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Bruna - Spinocerebellar ataxia (Brazil) Posted on July 31, 2014

Author Julia Views Posted at 2014/08/04

Name: Bruna Regina Inocente

Sex: Female

Country: Brazil

Age:25 years

Diagnosis: Spinocerebellar ataxia

Date: July 04, 2014

Days Admitted to Hospital: 24 days

Before treatment:

The patient suffered from obvious gait disorders 3 years ago. She also suffered from walking disability and falls down suddenly. The symptom progressed gradually and aggravated gradually. The patient went to one hospital for gene test and was diagnosed with spinocerebellar ataxia ADCA type 3. Before the treatment, the patient's lower limbs had balance disorders. She couldn't stand with single leg. She could'take care of most of the activities of her life. The patient's mother and elder brother died of the disease. There was no other genetic disease.

Admission PE:

Bp: 125/80mmHg; Hr: 93/min, temperature: 36.8 deg. Height: 166cm, weight: 53Kg. The nutrition was normal. The skin was intact, with no stained yellow or petechia. Thorax was symmetrical. The breath sounds in both lungs were clear, with no dry or moist rales. Through auscultation, we discovered that the heart sounds were strong. The rhythm of heart was regular, Hr: 93/min, with no pathologic murmur. The abdomen was flat and soft, with no masses. The liver and spleen was not touched under the rib. There was no edema in either of the lower limbs.

Nervous System Examination:

Bruna Regina Inocente was alert. Her speech was not clear as before. Her memory, calculation ability and orientation were almost normal. Both pupils were equal in size and round, the diameter was 3.0mm. Both eyeballs could move freely and flexibly and the pupils were sensitive to light stimulus. There was no nystagmus. The vision and visual field were normal. The forehead wrinkle pattern was symmetrical. The bilateral nasolabial sulcus was equal in depth. The chewing ability of both sides was symmetrical and strong. The tongue was centered in the oral cavity and the teeth were shown without deflection. She could raise the soft palate normally. The uvula was shifted to left side. There was slight air leakage when she drummed her cheeks. The hearing ability was normal. She could shrug shoulders and turn head with strong and symmetrical muscles. The muscle strength of her four limbs was at level 5. The muscle tone of her four limbs was almost normal. Bilateral tendon reflex was active. Bilateral Babinski sign was positive. She has normal deep and shallow sensation. She completed the finger-nose test in a stable manner. She did the rapid rotation test in a clumsy manner. She did the heel-knee test in an unstable manner. If she closed her eyes, we pushed her, she had difficulty to maintain balance. She was unable to stand with single leg and unable to walk straight. There were no signs of meningeal irritation.

Treatment:

We initially gave the patient a complete examination and she was diagnosed with spinocerebellar ataxia. The patient received treatment for nerve regeneration and to activate stem cells in her body. Then we proceeded with giving nutritional treatment for the neurons. She also received treatment to improve the blood circulation in order to increase the blood supply to the damaged neurons and neural cells repair. We also gave her rehabilitation training.

Post-treatment:

The patient's speech is clearer than before. The active index of bilateral patellar tendon reflex has reduced. Bilateral Babinski sign changed to negative. She did the rapid rotation test in a rapid manner. She did the heel-knee test in a stable manner. If she close eyes, we push her, the balance ability has improved. She can stand with single leg and walk straight which is better now.

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