James Dodds-Multiple sclerosis-(Canada)

Name:James Dodds                 
Sex: Male
Country: Canada
Age: 43
Diagnosis: Multiple sclerosis
Date: March 24, 2014

Before treatment:
The patient suffered from dead limb and astriction 8 years ago, without obvious incentive. The symptoms persisted with no remission. He went to a local hospital and received MR examination, he was diagnosed with multiple sclerosis. About 6 years ago, patient started intramuscular injections of interferon beta but his condition had no obvious improvement. About 3 years ago, the patient's left eye suffered from blurred vision and dyschromatopsia. 6 months later, the patient's right eye had the same symptoms too. He also had balance disorders and he easily get fatigue. He started to take oral Gilenya 1 month ago, the effect have not been good.

From the onset of disease, the patient had normal spirit. He lost his appetite for 6 months, the sleep was almost normal. He had constipation, the urination was normal. His weight was reduced to about 20 pound.

The patient's elder sister suffered Multiple sclerosis too. There was no other familial hereditary disease.

Admission PE:
Bp: 138/86mmHg; Hr: 64/min. The development and nutrition were normal. The thorax was symmetrical. Through auscultation, the respiration in both lungs was clear, with no moist rales. The heart sounds were strong, and the rhythm of heart was regular, with no obvious murmur in valve auscultated area. The abdomen was even and soft, with no palpable masses.

Nervous System Examination:
James Dodds was alert with good spirit. He speaks fluently. His memory, calculation abilities and orientation were all normal. Both pupils were equal in size and round, the diameter was 3mms. Both pupils reacted normally to light stimulus. There was no visual field defect in both eyes. There was no nystagmus. His eyes had blurred vision. There was no focusing when he looked straight into other people's eyes. Through course measure: right eye could distinguish number of fingers from 80cm. Left eye could distinguish number of fingers from 20cm. The grounding color was orange when he looks at object. He also unable to distinguish colors when brought closely. Fundus examination showed the border of optic nerve head was clear, the color was pale. The arteriovenous proportion was 1:3. The forehead wrinkle pattern was symmetrical. The bilateral nasolabial sulcus was equal in depth. The tongue was centered in the oral cavity and the teeth were shown without deflection. There was non-uniform atrophy in the tongue. The uvula was centered. The neck could move freely. The muscle tone of his four limbs was normal. The muscle strength of his four limbs was at level 5. The abdominal reflexes existed. The tendon reflex of both upper limbs reduced slightly. The tendon reflex of both lower limbs was normal. The sucking reflex was positive. The jaw reflex was positive. Bilateral palm jaw was positive. Bilateral Babinski sign was positive. The tuning fork vibration sensation and pinprick sensation was slow down. Other sensation through examination was normal. He was able to do the finger-to-nose test, the digit opposition test and rapid rotation test in an almost normal manner. The coordinate movement of both lower limbs was not flexible. The Rornberg sign was weak positive. He couldn’t stand with single leg. There was no meningeal irritation sign.

Treatment:
James Dodds received a complete examination after his admission. He was diagnosed with multiple sclerosis and hyperlipidemia. He received treatment for nerve regeneration and to activate stem cells in the body. He was also given treatment to expand the blood vessels in order to improve blood circulation and nourishment for the neurons. He received treatment to enhance the body's resistance. This was combined with physical rehabilitation training.

Post-treatment:
He can distinguish close colors more quickly. He looks at objects more clearly now. He has obvious focus when he look at others. Through course measure: right eye could distinguish the number of fingers from 1.2 meters, left eye could distinguish number of fingers from 80cm distance. Balance exercises:  there is almost no Romberg sign. He can stand 5-8 seconds with single leg. His walking gait is more stable than before. Feeling aspects: the tuning fork vibration sensation and pinprick sensation of both lower limbs has regain about 50%. The left lower limb gain more sensation as compared to the right lower limb.