Lucy-Multiple Sclerosis-(USA)
Name: Lucy
Sex: Female
Nationality: USA
Age: 43
Diagnoses: 1. Multiple Sclerosis 2. Iron Deficiency Anemia
Date of Admission: June 5th, 2016
Treatment hospital/period: Wu Medical Center/20 days
Before treatment:
Lucy felt heavy in left lower limb without any reason 10 year ago, she also had vision problems of left eye and she was not able to control her urination well. She went to hospital and diagnosed with ADEM, but her condition was not improved after treatment, her limbs were weak, she had nystagmus, accompanied with dizzy. Her left eye’s vision was worse. She went to hospital several times, received serum immunology examinations and cerebrospinal fluid examinations, the results were normal. She was diagnosed with Multiple Sclerosis 4 years ago, the doctor prescribed medicines, she also did rehabilitation training, but her condition got worse and worse. She completely blinded in left eye 2 years ago. It was hard for her to walk or move. She could only stand for a while. She felt it was hard for her to move left upper limb in a few months, It was difficult for her to take care of herself. She wanted a better life so she came to our hospital.
Her spirit was good. Her appetite and sleep were normal. She had constipation and incontinence of urine.
Admission PE:
Bp: 110/60mmHg, Hr: 85/min, body temperature: 36.2 degrees. Br: 19/min. Her physical condition was normal, her nutritional status was good. Her bony thorax was symmetrical. The respiratory sounds in both lungs were normal, there was no dry or moist rales. The heart sounds were strong. The cardiac rhythm was regular, with no obvious murmur in the valves. The abdomen was flat and soft, with no masses or tenderness. She was diagnosed with microcytic hypochromic anemia through examinations.
Nervous System Examination:
Lucy was alert and her spirit was good, her speech was clear. Her memory, orientation and calculation ability were normal. Both pupils were equal in size and round, the diameter was little than normal. It was 1.5mm. Both pupils were insensitive to light stimulus. Her left eye had no vision, her right eye was not able to see object clearly. Her eyes had obviously horizontal nystagmus. Her eyeballs could move flexibly except her left eye was hard to gather vision. The forehead wrinkles were symmetrical. Bilateral nasolabial sulcus was equal in depth. Her mouth and teeth were in the right position without deflexion. Her tongue was centered in her mouth, her tongue muscle was normal, uvula was in the right position. Her neck more freely, the muscle tension of her four limbs was basically normal. The muscle power of both upper limbs was at level 5. Left hand grip was at level 5-, right hand grip was at level 3. The muscle power of left lower limb was at level 3-. The abdominal reflexes were abnormal. The tendon reflex of both upper limbs was basically normal, both of her lower limbs’ tendon reflex was active. The sucking reflex was negative, palm jaw reflex, low jaw reflex and Hoffmman’s sign were negative. Babinski’s sign was positive. The deep sensation and superficial sensation were normal. Her right upper limb did rapid rotation test and finger to finger test normally, her left upper limb do these test a little slowly. She was not able to do the finger to nose test well. Her lower limbs were not able to do the coordinate movements well. She was not able to do rombergs sign or walk straight. Her meningeal irritation sign was negative.
Treatment:
After the admission, Lucy was diagnosed 1. multiple sclerosis 2. iron deficiency anemia. She received 4 neural stem cell injections and 4 mesenchymal stem cell injections to nourish nerves, improve blood circulation, reverse anemia, improve resistance to disease. She also had rehabilitation training.
Post-treatment:
After 20 days of treatment, she had less dizzy, the diameter of her pupils was 2 mms, her right pupil was more sensitive to light. Both eyes’ horizontal nystagmus was less. She was able to speak powerful. Her swallowing function was improved. She was able to control her urination. She had better muscle power, both grip was at level 5. She was able to move fingers flexible. She walked better, she was able to walk to bathroom. She could take care of herself better.
Follow up
Date: 2016-07-07
Good Day
Hope this email finds you all well
This is the sitter of the patient name Lucy.
Please find the attachment , it is the laboratory result.
The below is the weekly report about her status
- Monday 4 July:
stable
- Tuesday 5 July:
stable
- Wednesday 6 July:
stable
- Thursday 7 July:
she Feltnausea and weakness frommorninguntil 8 PM.
- Friday 8 July :
she felt again nausea and weakness from the morning until 8 PM.
- Saturday 9 July :
stable
- Sunday 10 July:
stable
- Monday 11 July:
stable
- Tuesday 12 July:
stable
- Wednesday 13 July:
stable
- Thursday 14 July:
she cant control in the urine.
- Friday 15 July:
stable
- Satuday 16 July:
stable
- Sunday 17 July:
stable
- Monday 18 July:
stable
- Tuesday 19 July:
stable
Note :
- the weather is very hot some time up to 50 or 52 C.
- the Vit D is undernormal so shall she take the medicationthat you stop it.
- i see the movement of her eyes back like before i mean the movement is little rapidly.
Thank you
Regards,
Rawabi
