Lim Gyesik-Ataxia,Cerebellar Atrophy-(Korea)

Name: Lim Gyesik 
Sex: Male
Nationality: Korean
Age: 56Y
Diagnosis: Ataxia, Cerebellar Atrophy
Discharge Date: 2018/06/22

Before treatment:    
The patient showed balance problems 4 years ago. He also had vision problems so he went to a local hospital and did an MRI. The result showed no abnormality in his brain and the doctor provided him a diagnosis based on his symptoms. He was diagnosed with ataxia. He did a brain MRI 3 years ago and the result showed mild cerebellar atrophy. 2 years ago he found it hard to speak. In the last year his condition got worse rapidly, he had balance problems, his speech was unclear and he felt dizzy. At present he has bad balance function even when he is standing, he can’t move his arms well but he can still dress himself, brush his teeth and wash his face. He can eat normally, his speech is unclear and slow and his vision function is worse than before.
His spirit is bad and he has sleep apnea so he uses a  non-invasive ventilator when he sleeps. His diet is normal, he has problems with urination and defecation. 
 
Admission PE:
Bp: 170/100mmHg, Hr: 70/min, There is no injury or bleeding spots of his skin and mucosa, no blausucht, no throat congestion and no tonsil swelling. 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 with no obvious murmur in the valves. The abdomen was soft and flat with no masses or tenderness. The liver and spleen were normal with no edema in the legs.

Nervous System Examination:
Patient was alert, has a mild slur in his speech but he can speak slowly.  The memory, orientation and calculation abilities were good. Both pupils were equal in size and round, diameter of 2.5 mm, react well to light and the eyeballs can move freely. The color vision was normal. The eyesight examination using a 3m chart: eyesight 0.6; left side was 0.5, right side was 0.4. Bilateral forehead wrinkle and nasolabial groove were symmetrical. He can make his tongue extend out and show teeth as normal. Chewing ability was normal, there is no tongue muscle tremor, his tongue can touch the cheek powerfully and he could bulge the cheeks powerfully without air leakage.  The muscle power of the arms and legs was 5 degrees. He could walk slowly with a wide step. The arm and leg muscle tone was normal. The 4 limbs tendon reflex and  leg patellar tendon reflex were active. Bilateral Hoffmann sign and Babinski sign were negative. His sensory examination was normal. Finger to nose test was not stable, his fast alternate movement was clumsy. Patient could perform the finger opposite movement slowly, the heel-knee-tibia test was clumsy, the Romberg sign was positive, he could not stand with one leg. The meningeal irritation sign was negative.

Treatment:
After the admission he received related examinations and received 3 nerve regeneration(neural stem cells and mesenchymal stem cells) treatments to active stem cells, repair his damaged nerves, replace dead nerves, nourish nerves, activate nerves, regulate his immune system and improve blood circulation. This was done with rehabilitation training.     

Post-treatment:
After 14 days treatment he spoke better and clearer, his balance control improved and his hands could perform the fast alternate movement in a much more flexible manner. The heel-knee-tibia test was much more stable, his gait was much better, he could stand with one leg for 30 seconds and he walked better and faster.

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