Ron Boisvert-Multiple Sclerosis-(sudan)

Name: Ron Boisvert
Sex: Male
Nationality: Canadian
Age: 47Y
Diagnosis: Multiple Sclerosis(MS)

Before treatment:
In September 2014, the patient felt weakness in right limbs, sometimes he fell down, his condition became worse day by day, he was diagnosed with MS after a series of examinations, he began to take oral Ribif, but 2 months later, his disease was worse, he was unable to walk, he change another medicine Tysabri for 3 months, but no useful, he stopped taking any medicine. One year ago, he felt weakness in upper limbs and he also noticed muscle atrophy, eight months ago, he began to have swallowing problems and language problems, he was unable to take care of himself at all. He wants a better life so he comes to our hospital.
His spirit is not good, he appetite and sleep are good, he has lost 45-50 KGs. He is unable to control his urination functions, and he defecates 3-4 times a day, he has cluster headache when he is upset or excited.

Admission PE:
Bp: 105/57mmHg, Hr: 75/min, body temperature: 36.4 degrees. Nutrition status is good, normal physical development. There is no injury or bleeding spots of his skin and mucosa, no blausucht. The chest develop is normal, chest movement was reduced when he was breathing, the respiratory sounds in both lungs were clear, while the breathing sounds of lower lungs was slightly weak, there was no dry or moist rales. The heart beat is powerful with regular cardiac rhythm, with no obvious murmur in the valves. The abdomen was flat and soft, with no masses or tenderness. The liver and spleen were normal, shifting dullness is negative. The spine column is normal; there was no edema in both lower limbs. Fingertip saturation oxygen is 93-95%.

Nervous System Examination:
Patient was alert and his mental status is weak, painful facial expression, speech was not very clear. His memory, the orientation and calculation ability were normal. Both pupils were equal in size and rounds, diameter as 3 mm, react well to light, eyeballs can move freely. No nystagmus. Eyesight was normal and no diplopia or visual field loss. Bilateral forehead wrinkle and nasolabial fold are symmetrical, show teeth is normal. His tongue is in middle and no tongue muscle atrophy, the uvula to the right side slightly, soft plate can not lift powerfully as normal, pharyngeal reflex was not sensitive. His neck can move freely, shrug ability was slightly weak, right shoulder joint had pain when he move his right shoulder joint, right upper limb muscle power was 2+degree, he can not grasp, left arm muscle power was 3 degree, grip force 2 degree, muscle power of right lower limb was 2-degree, of left lower limb was 1+ degree. There was obvious muscle atrophy of the bilateral shoulders, thenar muscles,hand interosseous muscles, bilateral quadriceps femoris, gastrocnemius muscles, etc. patient had obvious muscles fasciculation of proximal 4 limbs lateral side, muscle tone of upper limbs are basically normal, of lower limbs are mild higher, tendon reflex of 4 limbs are active. Abdominal reflex can not be induced, the Palm-jerk reflex of both sides was positive; Hoffmann sign of both sides are positive, bilateral Babinski sign was negative. Ankle clonus of both sides are positive. Patient can not perform the finger to nose test or fast alternate movement because of the weakness, left hand only can do the finger opposite movement with one finger, right hand can not do that. Patient can not do the Heel-knee-tibia test according to the muscle power limitation. The meningeal irritation sign is negative.

Treatment:
After the admission, he received related examinations and diagnosed with 1. MS 2. Cluster headache. He received 3 times nerve regeneration treatment to nourish nerves, regulate his immune system and improve blood circulation, with rehabilitation training.     

Post-treatment:
After 17 days’ treatment, his speech was much clearly, breathing function got better, fingertip saturation oxygen is 96-98%. His upper limbs muscle power increased, he can lift the upper limbs and touch the forehead. The muscle power of upper limbs was increased to 3 degree. The grip force increased to 3+ degree. The movement range of both lower limbs is enlarged. The muscle power of lower limb was increased to 2 level, he had better exercised tolerance.

 

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