Ivica Screzoski-Ataxia-(Macedonia)

Name: Ivica Screzoski
Sex: Male
Nationality: Macedonian
Age: 35Y
Diagnosis: Ataxia

Before treatment:
When the patient was 7 years old he was unable to walk with his heels. 15 years ago his condition became worse and he had problems with his balance function. He was unable to walk or go up or down stairs and he felt weak in his legs so he began to use a stick to help him walk. He was diagnosed with ataxia in 2009. 2 years ago someone recommended him to have a shower with cold water and eat fresh vegetables and fruits. His balance function became better but some months ago he again had a hard time as his condition became worse again. At present he has balance problems, he walks slowly, it is hard for him to go up and down stairs and he is unable to stand on one leg.
His spirit is normal, his diet, sleep and defecation function are all normal. He has urgent urination needs.

Admission PE:
Bp: 113/76mmHg, Hr: 51/min, body temperature: 36.7 degrees. The patient's nutrition status is normal with normal physical development. There is no injury or bleeding spots of his skin and mucosa, no blausucht, slight throat congestion and his tonsils do not have swelling. Chest development is normal, the respiratory sounds in both lungs were clear with no dry or moist rales. The heart beat is powerful 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 and there is no edema in the legs.

Nervous System Examination:
Patient was alert and had clear speech but he speaks slowly. The memory, orientation and calculation abilities were normal. Both pupils were equal in size and round, diameter of 2.5 mm, react well to light and the eyeballs can move freely. Bilateral forehead wrinkle is symmetrical and the bilateral nasolabial groove depth is the same. He he can chew food powerfully, can show his teeth as normal, the soft palate can lift powerfully, the uvula was in middle position and he can make his tongue extend out as normal. He  can turn his head or shrug powerfully. The muscle power of the arms was 5 degrees and of the legs 4- degrees. The 4 limbs muscle tone were normal. the bilateral biceps reflex, triceps reflex and radial periosteal reflex could not be induced. Right side patellar tendon reflex and ankle reflex were active, left side patellar tendon reflex and ankle reflex could not be induced. The abdomen reflex was normal, the bilateral ankle clonus were negative. Sucking reflex of both sides were negative, bilateral Hoffmann sign were negative, the Babinski sign of both sides were positive. His sensory exam was normal, the finger to nose test was not stable, he can perform the fast alternate movement but in a  clumsy manner. He could perform the both hands finger opposite movement slowly, the both sides heel-knee-tibia test were unstable, the Romberg's sign was positive, he could stand with a single leg. The meningeal irritation sign was negative.

Treatment:
After the admission 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 along with rehabilitation training.     

Post-treatment:
After 12 days treatment his left arm can move in a more flexible manner than before, he can perform the fast alternate movement much easier and the finger to nose test was much more stable.

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