TCM China:

Record of Herbal Treatment Of Vito from USA Improvement Of ALS

       
 

 

 

 

         

 

 

Brief Summary: On February 17, 2010, Vito from USA, who suffered from ALS, was hospitalized in our hospital. He had the symptoms of difficulties with speech and swallowing for 3 years, weakness in the left hand, and stiffness of his neck, somnolence, and weight loss obviously. After 88 days TCM treatment, he achieved significant improvement, he could speak clearer than before, and had obviously improvement with swallowing as well as his mental condition, there was no cold sense of his limbs.

 

Record of Hospitalization

Name: Vito                                           Sex: Male

Age: 47                                                Profession: Businessman

Nationality: USA                                 Marital Status: Married

Onset Season: Spring Equinox             Date of Admission: February 17, 2010  

Complainer: The patient himself            Reliability: Reliable

Major Complaint: The patient has suffered from difficulties with speech and swallowing for 3 years.

Present Illness: 3 years ago, the patient felt the difficulties with speech and swallowing and his condition became worse and worse. He was given MRI examination in the local hospital and was diagnosed with ALS. From then on, he was been offering Rilutek tablets, while there was no obvious improvement. And when he came here, he had the symptoms of difficulties with speech and swallowing, weakness of the left hand, obviously muscular jumping, fatigue, and stiffness of the neck, much saliva in the mouth, thick phlegm, cough sometimes and drowsiness. He had the cold sense of the four limbs, and obvious loss of weight. He seldom walked. He had normal bowel movement and urination.

Disease History: The patient was healthy before. No history of typhoid, hepatitis, tuberculosis, malaria or other infectious diseases. No allergic history of medicine or food. No operation or trauma history. History of preventive vaccination provided was unclear.  

Personal History: He was born in America. No contact history of schistosomiasis. No addiction to special food. He was even-tempered. And his living and working environment were fine.

Marital History: He got married at the age of 25. He has 5 sons. All of them have been healthy all the time.

Family History: No family history of the similar disease.

Physical Examination:

T 36.1P 94 beats/minute, R 20 times/minute, BP 120/80 mmHg.

He grew normally with common nourishment. His mind was clear. He had natural expression, his motion was limited slightly. He was cooperative in examination. There was no xanthochromia of the skin all over the body and sclera. No superficial lymph-node enlargement. Bilateral pupils were round, equal in size, and sensitive to light. He had normal size and shape of the head and the five sense organs. No enlargement of both of his tonsils. He had soft neck. Trachea was in the midline. No enlargement of the thyroid gland. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No respiratory rales or pleural friction rubs. Heart border was normal. Heart beat was 94 times/minute. No pathological murmurs on auscultation. Abdomen touched flat and soft without tenderness or rebounding tenderness. The liver and spleen were not palpable. No pressing pains in renal region. There was obvious muscular jumping in his four limbs. His tongue was light-colored with white tongue coating. His pulse was slippery.

Assistant Examination: MRI shows ALS

First diagnosis: 

TCM diagnosis: Wilting syndrome

Symptom identification: Vacuity of the liver and kidneys, phlegm-damp obstructing the network channels.

Western medicine diagnosis: Amyotrophic Lateral Sclerosis (ALS)

 

First Medical Record

February 17, 2010

The patient, Vito, a 47-year-old male, has suffered from difficulties with speech and swallowing for 3 years. He was picked up by our staff at Zhijiang Airport, and arrived in our TCM hospital for treatment at 13:00 p.m. on February 17, 2010.

Essentials for Diagnosis:

1. The patient has suffered from difficulties with speech and swallowing for 3 years.

2. The patient felt difficulties with speech and swallowing without obvious factors 3 years ago, and his condition has been aggravated. He was given MRI examination in the local hospital and was diagnosed with ALS. From then on, he was been offering Rilutek tablets, while there was no obvious improvement. And when he came here, he had the symptoms of difficulties with speech and swallowing, weakness of the left hand, obviously muscular jumping, fatigue, and stiffness of the neck, much saliva in the mouth, thick phlegm, cough sometimes and drowsiness. He had the cold sense of the four limbs, and obvious loss of weight. He seldom walked. He had normal bowel movement and urination.

