Name: Ashley
Sex: Female
Country: Argentina
Age: 29
Diagnosis: Cerebellar ataxia
Admission Date: September 18, 2012
Days Admitted to Hospital: 30 days

Before treatment:
The patient suffered from an unstable walk. This was accompanied with discontinuous dizziness. The patient was not pay attention to it and not received treatment immediately. Then the dizziness was relieved gradually. The patient felt sleepy and somnolence in April 2012. She went to the local hospital and was given an MRI examination, the result showed she had cerebellar atrophy and was diagnosed with Cerebellar ataxia. There was no special effect medication for treatment in the local hospital and it was suggested that the patient swim and exercise more. Before treatment, the patient mainly had spoken slowly and unclearly. The function of both upper limbs was almost normal. The lower limbs step was sound stage width. She walked unstably, shaking. She was able to go up and down stairs. She was able to walk for 30 minutes, but couldn't run.

Nervous System Examination:
ASHLEY was alert. Her responses were slower than normal. The speech was slow. The enunciating was occasionally not clear. The calculation abilities, orientation and memory were almost normal. Both pupils were equal in size and round, their diameter was about 3.0mms. Both pupils were sensitive to light stimuli. There was no nystagmus. The examination results of the vision and visual field were normal through coarse measurement. The bilateral forehead wrinkle pattern was symmetrical. The bilateral chewing was symmetrical and strong. The bilateral nasolabial groove was equal in depth. The teeth were shown without deflection. The muscles that raise the soft palate were strong. The uvula was in the center of the oral cavity. There was no air leakage when the cheeks were expanded. The tongue was centered in the oral cavity. The hearing was normal. The patient could turn the neck and shrug the shoulders strongly and symmetrically. The muscle strength of all four limbs was level 5. The muscle tone of all four limbs was almost normal. The bilateral biceps reflex, triceps reflex, radial periosteal reflex, patellar tendon reflex and ankle reflex were normal. The abdominal reflex was normal. The bilateral sucking reflex was negative. The bilateral Hoffmann's sign was negative. The bilateral Babinski sign was negative. The deep and shallow sensation was normal. When the patient closed her eyes, she could complete the finger-to-nose test, but in an unstable manner. She could complete the rapid rotation test normally. She could complete the heel-knee-shin test, but in an unstable manner. The Romberg sign was negative. The patient had difficulty with walking in a straight line, standing on the tips of her toes, standing on the heels and standing on one foot. There were no signs of meningeal irritation. Head MRI:(2012.4.13). The diagnosis was Cerebellar atrophy.

Treatment:
ASHLEY received all of the relevant examinations. She was clearly diagnosed with Cerebellar ataxia. The patient was given treatments in order to expand the blood vessels, to get rid of the anti-free radicals, and nourishment for the neurons. She also received treatment to repair the neural cells. This was combined with physical rehabilitation therapy.

Post-treatment:
The patient fell down when she was jogging. This hurt her left arcus superciliaris. The wound was about 2.5cm length and 0.5 deep. There was no foreign body in the wound. The patient was given antibiotics to prevent infection. Doctor changed her dressings regularly. At present, the wound has healed and the stitches have been taken out. ASHLEY's condition has improved. There is no longer any dizziness. The distance of both feet is normal when she walks, the gait is more stable. The enunciating is clearer than before. The responses are quicker than before. When the patient closes her eyes, she can complete the finger-to-nose test more stable than before, both sides can do the finger-to-nose test almost normally. The patient can walk in a straight line, stand on the tips of her toes, stand on the heels and stand on one foot better than before. She can stand on one foot for 5-15 seconds.

2012-10-24

Dear Dr. Terri,

After back from WSCMC, wijanni follow hospital treatment take a routine medicine.

Rgds,
Dony