Имя: Gabriel Andres Zabala
Возраст: 23 года
Диагноз: 1. Спинальная мышечная атрофия Тип II. 2. Апноэ
Дата госпитализации: 10 августа 2015
Длительность лечения: 31 день
The patient was found to have whole body weakness at the age of 1 and half; he couldn’t stand up, sit-up, stand or walk. His elder brother had the same condition. He was diagnosed with spinal muscular atrophy type II. He received regular rehabilitation training. He feels weak, easily gets tired, and finds it difficult to breath. He wants a better life, so he came to our medical center. He has sleep apnea syndrome for many years.
His spirit, diet, urination, excrement and weight are normal.
Temperature: 36.5 degree, Hr: 90/min, Br: 21/min, Bp: 139/93mmHg. His nutrition was good. His was overweight. There was no breakage or hemorrhagic spots on skin. His pharynx and tonsil were normal. His thorax was symmetrical. The respiratory sounds in both lungs were clear, with no obvious dry or moist rales. The heart sounds were powerful; the cardiac rhythm was regular, with no obvious murmur. The abdomen was bulge and soft, with no palpable masses. His liver and spleen were normal. Both of his lower limbs and foot had pitting edema. His four limbs were shorter than normal. Left elbow joints and both knee joints had contracture and were unable to straighten. The let side elbow joint could stretch to 160 degrees passively. The left knee joint could stretch to 90 degrees passively. The right knee joint could stretch to 100 degrees passively. Degree of blood oxygen saturation during night: 60%-80%.
The patient was conscious and alert. The calculation abilities, insight ability and orientation were normal. The speech was clear. Both pupils were equal in size, the diameter was 3.0mms. Both eyeballs could move flexibly and the pupils reacted normally to light stimulus. There was no obvious nystagmus. His vision and vision field were normal. The forehead wrinkle pattern was symmetrical. The tongue was centered in the oral cavity. He couldn’t show his teeth. The muscle power to shrug right shoulder was at level 4-, left shoulder was at level 4.The muscle strength of both upper limbs’ proximal-end was at level 3-. The flexor muscle power of left limb’s proximal-end was at level 3-, and extensor muscle power was at level 2. The flexor muscle power of right limb’s proximal-end was at level 3+, and extensor muscle power was at level 3. His left hand’s grip was at level 2, right hand’s grip was at level 3. The flexor muscle power of lower limbs’ was at level 1, the extensor muscle power of lower limbs’ was at level 0-1, and the muscle tension of four limbs was lower than normal. The abdominal reflexes and tendon reflexes of all four limbs disappeared. The bilateral pathological sign was negative. The sensory examination results were normal. His right hand could do finger to finger test normal, but his left hand’s little finger couldn’t do it. His left hand couldn’t do the rapid rotation test very well. He couldn’t do heel knee shin test or romberg’s sign.
The patient was diagnosed as 1. Spinal Muscular Atrophy type II (SMA) 2. Sleep Apnea Syndrome(SAS). He received 4 times of neural stem cell injection and 4 times of mesenchymal stem cell injection to activate the cells, nourishes neurons, improve circulation and immunity. He wore non-invasive ventilator at night to improve his oxygen. He also had physical rehabilitation to improve his motor function and respiratory function.
After treatment, his condition was better: 1. respiratory function: his thorax had enlargement when he breathed, SAT during night was higher to 85%-95% when he didn’t wear breathing machine and 90%-99% when he wore breathing machine. 2. Motor function: endurance was better; the muscle power when he shrugs his shoulder was higher to 4+. His trunk was powerful. He could turn over to left and right in supine position. The muscle power of his four limbs was higher, and his motor function was better. He could touch his nose with right upper limbs in sitting position while his left upper limb could touch his jaw. The grip of both hands increased. The flexor muscle power was at level 2-, extensor muscle was at level 1. Both of his lower limbs didn’t have dropsy.