Name: Daniel Ronnie
Age: 48 years
Diagnosis: 1. Huntington Disease 2. Hyperlipemia
Date: May 3rd, 2015
Days Admitted to Hospital: 21 days
The patient experienced headache without any reason in June 2014. He had dyssomnia since Nov. 2014. He couldn’t control his mood, easily get upset and he liked been quiet. He went to a local hosptial and had blood examination and gene analysis. He was diagnosed as Huntington Disease. He took Duloksetien and Zolpidem to treat his disease but with little success. His step was a little abnormal 3 months ago. His balance was bad, both hands had involuntary tremor and left foot had involuntary twisting. He could take care himself. He wanted a better treatment so he came to our hospital.
His spirit was good. He could’t control his mood and easily get upset. His diet was good. He could sleep well with medicine. His urination and defecation were normal. His weight was normal.
Bp: 133/83mmHg; Hr: 70/min. RP: 20/min. His nutrition was normal. The skin and mucosa were without yellow stains or petechia. His pharyngeal with no congestion, both tonsils were normal. The respiration of both lungs was normal, with no dry or moist rales. His heart rhythm was normal and strong, without obvious murmur in the valves. The abdomen was bulge with no tenderness or rebound tenderness. The liver and spleen were normal, when the doctor palpated it. The abdomen had tympanic sound. His four limbs and spinal were normal. There was no dropsy on both lower limbs.
Daniel Ronnie was alert and good spirit. His memory, calculation and orientation abilities were normal. The diameter of both pupils was 3.0mms, and both pupils were equal in size and round. Both eyeballs could move freely and the pupils reacted normally to light stimulus. He had horizontal nystagmus and nystagmus verticalis. He had head tremor, the forehead wrinkle pattern was symmetrical. He could close his eyes strongly. Both nasolabials were equal in depth. The tongue was in the centre of the oral cavity. Both soft palates could be lifted strongly. His neck was weak. The muscle power and muscle tension of four limbs were normal. Both hands had involuntary tremor. Left foot had involuntary twisting. Lower limb had mild uncoordinated muscular movements, his step was a little abnormal. The tendon reflex of four limbs was normal. The depth feeling was normal. The pathology sign was negative. The finger-nose test, finger-to-finger text and rapid rotation test were normal. Both side heel-knee-tibia test was hard to finish. The rombergs sign was negative. The meningeal irritation sign was negative.
We diagnosed Daniel Ronnie based on the examination as: 1. Huntington Disease 2. Hyperlipemia. He received treatment for nerve nutrition, improving blood supply, increasing nerve regeneration, muscle nutrition and controlling blood lipid. We also gave him daily physical rehabilitation.
After the treatment, the patient could sleep well, his spirit was good. His blood pressure has been well controlled. His exercise tolerance was better. The nystagmus was less. The tremor of his hands and head were less. He could control his left toes better.