Brief Summary: On January 22, 2010, Andon from Albania, who has suffered from ALS, was hospitalized in our hospital. He had the weakness of his two lower limbs especially the right lower limb. At the same time, he had spasms of the four limbs. However, he has achieved obvious improvement after 30 days TCM treatment here.

Record of Hospitalization

Name: Andon                                               Birthplace: Albania

Sex: Male                                                     Profession: Businessman

Age: 60                                                        Date of Admission: January 22, 2010

Nationality: Albania                                     Date of Record: January 22, 2010

Marital Status: Married                              Onset Season: Autumnal Equinox

Complainer: The patient himself

First Medical Record

Date: January 22, 2010                                       Time: 1: 00 a. m.

Andon, who has suffered from ALS, was hospitalized in our hospital. He had the weakness of his two lower limbs especially the right lower limb. At the same time, he had spasms of the four limbs. Besides, he had difficulty in walking.

Essentials for Diagnosis:

1. The patient had weakness of his both lower limbs. And he had had difficulty in walking for one year.

2. In January, 2009, the patient began to feel the weakness of the lower limbs without obvious reasons, but he didn’t pay much attention to this. And he hadn’t taken any examination and treatment. Then the condition gradually became worse. In May of 2009, he was given MRI examination in a local hospital and was diagnosed as MND. The doctor told him that there was no treatment for it. Then he did not receive any treatment from then on. So his condition became worse. At last, he came to our hospital on January 22, 2010 for better treatment.

3. T 36.5℃, R 20 times/minute, P 78 times/minute, BP 190/70mmHg.

4. He grew normally with medium nutrition. Her mind was clear. She had an expression of chronic illness and tiredness. Her body was cooperative with her 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 78 times/minute. Cardiac rhythm was regular. No pathological murmurs on auscultation.

6. The patient felt the weakness of his two lower limbs. He had spasms of the four limbs. His pulse was wiry and weak.

7. Accessory examination: None.

Diagnostic Basis:

TCM: The patient had weakness of his two lower limbs. Besides, he had difficulty in walking for one month. Insufficiency of essence-blood, sinews and vessels deprived of nourishment, liver-kidney depletion, liquid-blood could not provide enough nutrition to sinews. The waist is the house of the kidneys, the kidneys govern the bones. Lack of the essence causes the limp waist and knees. His tongue body was dark red. His tongue coating was thin and white. His pulse was wiry and weak. According to the symptoms of the tongue and pulse, he was diagnosed as wilting pattern.

Western Medicine: The patient had weakness of his two lower limbs. Besides, he had difficulty in walking for one month. In May of 2009, he was given MRI examination in the local hospital and was diagnosed as MND.

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: it should be differentiated from progressive muscular dystrophy, which is characterized by obvious muscular dystrophy in the legs. But there is no muscular trembling in the fascicle. The disease can be diagnosed clearly by the examination of MRI.

First Diagnosis:

TCM diagnosis: Wilting pattern

Symptom identification: sinews and vessels deprived of nourishment, liver-kidney depletion

Western Medicine diagnosis: MND

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. Common food.

5. TCM treatment strategy: enrich the liver and the kidneys, soothe the sinews and free the 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: January 22, 2010                                       Time: 11: 00 a. m.

 The patient had weakness of his both lower limbs. And he had had difficulty in walking for one year. Then he came to our hospital on January 22, 2010 for better treatment. From the idea of TCM(Traditional Chinese Medicine), his condition was due to sinews and vessels deprived of nourishment, liver-kidney depletion. Then our strategy was to soothe the sinews and free the network vessels and enrich the liver and the kidneys. So our expert team prescribed a special formula for him. 

Date: January 26, 2010                                      Time: 10: 00 a. m.

The patient’s spirit was good as well as his appetite. He could walk without the crutch. His pulse was wiry and weak. Then he was told to use the same formula to see the effect.  

Date: February 1, 2010                                       Time: 10: 00 a. m.

The patient felt good. He could feel the strength of his two lower limbs. Besides the times of spasms of the fours limbs reduced. The tongue body was dark red. Then according his latest condition, we changed his formula a little for the first time. 

Date: February 6, 2010                                       Time: 10: 00 a. m.

The patient’s feedback was good. So he continued to use the above formula to consolidate the result.

Date: February 11, 2010                                        Time: 10: 00 a. m.

The patient’s spirit, appetite and sleeping were in normal condition. At the same time, his walking had got much improvement. For example, during yesterday’s shopping time, he had walked for one hour in the super market. His blood pressure was normal. Then we changed his formula a little for the second time to let him get further progress.

Date: February 20, 2010                                      Time: 10: 00 a. m.

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