Craig Reagan-Amyotrophic Lateral Sclerosis-(USA)

Name: Craig Reagan
Sex: Male
Nationality: USA
Age: 52Y
Diagnosis: Amyotrophic Lateral Sclerosis (ALS)
Discharge Date: 2019/11/18

Before treatment:
The patient was injured after falling off a horse 5 years ago. Six weeks after the injury he developed numbness of the left hip and had left foot drop. This was followed by weakness of the left leg which gradually developed to weakness of the left arm and right side limbs making it difficult to walk independently. He was clearly diagnosed as having "amyotrophic lateral sclerosis" in July 2016. He began to use "riluzole and Edaravone" and other drugs but there was no improvement. The patient's limb weakness continued to worsen and he was completely unable to walk 10 months ago. The function of speech and respiration has been weakened in the past half year. At present he cannot take care of himself, cannot turn over, sit up, stand, walk, eat, wash and so on.
He has good spirit, his sleep occasionally needs drugs, he has a normal diet, urination and defecation functions. He has lost around 9kgs weight. 

Admission PE:
Bp: 145/99mmHg, pulse rate: 92/min, breathing rate: 20/min, body temperature: 36.5 degrees, blood oxygen: 90%; weight: 99kg. The patient has normal physical development, good nutrition, no cyanosis of the lips, swelling of pharynx and a symmetrical chest. He has an obviously declined respiratory motility, reduced respiratory sound of both lower lungs, no remarkable dry or moist rales heard, no bulging of precordia, strong heart sounds, regular heart rhythm and no obvious murmur heard of various valves. With a flat abdomen, no tenderness or rebound tenderness, no masses, normal liver and spleen, negative shifting dullness, normal curves of the spinal column, no edema of the legs and good dorsal arteriopalmus of the feet.

Nervous System Examination:
Patient was alert, in good spirit, had slurred speech with normal calculation,  memory and orientation abilities. He had equal and round pupils with a diameter of 3mm, reacting sensitively to light, free eyeball movement without nystagmus, a symmetrical forehead wrinkle and nasolabial fold. His tongue was in the middle when extended, there was muscle atrophy and fasciculation of the tongue, limited tongue movement, disabled cheeks-puffing, normal chewing, strong soft palate-lifting bilaterally, the uvula was in the middle, soft neck, normal neck-turning and a strong shrug. He had grade 2 muscle power of bilateral upper proximity, grade 2 muscle power of left arm distal adductor, grade 3 muscle power of left arm distal abductor, grade 3 muscle power of right arm distal adductor, grade 2 muscle power of right arm distal abductor, grade 2 of right gripping power, grade 2+ of left gripping power. He had grade 2 muscle power of the right leg, grade 1 muscle power of left leg, disabled dorsal foot flexion bilaterally, normal muscle tone of both arms, slightly high muscle tone of the left leg, normal muscle tone of the right leg. Muscle atrophy was observed of bilateral supraspinatus, infraspinatus, deltoid and 4 limbs, normal sensation of the 4 limbs, no tendon reflex of both arms and normal tendon reflex of both legs. There was a negative Hoffmann sign, Rossolino sign, and Babinski sign bilaterally. He was unable to do the finger to nose test or the finger to finger test, had clumsy fast alternate test, unable to do heel-knee-tibia test and a negative meningeal irritation sign.

After the admission he received 3 nerve regeneration treatments (neural stem cells and mesenchymal stem cells) to repair his damaged nerves, replace dead nerves, nourish nerves (ganglioside, nerve growth factors, neurotrophic factors, Edaravone and Riluzole), improve body environment, regulate his immune system and improve blood circulation. This was combined with rehabilitation training.   

After 14 days treatment his speaking ability got better, he spoke louder and clearer, respiration function got better with a clearer breathing sound, saturation oxygen increased 96%, the muscle power of his arms increased 30%, the distal muscle power increased 20%. He could now raise his arms easier to the lips and move his shoulder easier, grip force improved, he could raise his foot with the muscle power of legs now increased 20%.  

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