Juan Nietch-Spinocerebellar Ataxia-(America)

Name: Juan Nietch
Sex: Male
Nationality: American
Diagnosis: spinocerebellar ataxia I

Before treatment:
The patient was unable to walk normally 8 years ago then his condition became worse 7 years ago. He went down stairs slowly so he did a gene test in 2011 and he was diagnosed with spinocerebellar ataxia I. In the last year it has been difficult for him to write with his right hand and he couldn’t speak clearly when he spoke fast. He was unable to lie on his back due to saliva buildup so he had to lift the head off the bed at 25 degrees. He did an MRI and the result showed cerebellar atrophy. For now, his balance function is bad, his walking position is abnormal and he walks slowly, it is hard for him to go down stairs, he is unable to stand on his left foot and he could only stand for 2-3 seconds on his right foot.
His spirit and diet are normal. His urination and defecation functions are normal.

Admission PE:
Bp: 132/81mmHg, Hr: 72/min, body temperature: 36.7 degrees. Nutrition status is good with normal physical development. There is no injury or bleeding spots on his skin and mucosa, no blausucht, no throat congestion and no tonsil swelling. Chest development is normal, the respiratory sounds in both lungs were clear with no dry or moist rales. The heart beat is strong with regular cardiac rhythm and no obvious murmur in the valves. The abdomen was soft and flat with no masses or tenderness. The liver and spleen were normal, shifting dullness was negative, spinal column is normal and there is no edema in the legs.

Nervous System Examination:
Patient was alert and mental status was good. He had a mild slur in his speech, the memory, orientation and calculation abilities were normal. Both pupils were equal in size and round, diameter of 3.0 mm, react well to light, with no nystagmus and the eyeballs can move freely. Bilateral forehead wrinkle and nasolabial groove were symmetrical. He can chew as normal and  can show teeth as normal. The soft palate could lift as normal,  no uvula, he could make his tongue extend out as normal. He could turn his neck and shrug powerfully. The muscle power of the 4 limbs was 5 degrees, his left leg was  trembling slightly in the knee and hip bend position. The muscle tone of all 4 limbs was normal. The bilateral biceps reflex, triceps reflex, radial periosteal reflex and ankle reflex were active, the patellar tendon reflex of both sides were hyperactive. The abdominal reflex was normal, the bilateral ankle clonus was positive. Sucking reflex of both sides were negative. Bilateral Hoffman signs were negative, the Babinski sign was neutral, intensity was positive. Sensory system was normal. Left side finger to nose test was not stable as normal, fast alternate movement was clumsy, right side finger to nose test and fast alternate movement were much better. The bilateral heel-knee-tibia test were normal, the Romberg's sign was positive. He could stand on his right leg for 2-3 seconds but cannot do so on his left leg. He could not walk straight. The meningeal irritation sign was negative.

After the admission, he received related examinations and was diagnosed with SCA1. He received 3 times nerve regeneration treatment to repair his damaged nerves, replace dead nerves, nourish nerves, regulate his immune system and improve blood circulation. This was done with rehabilitation training.     

After 14 days treatment his balance function is better,the flexibility of his left arm is better,the rapid rotation test is more flexible and the finger to nose test  can now be finished with more accuracy. The Romberg's sign is better,he can stand using only his left leg for 5 seconds and stand with just his right leg for 7 seconds.


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