Rodney Hargrave-Cerebellar Ataxia-(Australia)

Name: Rodney Hargrave
Sex: Male
Nationality: Australian
Age: 37Y
Diagnosis: Cerebellar Ataxia

Before treatment:
The patient was unable to speak clearly 11 years ago, especially at night. He went to a local hospital and did CT and MRI examinations and was diagnosed with Cerebellar Ataxia. His condition became worse and worse. He had balance problems 9 years ago, was unable to walk well and he sometimes  fell down. He felt depression and anxiety 7 years ago but took citalopram 30mg qd and became better. For now he is able to take care of himself but speaks unclearly, especially with long sentences. His balance function is bad, he walks slowly and in an unstable way.
His appetite, sleep, urination and defecation functions are normal.

Admission PE:
Bp: 119/74mmHg; Hr: 54/min. Br: 19/min. Body temperature: 36.2 degrees. Height:199cm,weight:104 kg. His development was normal and he had good nutrition. There were no yellow stains or petechia on the skin or mucosa, no congestion of throat and no tonsil swelling. The breathing sounds of both lungs were clear with no rales. The rhythm of the heartbeat was normal and the heart sounds were strong with no obvious murmur in the valves. The abdomen was flat with no pressing pain or rebound tenderness. Spinal physiological bending existed. The liver and spleen were normal and there was no edema in either leg.

Nervous System Examination:
Patient was alert, had a natural facial expression but was slurred and slow in his speech. His memory, calculation abilities and orientation were normal. Both pupils were equal in size and round, the diameter was 3.0 mm. Both eyes had sensitive responses to light stimuli. Both eyeballs could move freely. There was no nystagmus. The nasolabial fold and forehead wrinkle pattern were symmetrical. He could close his eyes and show the teeth as normal. Chewing ability was normal. His tongue could touch the cheek powerfully with no tongue muscle tremor. He could bulge the cheek as normal and could turn his neck and shrug as normal. Muscle power of the 4 limbs was 5 degrees, muscle tone was normal. Tendon reflex of the 4 limbs was normal. Bilateral Hoffmann sign was negative, Babinski sign of both sides was negative, sensory examination was normal. His finger opposite movement was basically normal but both sides finger to nose test were not as stable as normal. Right side fast alternate movement was performed slowly and the left side was clumsy. The heel-knee-tibia test was nearly normal. He had an abnormal walking gait, wide step pace and short pace. He could not walk straight or stand on one leg. The Romberg's sign was positive, the meningeal irritation sign was negative.

Treatment:
After the admission he received related examinations and 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.     

Post-treatment:
After 14 days treatment his balance control was better than before, he could walk and do movement in a much more stable manner. He could walk a distance in less time compared with before and he walked for longer. He could try to control the body posture with his eyes closed and while standing. He could stand on one leg and his balance function was improved.

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