3. T 36.1P 94 beats/minute, R 20 times/minute, BP 120/80 mmHg.

4. He grew normally with common nourishment. His mind was clear. He had natural expression, his motion was limited slightly. He was cooperative in examination.

5. No thoracic deformity. Sound of breath was bilaterally normal on auscultation. No respiratory rales or pleural friction rubs. Heart border was normal. Heart beat was 94 times/minute. Heart beat was regular. No pathological murmurs on auscultation.

6. Obviously muscular jumping. His tongue was light-colored with white tongue coating. His pulse was slippery.

7. Assistant Examination: The patient was diagnosed with ALS by MRI examination in local hospital.

Diagnostic Basis:

TCM: The patient has suffered from difficulties of speech and swallowing for 3 years. Currently, the patient had difficulties of speech and swallowing with the symptoms of weakness of the left hand, obvious muscular jumping, fatigue, stiffness of the neck, much saliva in the mouth, thick phlegm, cough sometimes and drowsiness. He had the cold sense of the four limbs, and obvious loss of weight. The main symptom was weakness of the limbs, so it was not difficult to be diagnosed as wilting pattern.

Western medicine: 1. The patient has suffered from difficulties of speech and swallowing for 3 years. 2. Obviously muscular jumping of the whole body. 3. The patient was diagnosed with ALS by MRI examination in local hospital.

Diagnostic Differentiation:

TCM: The patient's wilting pattern should be differentiated from impediment pattern. Wilting pattern is characterized by wilting the sinews and bones, weakness of the four limbs. Generally, it is irrelative with the 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 Myasthenia Gravis. For the Myasthenia Gravis patients, the condition would be worse after exercise, improved after rest. It rarely occurred for muscular atrophy patients, and there is no pseudohypertrophy. They could be distinguished.

First diagnosis: 

TCM diagnosis: Wilting syndrome

Symptom identification: Vacuity of the liver and kidneys, phlegm-damp obstructing the network channels.

Western medicine diagnosis: Amyotrophic Lateral Sclerosis (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, high protein diet.

5. Herbal tea: (herbs need to be decocted with water) one dosage a day and drink twice, 180ml per time.

6. Acupuncture and massage: once a day.

7. Perfect examinations of hospitalization.

 

Date: February 18, 2010                              Time: 9:00 a.m.

The patient has suffered from difficulties with speech and swallowing for 3 years. He felt difficulties with speech and swallowing without obvious factors 3 years ago, and his condition has been aggravated. He was given MRI examination in the local hospital and was diagnosed with ALS. From then on, he was been offering Rilutek tablets, while there was no obvious improvement. And when he came here, he had the symptoms of difficulties with speech and swallowing, weakness of the left hand, obviously muscular jumping, fatigue, and stiffness of the neck, much saliva in the mouth, thick phlegm, cough sometimes and drowsiness. He had the cold sense of the four limbs, and obvious loss of weight. He seldom walked. He had normal bowel movement and urination. His tongue was light-colored with white tongue coating. His pulse was slippery. According to the signs of the tongue and pulse, Dr. Yang diagnosed the patient as wilting pattern which is caused by spleen-kidney vacuity, phlegm damp obstructing the network channels. The treatment for him is to fortify the spleen and boost the kidneys, transform phlegm and free the network channels. Doctor¨s requirement is to take five dosages of herbal tea of the same formula. One dosage a day and drink twice. Acupuncture and massage for once a day.

 

Date: February 19, 2010                              Time: 10:00 a.m.

Examination: Blood R (-)Urine R (-), hepatic/renal function (-)

 

Date: February 22, 2010                              Time: 10:00 a.m.

The patient felt a little improvement with speech and swallowing, but there was much saliva in the mouth, cough sometimes. The prescription was changed a little. 6 dosages in total.

 

Date: February 28, 2010                              Time: 9:00 a.m.

