Booe James-MSA-(USA)
Name: Booe James
Sex: Male
Country: USA
Age: 70 years
Diagnosis: Multiple system atrophy (MSA), Hyperlipidemia, Chronic Obstructive Lung Disease, Pulmonary Infection
Date: Nov. 28, 2014
Days Admitted to Hospital: 19days
Before treatment:
The Patients couldn’t walk well, stand unsteady and step base broadened, with occasional fall. Both hands holds things in a difficult manner, fingers’ flexibility decreased, appeared ambiguous pronunciation, body’s decreased balance. The gait disturbance and dysarthrosis are the main performance. He could walk only with the help of a crutch. He would be out of balance when he suddenly turned round. And he also had binocular coordination disorder and he couldn’t pass through barriers. His right hand had slightly postural tremor, sometimes he finds it difficult to speak some words. The patient's condition worsened for the past six months, he could walk only with the help of ambulatory aid, a local hospital diagnosed as: Multiple system atrophy (MSA), but didn’t give him any special treatment. His mental state is good, but his pronunciation is unclear, speed is slow, and he is difficult to speak some words. He can turn over, sit up and stand up by himself, but his movement is very slow. He can walk slowly in a short distance with the help of ambulatory aid. He wants to have a better treatment, so he came to our hospital.
He sleeps 6 hours per day since he was ill, his family found out that he sometime attack people during sleeping, but he doesn’t remember that when he wakes up. His appetite is good, absences of nausea and vomiting, defecates every two days once, urine is normal.
Admission PE:
Bp: 143/88mmHg, Hr: 85 / min, Br: 22 / min , superficial lymph node touched, no enlargement, skin and mucous membranes without yellow stains and bleeding, conjunctival hyperemia , sclera without yellow stains , lips no cyanosis , barrel chest , lungs breathing; sounds clear , no dry and wet rales , heart sounded low blunt , regular rate, the valve auscultation area was not known obvious noise , abdominal distension, palpation slightly harder , upper abdominal percussion drum sound , no tenderness and rebound pain , no palpable mass , liver and kidney area without obvious percussion pain ,no lower extremity edema.
Nervous System Examination:
Spirit was good, speech unclear, speed slow, difficult to find a word , memory was normal , his calculation, orientation, understanding and judgment were normal. Both pupils were equal in size. The diameter of both pupils was 3.5mms and both pupils were sensitive to light stimulus. The forehead wrinkle pattern was symmetrical, he was able to close his eyes with ease, bilateral nasolabial sulcus was equal in depth, the corner of mouth was symmetrical and the tongue was almost in the center of oral cavity. No tongue tremor, chewing strong, he could raise soft palate symmetrically. Uvula was on the center. the muscle strength of both upper limbs was at level 5, and both lower limbs was at level 4+, the muscular tension of four limbs was normal. The tendon reflex of both upper limbs was normal, the tendon reflex of both lower limps was weak. Ankle clonus negative, no abdominal reflexes, four limbs’ pathological features were negative. Depth of feeling were normal, finger-to-finger test was not good, rotation slow, uneven rhythm, heel-knee-tibia test unsteadiness, turned over, sit-up and stand up slowly, he could walk short distances with the help of ambulatory aid, step base was wide. He couldn’t open his eyes soon after he closed his eyes, eyes closed was positive. Meningeal irritation sign was negative.
Treatment:
He was given nerve repair and nerve regeneration treatment to active stem cells, improve circulation, modulate the immune system, improve the blood circulation and trophic nerve, decreased blood-lipid and combined with physical rehabilitation training. After treatment for 3 days, he had a fever, began to cough, sputum, wheezing, after examination, he had scattered wheezing lungs, asked the history of patient, his family members said he had been diagnosed as chronic obstructive lung disease, we considered as pulmonary infection, treated with anti-inflammatory drugs, relieve cough and reduce sputum , asthma and other treatments.
Post-treatment:
After treatment, lung infection under control, the patient breathed steadily, no cough, no sputum, and no fever. Four limbs’ freemasonry barriers mild improved. He can put his fingers together better, alternate motion is better. He can turn over better, and knee-tibia test is flexible.
