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Gastler Josy - Type 2 diabetes (Mexico) Posted on August 11, 2014

Author Admin Views Posted at 2014/08/27

Name: Gastler Josy         

Sex: Male

Country: Mexico

Age: 69 years

Diagnoses:1.Myeloradiculopathy syndrome 2. Syphilis 3. Type 2 diabetes

Date:June 28, 2014

Days Admitted to Hospital: 21 days

Before treatment:

The patient suffered from pain of both lower limbs 27 years ago without obvious inducement. He suffered from limp. The disease was aggravated gradually and damaged both upper limbs. He went to a local hospital and the image showed he suffered from degenerative osteoarthropathy. He was diagnosed with Myeloradiculopathy syndrome. With progress of disease, the pain of his four limbs was more severe. He suffered from muscle atrophy and received three times operation in lumbosacral region. After operation, the patient's disease still aggravated. About 20 years ago, the patient lost the ability to walk. He needed wheelchair in his daily life. He received 2 times operation to reduce pressure for his carpal canal in 1999 and 2011. He received neck operation 8 years ago. He had heart disease for the past 12 years. He was implanted with cardiac pacemaker 12 years ago. He had changed the pacemaker for two times. The last time he changed the pacemaker was 2011. The patient took digoxin, carvedilol, spironolactone and furosemidum for 12 years. The patient was diagnosed with Type 2 diabetes in 2002. He took glybenzcyclamide for many years, and the blood sugar level was under control. Before the treatment, he took glybenzcyclamide but was not regular and did not monitor blood sugar. He suffered from Benign Prostatic Hyperplasia for the past 8 years and took terazosin for therapy.  The patient took nitrofurantoin tablets in recent years and the reason was unclear.

There was no infectious disease, such as hepatitis or tuberculosis. There was no history of blood transfusion. There was no drug allergies. From onset of disease, the patient had poor sleep quality and sleeps 3-4 hours every day. Both lower limbs had involuntary twitch. He had bad control of urine. He needed great effort for defecation and defecates every 5-6 days. There was no family infectious diseases.

Admission PE:

Bp: 135/78mmHg; Hr: 80/min. Temperature: 36 degrees. The oxygen saturation was 95% to 98%. The development and nutrition was normal. Thorax was symmetrical. Through auscultation, the respiratory sounds in both lungs were clear with no signs of dry or moist rales. The heart sounds were low and dull, the cardiac rhythm was regular, with no murmur in the valves. The abdomen was flat and soft, with no masses. There was mild concavity edema.

Nervous System Examination:

Gastler Josy was alert and his spirit was good. The examination of memory, calculation and orientation were almost normal. Both pupils were equal in size and round, the diameter was 3.0mms. Both eyes were sensitive to light stimuli. Both eyeballs could move freely to each side. Right eye was unable to close. But left eye had strong muscles to close. The forehead wrinkle pattern was symmetrical. The bilateral nasolabial sulcus was equal in depth. The tongue was in the center of oral cavity. There was no atrophy in tongue. The neck could move freely. The muscle strength of both upper limbs was at level 5-. The hold power of both hands was at level 4. The muscle strength of both lower limbs was at level 1. The muscle tone of for limbs was almost normal. There was paroxysmal convulsive seizure in his far-end four limbs'. The abdominal reflexes disappeared. The tendon reflex of both upper limb was normal. The tendon reflex of both lower limbs was slow down. The Babinski sign of left lower limb was positive. The Babinski sign of right lower limb was positive. The deep sensation and shallow sensation of both lower limbs was slow down. Other deep and shallow sensation existed. Both lower limbs couldn't finish coordinate movement. Both upper limbs was able to finish the finger-to-nose test, rapid rotation test and point thumb with other fingers normally. There were no signs of meningeal irritation.

Treatment:

We initially gave Gastler Josy a complete examination, and he was diagnosed with Myeloradiculopathy syndrome. The patient received treatment to nourish the neurons and improve the blood circulation in order to increase the blood supply. He received treatment for nerve regeneration and to activate stem cells in vivo. He also received treatment to stabilize his blood sugar and blood pressure, improve organ function and enhance his immunity. This was accompanied with rehabilitation therapy.

Post-treatment:

The numbness and pain at his four limbs is alleviated obviously. The involuntary twitch of both lower limbs is alleviated. The muscle strength of both lower limbs has increased to level 2. Both lower limbs can move in bed surface. The knee joints can lift bed surface. The spirit and mood are more stable than before. The sleep quality is better than before. He can sleep 6-7 hours in the night. He can control urine better in daytime. He can urinate in daytime without urinary catheterization discontinuously. The defecation function is better than before, and the patient had defection every 1 or 2 days. The patient's condition is better than before.
 

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