Nick Kooh Heng - Sequelae of cerebral hemorrhage (Malaysia) Posted on July 14, 2014

Name: Nick Kooh Heng   
Sex: Male
Country: Malaysia
Age:39 years
Diagnoses:1.Sequelae of cerebral hemorrhage 2. Hypertension 3. Hyperhomocysteinemia
Date:May 15, 2014
Days Admitted to Hospital: 28 days

Before treatment:
The patient suffered from movement disorders of his left limbs and hemianesthesia in the night about 1 and half years ago. The patient had no obnubilation, headache or vomit. About 10 hours later after onset of these symptoms, the patient was sent to hospital and received CT head examination. He was diagnosed with cerebral hemorrhage and hypertension. The patient received medication for therapy and received rehabilitation. After that treatment, the patient's muscle strength of his left limbs was improved slightly. But the movement of his left limb was still not flexible. Left hand had no activity. Left lower limb had difficulty to take a step.

From onset of disease, the patient had normal diet and sleep. The defecation was normal. The weight had no obvious change.

Admission PE:
Bp: 129/88mmHg; Hr: 84/min. The respiratory sounds in both lungs were clear, with no dry or moist rales. The heart sound was strong, with no murmur in each vales. The abdomen was flat and soft. The liver and spleen were not palpable. There was no edema in both lower limbs.

Nervous System Examination:
Nick Kooh Heng was alert, and his spirit was okay. His speech was clear. The examination of memory, calculation and orientation were normal. Both pupils were equally rounded; the diameter was about 3.0mm. Both eyeballs were sensitive to light stimulus. Both eyes could move freely. There was discontinuity horizontal nystagmus when looked left side or right side. The forehead wrinkle pattern was symmetrical. The teeth was in the center of oral cavity. The tongue was shifted to left side. The neck was soft. The muscle strength of left upper limb's near-end was at level 4-. The muscle strength of left upper limb's far-end was between level 2 to 3. The muscle strength of left wrist joint was between level 1 to 2. He had difficulty to do dorsal flexion. The hold power of left hand was at level 3-. The muscle strength of left lower limb's near-end was at level 4- and the left lower limb's far-end was at level 3. The muscle strength of left ankle was between level 1 to 2. His left foot couldn’t do dorsal flexion. Left foot could bend downward slightly. The muscle tone of left upper limb's far-end was higher than normal. The tendon reflex of left upper limb was active. There was tendon hyperreflexia of left lower limb. The ankle clonus of left side was positive. Left Hoffmann sign was positive. Left side Rossolimo sign was positive. Right side Babinski sign was positive. Left side suffered from obvious hemihypalgesia. Left upper limb couldn't cooperate with the examination of coordinate movement for the weakness of muscle strength. Left lower limb was able to finish coordinate movement examination, but for the muscle strength was weak, so the action was not good. There were no signs of meningeal irritation. The laboratory test showed increased HCY level.

Treatment:
Nick Kooh Heng received all of the relevant examinations. He received treatment for nerve regeneration and to activate stem cells in vivo. He received treatment to improve blood circulation in order to increase the blood supply to the damaged nerves and to nourish the neurons. He also received treatment to stabilize blood pressure, reduce blood lipid and nerve regeneration. This was combined with physical rehabilitation training.

Post treatment:
The muscle strength of his left limbs has improved. The muscle strength of his left upper limb's near-end is at level 4. The grasp ability of his left hands fingers is more flexible than before. The hold power of left hand has increased and reached level 4-. Left wrist joint can do dorsal flexion in a flexible manner and the angle has increased. The muscle tone of left limbs has reduced. Left side pathological character index has reduced than before. The level of HCY has reduced to normal level.

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