Hardin Fletty - Muscular dystrophy (Macedonia) Posted on August 29, 2014

Name: Hardin Fletty  

Sex: Male

Country: Macedonia

Age:20 years

Diagnoses: Muscular dystrophy, Mild anemia

Date:July 25, 2014

Days Admitted to Hospital: 21 days

Before treatment:

            The patient suffered from walking difficulty when he was 5 years old. The disease aggravated gradually. The patient lost walking ability 7 years ago. The patient suffered from weakness of upper limbs 3 years ago. After gene detection, the patient was diagnosed with Duchenne muscular dystrophy. The patient received rehabilitation training. With the progression of the disease, the patient was kept in bed completely. He had deformity of his four limbs and spine. The muscle strength of his four limbs were at level 1 to level 2. The muscle tone was low. For further therapy, the patient went to Wu Medical Center and was diagnosed with Duchenne muscular dystrophy.

            From the onset of disease, the patient had normal spirit. The diet and sleep quality were normal. The patient had normal defecation and urination. The patient had an elder brother who had the same disease. And his brother died at age 13. He has an elder sister and a younger sister, all of them are healthy.

Admission PE:

            Bp: 96/60mmHg; Hr: 84/min, temperature: 36.0 degrees. Weight: 26.5Kg. He suffered from severe mal-nutrition. The skin and mucosa were normal, with no yellow stains or petechia. Through auscultation, the respiratory sounds in both lungs were clear, with no dry or moist rales. The heart sounds were strong, the cardiac rate was normal, with no obvious murmur in each valves. The abdomen was soft. There was no pressing pain or rebound tenderness. The liver and spleen were not enlarged. There was tendon contracture in bilateral elbow joints, wrist joints, knee joints and ankle joints. Both elbow joints couldn't be straightened and presented with 125 degrees. Bilateral wrist joints bent inside. All the fingers were bent slightly and couldn't be straightened. Both knee joints couldn't be straightened. Left knee joint couldn't be straightened and presented with 130 degrees. Right knee joint couldn't be straightened and presented with 160 degrees. Bilateral knee joints had slight introversion and the dorsal flexure was restricted. Both feet had ptosis. The lumbar vertebra had obvious forward protuberance and bent to left side slightly.

Nervous System Examination:

            Hardin Fletty was alert, and his spirit was good. His speech was clear. His memory, calculation ability and orientation were all normal. Both pupils were equal in size and round, the diameter was 3.0mms. Both pupils were sensitive to light stimulus. Both eyeballs had flexible movement. The forehead wrinkle pattern was symmetrical. The ability to close his eyes was strong. The bilateral nasolabial sulcus was equal in depth. The tongue was centered in the oral cavity, with no teeth deflection. There was no air leakage when he drummed his cheeks. He could raise the soft palate strongly. The muscle strength of neck was at level 2. He could turn neck side ward for 30 degrees. The muscle strength to shrug his shoulders was at level 1. The muscle strength of his four limbs was at level 1. The muscle tone of his four limbs was low. He was unable to turn over, sit, stand or walk. The tendon reflex of his four limbs was not elicited. The abdominal reflexes was not elicited. Bilateral palm jaw reflex, Hoffmman sign, Rossilimo sign and Babinski sign were negative. The deep and shallow sensation, sophisticated sensation was normal through loose measure. He was able to finish the finger-nose test, digital opposition test and the rapid rotation test. He had difficulty with the heel-knee-shin test. There were no signs of meningeal irritation.

Treatment:

            We initially gave Hardin Fletty a complete examination. He received treatment for muscle fiber repair and muscle fiber regeneration. He received treatment to enhance the function of each organs and to promote muscle regeneration. He also received treatment to improve the blood circulation in order to increase the blood supply to the damaged neurons, nourish the nerves and promote nerve regeneration. This was accompanied with physical rehabilitation treatment. The test at the admission showed, the blood routine: HGB 112g/L, RBC 3.81*1012/L, HCT 34.3%. So the patient was diagnosed with mild anemia. The patient received folic acid and iron supplements for the mild anemia therapy.

Post-treatment:

           The patient's condition has improved. HGB has improved. The joint contractures of his four limbs are alleviated. At present, both elbow joints presented 145 degrees. The muscle volume of both upper limbs are better. The muscle strength of both upper limbs have improved. Both upper limbs have parallel translation in bed surface. The muscle strength of both upper limbs' near-end are at level 1+. The muscle strength of both upper limbs' far-end are at level 2. The hold power of both hands have improved. The hold power of left hand is at level 2. The hold power of right hand is at level 2+. The muscle strength of both lower limbs is at level 1+. He does not feel tired easily when he does exercises. The endurance has strengthen than before.

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