Yasir Eid B Alharbi-Multiple sclerosis-(Saudi Arabia)

Patient Name: Yasir Eid B Alharbi
Gender: Male
Age: 46 years
Nationality: Saudi Arabia
Diagnosis: Multiple sclerosis

Admission Condition:
The patient was admitted with the chief complaint of "progressive left-sided limb weakness for over 12 years and difficulty walking for over 1 year," diagnosed as "multiple sclerosis." He had a history of good health prior to this.

Physical Examination upon Admission:
The patient's blood pressure was 127/77 mmHg, heart rate was 60 beats/min, with normal development and moderate nutrition. There was no congestion in the oropharynx, and the tonsils were not enlarged. Cardiac, pulmonary, and abdominal examinations were unremarkable. Bilateral lower limb edema was noted.

Neurological Examination:
The patient was alert and in good spirits. His speech was clear. Memory, calculation, and orientation were normal. Both pupils were 3 mm in diameter, with a brisk light reflex, and there were no visual field defects. The nasolabial folds were symmetrical, and his tongue was midline. He showed strong elevation of the soft palate. Neck mobility was normal. Muscle strength in the proximal left upper limb was grade 3, while distal muscle strength and grip strength were also grade 3; left shoulder joint elevation was limited, with abduction of only about 90 degrees. The muscle strength of the right upper limb was approximately grade 4. Muscle strength in the left lower limb was grade 2, with the left lower limb unable to lift off the bed; the right lower limb strength was approximately grade 4. Muscle tone in the left lower limb was slightly elevated, with the rest being normal. The patient had difficulty standing and walking and required assistance for slow, short-distance ambulation. Tendon reflexes in his all four limbs were slightly hyperactive. Pathological signs were positive in his left lower limb. Skin temperature in the left ankle was elevated. The patient exhibited diminished pinprick sensation on the left side of the body. The left-sided finger-to-nose and finger opposition tests were unsteady and clumsy, while the right side showed acceptable performance. He tested positive for the inability to stand with eyes closed. Meningeal signs were negative.

Treatment Process:
The patient was diagnosed with "multiple sclerosis." He received inpatient treatment for 2 weeks, including mesenchymal stem cell therapy to modulate immunity, neural stem cell therapy to repair nerve axons and myelin lesions, supportive medication with CAST therapy, and comprehensive rehabilitation treatment.

Post-Treatment:
The patient showed significant improvement in mental state and limb strength. Proximal muscle strength and grip strength in his left upper limb improved to grade 4, with a significant increase in the range of motion of the left shoulder joint to 135 degrees; muscle strength in the right upper limb was nearly grade 5. Muscle strength in his left lower limb improved to grade 3, while the right lower limb strength remained at nearly grade 5. Overall muscle strength increased by 20-30%. Pinprick sensation on his left side of the body returned to approximately normal. Skin temperature in his both lower limbs was essentially consistent. Standing and walking functions improved significantly, with a remarkable increase in walking distance.