m.
His speaking was
clearer. The strength of the upper limbs increased, but there was slight
muscular jumping of the arms and prothorax. There was
discomfort in the throat and he consciously felt there was phlegm. The
prescription was made a little change.
Date: Jun. 5, 2009 Time: 10: 00 a. m.
He
felt the weakness all over the body and slight heavy sense. The other condition
was ok. Doctor thought it was due to his diarrhea on Jun. 3 which had relation
with dietary irregularities. So the prescription was changed and the doctor
added some herbs to fortify the spleen and transform dampness. 5 dosages in
total.
Date: Jun. 10, 2009 Time: 10: 00 a. m.
The strength increased and his speaking was clearer compared with before. He
didn¡¯t feel the heavy sense all over the body. He had dry mouth, especially in
the night. The prescription was changed. 5 dosages in total.
Date: Jun. 15, 2009 Time: 9: 30 a. m.
Compared with before, his speaking was clearer. The gripping power of the left
hand was 12.2 kg and that of the right hand was 9.7 kg. He felt aching pains on
his shoulders. His sleep was ok. His urine and stool were normal. Continue to
take the same prescription. 5 dosages in total.
Date: Jun. 20, 2009 Time: 9: 00 a. m.
His condition was stable. There was no obvious change. His sleep was not good
due to hot weather in the recent days. His pulse was wiry and thready. His
tongue was pale. His tongue coating was thin and yellow. The prescription was
the same as before. 4 dosages in total.
Date: Jun. 23. 2009 Time: 9: 00 a. m.
His condition was stable. His diet and sleep were normal. His pronunciation was
clear and resonant. His sleep
was ok. His urine and stool were normal. He kept in good mood. His tongue was
slight moist, slippery and dark. His tongue coating was thin and yellow. The
prescription was as follows: chuanxiong (ligusticum root), danggui
(tangkuei), etc. 4 dosages in total.
Date: Jun. 30, 2009 Time: 9: 30 a. m.
His spirit and sleep were good. His urine and stool were normal. Compared with
before, his speaking was obviously clearer. The strength of the hands increased.
His tongue was pale with slightly dark. His tongue coating was thin and yellow.
Continue to take the same prescription. 5 dosages in total.
Date: Jul. 5, 2009 Time: 10: 00 a. m.
His condition was stable. There was no obvious change. He was easy to sweat. The
other condition was normal. The prescription was changed a little. 5 dosages in
total.
Date: Jul. 10, 2009 Time: 10: 00 a. m.
The symptom of the weakness all over the body was improved. There was obvious
improvement of sweating. His speaking was clear. His sleep was ok. His urine and
stool were normal. The prescription was made a little change on the basis of the
prescription on Jul. 5. 5 dosages in total.
Date: Jul. 11, 2009 Time: 10: 00 a. m.
His spirit and sleep were good. His urine and stool were normal. The weakness
all over the body and pronunciation were improved. The doctor added fuxiaomai
(light wheat grain) in the previous prescription. 5 dosages in total.
Date: Jul. 20, 2009 Time: 10: 00 a. m.
The patient said his condition was good. His pronunciation was
resonant. There
was no weakness all over the body. His sleep was ok. His urine and stool were
normal. The prescription was the same as before. 5 dosages in total.
Date: Jul. 25, 2009 Time: 10: 00 a. m.
The patient decided to leave the hospital tomorrow.
¡¡
More ALS cases that we helped
well:
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Case-7
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