Name: Keng Tang
Sex: Male
Country: Malaysia
Age: 57 years
Diagnoses: 1.Sequela of cerebral infarction 2. Diabetes mellitus 3. Hypertension (very high-risk group) 4. Pneumonia 5. Hypoproteinemia 6. Malnourished anemia 7. Syphilis 3 phase 8. Hypothyroidism 9. Liver and kidney dysfunction
Admission Date: 2013-04-03
Days Admitted to the Hospital: 27

Before treatment:
Suddenly 3 years ago, the patient suffered from dizziness, nausea and vomiting. Then the patient suffered from movement disorders of the left limbs. Then the patient received a CT examination of the head and was diagnosed with a stroke. The patient received medical treatment. 1 month later, the patient´s right limbs suffered from movement disorders too. Then the patient suffered from aphasia and was kept in bed. The examination showed the patient had severe vertebrobasilar artery stenosis, poor diet. The patient received diet through nasal feeding. He also received rehabilitation training. The movement of both upper limbs has improved obviously. He had pneumonia from aspiration of food. He was sent to the ICU many times. The motor function of the four limbs was obviously slow downed post pneumonia. He was fed his diet through a gastrostomy 2 years ago. Before the treatment, the patient was kept in bed, logagnosia, movement disorders of the four limbs, breathing difficulty and apnea during the night. He couldn´t take care of himself completely.

Medical physical examination: The nutrition of the whole body was poor, dyscrasia. The color of the skin over the whole body was faint yellow. The respiratory sounds in both lungs were rough, with obvious phlegm sound. The heart sounds were low and dull, with a regular rhythm, and no obvious murmur in the valve auscultation area. He had scaphoid abdomen and had a gastrostomy pipe. The location of fistulization was clean and dry, with no swelling, redness or exudation. The abdomen was soft. There was tympanitic note when we tapped the abdomen with a percussion hammer. There was no enlargement of the liver or spleen. There was edema in the eyelids, hands and hydrocele. There was a congenital absence in the second toe of the left foot fibular. There were multiple scars on both calves´ shins. There was a bedsore in the sacrococcygeal region; the diameter of the bedsore is 4mm. There was no sign of infection of the bedsore.

Nervous System Examination:
Keng Tang was alert. He breathes with an open mouth. He had dysarthria. The comprehension was still okay. He couldn´t cooperate with the examination of memory, calculation or orientation abilities. He had difficulty with self-care. The muscle strength of the closed left eye was weak. The right eye was blind. The strength of the closed right eye was strong. Bilateral pupils presented like needle point, the diameter was 1.5 mm. He had no response to light stimulus. There was no edema in the bulbar conjunctiva. He could blink eyes and the movement of the eyeballs was normal. There was no nystagmus.On the right of face lack of sweat and Corners of the mouth skewed to the right side. He had difficulty with showing teeth or tongue. The uvula was shifted to the right side. He had difficulty with swallowing and the chewing ability was weak. The left ear had hearing, but he was deaf in the right ear. The neck was soft. He could turn neck strongly, but couldn´t shrug shoulders. The muscle strength of the four limbs was level 0. The muscle tone of the four limbs was low. There was no contracture in joints. He had difficulty with turning over. The four limbs had sensation when acupuncture was applied. He couldn´t cooperate with the examination of sensation. The tendon reflex of the left upper limb was elicited normally. Other tendon reflexes have disappeared. The abdominal reflexes have disappeared. The bilateral palm jaw reflex was negative. The Hoffmann sign was negative. The Rossilimo sign was negative. The Babinski sign was negative. The meningeal irritation sign was negative. He had difficulty with other examinations. Head CT: obsolescence of cerebral infarction, brain atrophy, severe intracranial vascular arteriosclerosis. The blood routine examination showed he suffered from anemia. The blood sugar level was obviously increased and reached 15mmol/L. Thyroid function: the level of T3 and T4 were reduced. The blood gas analysis showed he had respiratory failure type 2.

Treatment:
According to the patient´s medical history and related examination, we gave the patient treatment to repair the damage to the neurons, improve the blood circulation in order to increase the blood supply to the damaged neurons, to nourish the neurons, nutritional support and control the blood sugar. We selected an antibiotic for anti-inflammatory according to the sputum culture. We gave the patient treatment to correct acid-base imbalance and anemia. We gave the patient treatment for supplementary thyroxine and protein. The patient also received treatment to keep bowels open, promote sputum discharge and other symptomatic treatment. The patient received non-invasive ventilator (mode BiPAP) to breathe.

Post treatment:
At present, the pulmonary infection has been cured. The blood sugar level is under control. The preprandial blood glucose is between 5-8mmol/L, the postprandial blood glucose is between 7-10mmol/L. There is no apnea sign. The blood gas analysis showed the improvement is obvious. He has better articulation abilities and can speak syllables of words. His right hand can make a fist slightly. The fingers of the left hand have a few movements. The thyroid function is better than before and the hypoproteinemia is not as severe. The electrolyte acid base disturbance has been corrected.