Pedro Vicente Marrero Fuenmayor-MD-(Venezuela)-Posted on Mar.31th, 2015

Name: Pedro Vicente Marrero Fuenmayor            
Sex: Male
Country: Venezuela
Age: 31 years
Diagnosis: Muscular Dystrophy
Date: Feb. 26th, 2015
Days Admitted to Hospital: 29 days

Before treatment:
28 years ago(at the age of 3 year old), his family members found his gait was instable. After that, he had difficult to walk and turn around, but he didn’t went to hospital. At the age of 8, he couldn’t run, had difficult to turn around and squat. After a variety of inspections in a Canadian hospital, he was diagnoses as “Muscular Dystrophy”. It was difficult for him to go up and down the stairs at the age of 10, he had taken L-carnitine some times. He swam for a year 6 years ago, then he did rehabilitation exercise twice a week. But his disease got worse. He had obvious atrophy of the muscles, the muscle got more weakness. His ankles were contractural. 1 year ago, his disease became worse, he couldn’t stand, turn over or sit by himself. He is in bed now. he has severe shoulder girdle muscle, pelvic girdle muscle and both upper limbs muscle atrophy. The muscle power of four limbs was at level 1-2, low muscle tension. He wants to have a better treatment, so he came to our hospital. he was diagnosed as” Muscular Dystrophy”.

He was in good spirit. His eating, urination and excrement were good. Sometimes it was hard for him to go to sleep, he could sleep 7-8 hours each day.

Admission PE:
Bp: 135/89mmHg; Hr: 78/min. BT: 37 degree. There was no ecchymosis or petechia on skin. The respiration of both lungs was clear, without moist or dry rales. The heart sound was strong, and the cardiac rhythm was regular, and there was no obvious murmur in the valves. The abdomen was soft and bulge, with no tenderness or rebound tenderness. The liver and spleen were normal. The remote end of both lower limbs were low skin temperature. There was no edema on both lower limbs. Kinase was at high level, CK1580IU/L.

Nervous System Examination:
Pedro Vicente Marrero Fuenmayor was alert and his spoke fluently. He was in good spirit. His memory, calculation and orientation abilities were normal. Both  pupils were equal in size and round, the diameter was 3.0mms, both eyeballs could move freely and the pupils reacted normally to light stimulus. The forehead wrinkle pattern was symmetrical. He had strength to close his eyes, Both nasolabials were equal in depth, cheed blowing strength was normal, the tongue was centered in the oral cavity, and the teeth were normal and shown without deflection. Both soft palates could lift, and the strength was strong. The muscle power of neck was at level 4, The muscles of shoulder girdle, Pelvic girdle and both upper limbs were Severe atrophied. Both side knee joints, ankle joints and tendon were contractural. Both hand fingers were mild crooked and couldn’t extend. Both side ankle were introrsus. It was difficult for his to do dorsal flexure. Both of his foot were pendulous. The muscle power of shrug his shoulder and proximal end of both upper limbs were at level 1. The muscle power of remote end of both upper limbs were at level 2. The grasp power of hand was at level 3. The muscle power of both lower limbs was at level 1. The four limbs’ muscle tension were lower. He couldn’t turn over, sit, stand or walk by himself. Both sides ankle reflex and abdominal reflexes were abnormal. Both side palm jaw reflex, Hoffmann sign, Rossilim and Babinski sign were negative. The rough depth determination and epicritic sensibility of both sides were normal, finger-nose test, rapid rotation test, both legs’ heel-knee-tibia test and finger-to-finger test were hard to finish because of muscle power. The meningeal irritation sign was negative.

Treatment:
He received consummate examination at the same time he received treatment for protecting hepatic function, decreasing creatase, improving nerve nutrition, improving blood supply, promoting nerve repair and stabilized organ function. We also gave him daily physical rehabilitation.

Post-treatment:
After the treatment, his condition gradually improved, the muscle power of upper limbs were better. Right side proximal end adductor muscle power was better. The upper limbs could adduct in the abduction position. He could lift his left wrist better than before. The grip of left hand was higher. The proximal end muscle power of lower limbs was better, He could adduct his legs on smooth flat. The destroy speed of muscle fiber was slower, the creatase level was lower. CK had decreased to 490IU/L. He was not that tired when he doing the rehabilitation exercise. His endurance was higher.