Имя: Albert Tucan
Возраст: 59 лет
Диагноз: 1. Атаксия 2. Нейродегенеративное заболевание
Дата госпитализации: 16 ноября 2016 г.
Длительность лечения: 15 дней
Albert could walk well 2 and half years ago, but he felt dizzy, his condition became worse, he had balance problems, his stride became wider, he couldn’t speak clearly. He had a brain MRI done 2 years ago, the result showed: recessive disease in the cerebella pons, he did some rehabilitation training, but his condition became worse. He was diagnosed with ataxia 1 year ago. Currently, he has poor balance, he can’t walk well, he walks slowly and his stride is wider. He is unable to do fine movements well, it is difficult for him to write or speak clearly. He also feels dizzy. His condition is worse during the night. He is able to turn over, sit up, stand and walk.
His eating and sleeping pattern are normal. He has bowel movements once every 2-3 days, his urination function is normal.
Bp: 140/89mmHg, Hr: 65/min, breathing rate: 20/mim, body temperature: 36.3 degrees. His height is 171 cm; weight 56Kg. Nutritional status is good, with normal physical development. There is no injury or bleeding spots on the skin and mucosa, no cyanosis, no throat congestion, and the tonsils are not swollen. The respiratory sounds in both lungs are clear; there are no dry or moist rales. The heart beat is powerful with a regular cardiac rhythm, and no obvious murmur in the valves. The abdomen is flat and soft, with no masses or tenderness. The liver and spleen are normal. The spinal column is normal; there is no edema in the lower limbs.
Albert was alert and his facial expression was natural. He slurred his speech. His memory, orientation and calculation ability were normal. Both pupils were equal in size and round, with a diameter of 2.5 mm, and reacted well to light. The eyeballs could move freely. There was no nystagmus. The bilateral forehead wrinkle pattern and nasolabial fold are symmetrical. The eyes can be closed strongly. The teeth were shown without deflection. He can chew food normally. H would sometimes choke while eating or drinking. The movement of the lower jaws is normal. There are no tremors in the tongue muscle and the tongue can touch the inside of the cheeks normally. . The cheeks can be expanded powerfully. The neck can be turned freely and the shoulders can shrug powerfully. The muscle power of the upper limbs is 5 degrees. There is no Wax-Waning Sign, no static tremors. Albert had some difficulty writing. The muscle power of the lower limbs is 5 degrees. Albert can stand up, turn over in bed and sit up by himself. He has an abnormal gait when walking. Albert cannot walk straight, and he cannot stand on one leg. The muscle tone is normal and the tendon reflex of all four limbs and abdominal reflex is normal. The bilateral pathological sign was normal. The deep and superficial sensation examinations were normal. The fingers-to-nose test was not very stable, he could perform the fast alternating movements and opposing fingers movement tests slowly. The heal-knee-tibia test was uncoordinated. The Romberg’s sign was positive. The neck resistance test was negative; the Kerning sign was negative; the Brudzinski sign was negative.
After the admission, Albert was diagnosed with 1. Ataxia 2. Neural degenerative disease. He received 3 neural stem cell injections and 3 mesenchymal stem cell injections to repair his damaged motor nerves, replace the dead nerves with new injected stem cells, nourish the nerves and improve the blood circulation. This was combined with rehabilitation training.
After 15 days of treatment, Albert’s balance control ability improved, his gait when walking or turning round improved. He could stand on his right foot for 2-3 seconds, and he could stand on his left foot for 10 seconds.