Ms.Becker-Multiple Sclerosis-(America)

Name: Ms.Becker
Sex: Female
Nationality: American
Age: 45Y
Diagnosis: Multiple Sclerosis (MS) 

Before treatment:
The patient fell down on the road 10 years ago so she went to local hospital and was diagnosed with multiple sclerosis. Her condition was stable but sometimes she walked in an unstable manner. She had interferon injections once a week 6 years ago but her condition was not improved so she stopped 4 years ago. Her condition became worse 2 years ago, her left leg was weak, her balance function was bad and her condition became worse and worse. At present the left side of her body is weak, she limps when walking and it is difficult for her to raise her leg.
Her spirit, diet and sleep are normal. Her urination and defecation functions are normal.

Admission PE:
Bp: 126/85mmHg, Hr: 85/min, body temperature: 36 degrees. Height: 151cm, weight: 60Kg. Nutrition status is good with normal physical development. There is no injury or bleeding spots of her skin and mucosa, no blausucht and no throat congestion. Chest development is normal, the respiratory sounds in both lungs were clear with no dry or moist rales. The heart beat is strong with regular cardiac rhythm and no obvious murmur in the valves. The abdomen was soft and flat with no masses or tenderness. The liver and spleen were normal, shifting dullness was negative, spinal column is normal and there is no edema of the legs.

Nervous System Examination:
Patient was alert and mental status was fine with clear speech and the memory, orientation and calculation abilities were normal. Both pupils were equal in size and round, diameter of 3.0mm, react well to light, there is no visual field loss but some horizontal nystagmus. Bilateral forehead wrinkle and nasolabial groove are symmetrical, she can make her tongue extend out as normal, there is no tongue muscle atrophy and showing the teeth was normal. The neck could move freely. Muscle tone of the 4 limbs were normal, muscle power of right arm was 5 degrees, the right leg was 4 degrees, right arm muscle power was 4 degrees, left arm muscle power was 2+ degrees. The feet dorsal stretch ability was weak. Tendon reflex of right body side was basically normal, of  the left arm was reduced and the left leg was active. The abdominal reflex could not be induced, the bilateral Palm-jaw reflex were negative. Hoffmann sign of both sides were negative, Babinski sign of both sides were positive, the bilateral ankle clonus were positive. Sensory examination was normal. Finger to nose test was not accurate or stable. Fast alternate movement of left side was clumsy, fast alternate movement of right side and finger to opposite movement were basically normal. Both sides Heel-knee-tibia test were normal. Romberg's sign was positive. She could not stand on one leg without support. She could not walk straight, the meningeal irritation sign was negative.

After the admission, she received related examinations and was diagnosed with Amyotrophic Lateral Sclerosis and diabetes (type 2). She received 3 times nerve regeneration treatment to nourish nerves, regulate her immune system and improve blood circulation. This was done with rehabilitation training.     

After 8 days treatment her muscle power got better. The muscle power of her left leg was 3 degrees, her walking position improved and her movement strength increased.

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