Marrya-Cerebellar ataxia-(England)-Post on February 23, 2012
Name: Marrya
Sex: Female
Country: England
Age: 55
Diagnoses: 1. Cerebellar ataxia 2. Multiple sclerosis 3. Urinary tract infection (treated) 4. Hypothyroidism
Admission Date: 2011-12-16
Days Admitted to Hospital: 32
Marrya started experiencing weakness in the right leg and difficulty walking 18 years ago. At that time she did not receive a clear diagnosis for the symptoms. Eventually she developed weakness in the left leg which increased her difficulty with walking. She went to the local hospital several times and received Avonex through intramuscular injection 8 years ago and continued using the medication for 7 years. The medication was largely ineffective. Marrya was eventually diagnosed with multiple sclerosis. After the diagnosis her doctor prescribed Copaxone which also had little effectiveness. This medication was discontinued and the symptoms got worse and additionally the right arm became weak. Marrya also developed a balance disorder. She sometimes inspect content into double.
Examination of the nervous system:
The horizontal movement of the eyeballs was limited, and the convergence ability of both eyes was slightly poor. The eyes had flexible movement in the other directions. There were no visual field defects or nystagmus. The forehead wrinkle pattern was symmetrical. The nasolabial grooves were symmetrical. The tongue and teeth were shown without deflection. There was no atrophy in the tongue muscle. The neck had flexible movement. The muscle tone of all four limbs was normal. The muscle strength of the right upper limb was level 4+, the muscle strength of the left upper limb was level 5. The muscle strength of the right lower limb was level 4-. The muscle strength of the left lower limb was level 4. The abdominal reflexes were not elicited. The tendon reflexes of all four limbs were active. The sucking reflex was negative. The palm jaw reflex was negative. The bilateral Hoffmann's sign was negative. The Rossolimo's sign of both upper limbs was positive. The pathological reflex of both lower limbs was positive. The deep and shallow sensation was normal. Both upper limbs could finish the finger-to-nose test, digit opposition test and rapid rotation test in a stable manner. The lower limbs could do the heel-knee-shin test slowly. The Romberg's sign was positive. There were no signs of meningeal irritation.
Treatment:
Marrya received all of the relevant examinations. Combined with the patient's medical history and current status, she was diagnosed with 1. Cerebellar ataxia 2. Multiple Sclerosis 3. Urinary tract infection (healed) 4. Hypothyroidism. She received treatment to improve the blood circulation in order to increase the blood supply to the damaged neurons. She also received treatment to nourish the nerves, anti-infection, supplementary thyroid hormone treatment, stem cells injections and other symptomatic treatment. This was combined with daily physical rehabilitation training.
Post-treatment: The urine routine results were restored to a normal level. The thyroid functioning has been restored to a normal level. The headache is not so severe as before. But the dizziness is still experienced. The muscle strength of the right lower limb has been increased and reached level 4. The right lower limb could be lifted off the floor. She has better walking posture and balance ability.