The patient¨s condition was stable. The symptoms of the patient were improved. So the prescription was the same as the one on February 22. 5 dosages in total.

 

Date: March 5, 2010                              Time: 9:00 a.m.

Recently, the weather changes very obviously. The patient felt very tired, and sleeping was not so good. The muscular jumping was obvious. The prescription was changed. 5 dosages in all.

 

Date: March 10, 2010                              Time: 9:00 a.m.

The spirit of the patient was good. The sleeping and appetite were good, too. The feeling of fatigue was improved obviously. But there was still much saliva. The prescription was changed a little. 5 dosages in total.

 

Date: March 15, 2010                              Time: 9:00 a.m.

The condition of the patient was stable, the sleeping and appetite were good. The patient¨s bowel movement and urination were normal. There was more saliva. The prescription was changed a little. 5 dosages in total.

 

Date: March 20, 2010                              Time: 9:00 a.m.

The patient said the sleeping of last night was not good, he felt difficult to fall asleep. There was much saliva in the mouth. Sometimes, the patient coughed as laryngeal itching. The treatment for him is mainly to fortify the spleen and boost qi, dry dampness, transform phlegm and free the network vessels. The prescription was changed. 5 dosages in total.

 

Date: March 25, 2010                              Time: 9:00 a.m.

The patient had good sleeping. But there was much saliva in the mouth, his speech was still unclear. The prescription was changed. 6 dosages in total.

 

Date: March 31, 2010                              Time: 9:00 a.m.

The patient said that there was still much saliva in the mouth which influenced his speech. His sleeping and appetite were good. His bowel movement and urination were normal. The prescription was changed. 5 dosages in total.

 

Date: April 5, 2010                              Time: 9:00 a.m.

The patient said that the saliva in the mouth had reduced. His speech has been improved. The other symptoms were good. The prescription was not changed. 5 dosages in total.

 

Date: April 8, 2010                              Time: 9:00 a.m.

The patient had watery diarrhea, 4-5 times a day. The prescription was changed a little. 2 dosages in total.

 

Date: April 10, 2010                              Time: 9:00 a.m.

The condition of the patient was stable. No diarrhea. The prescription was the same with the one on March 31. 5 dosages in total.

 

Date: April 15, 2010                              Time: 8:40 a.m.

The patient felt good in sleeping and appetite. The bowel movement and urination were normal. The symptom of swallowing was improved. He complained much saliva which was much less than before. The prescription was the same with before. 5 dosages in total.

 

Date: April 20, 2010                              Time: 8:30 a.m.

The patient felt good in sleeping. He slept 7 hours last night. His appetite was good. The bowel movement and urination were normal. His speech and swallowing were improving. The prescription was the same. 5 dosages in total.

 

Date: April 25, 2010                              Time: 8:30 a.m.

Because of having a cold yesterday, the patient had cough, nasal discharge, felt tired. He had slightly reddish tongue body, thin tongue coating, thin pulse body like thread. The prescription was adjusted accordingly. 5 dosages in total.

 

Date: April 30, 2010                              Time: 8:40 a.m.

The condition of the patient was good. There were no cough, nasal discharge, headache and body aches. His sleeping and appetite were good. His speech was much clearer. His saliva was less. He had cough when he was in the diet sometimes. He had slightly reddish tongue body, thin tongue coating, and powerful pulse. The prescription was the same with the one on March 31. 5 dosages in total.

 

Date: May 5, 2010                              Time: 8:50 a.m.

The patient said everything was normal. His speech and swallowing have improved a lot. He had slightly reddish tongue body, thin tongue coating, and powerful pulse. The prescription was the same with last time. 5 dosages in total.

 

Date: May 10, 2010                              Time: 8:40 a.m.

The condition of the patient was stable. His sleeping and appetite were good. His bowel movement and urination were normal. His tongue body was slightly reddish, his tongue coating was white, and he had string-like pulse. The prescription was the same.

 

Date: May 15, 2010                              Time: 8:00 a.m.

The patient decided to leave the hospital tomorrow. 

 

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