Discharge Summary from the doctor

October 3rd, 2008

Admission Conditions: Pancy complaints of vague words and unstable gait for 6 years. Nystagmus (+); Dystagmus present; finger to nose test (+), heel-knee-shin test (+). Unable to stand with feet together and eyes either open or closed; Tandem gait is impaired; Hypotonia of four limbs; Berg scores:41

 

Admission Diagnosis: Spinocerebellar Ataxia

 

In-hospital Conditions: Pancy has accepted four times Stem Cells transplantations altogether. One time Stem cells transplantations via IV (Aug 29 2008) and three times via Lumber puncture (Sep 3 2008; Sep 8 2008; Sep 12 2008) were completed and physiotherapy treatments were performed. Now, the patient can speak words much clearer and fluenter than before. finger to nose test expressed more accurate than before. Nystagmus (-), heel-knee-shin test(-).Pancy can control balance much better on walking.Berg Scores:47

 

                     Pancy mentioned that she has experienced cold feeling of  all toes for nearly 8 years. We ordered ultrasound for the arteries of both lower limbs which showed a angiosclerosis changes. After ST treatment, the condition improved a lot.

 

                     Related Lab tests were done completely. The results of Triglycerides, Cholestorol, HDL and LDL are all in normal range. The WBC account and Bacteria account were abruptly high in Urine test for 3 consistent tests. It was considered Asympomatic Bacteriuria since Pancy had no any symptoms.

 

Affiliated medical treatment:   Physiotherapy

 

 

Pathology Result:             N/A

 

Discharge Diagnosis:   1 Spinocerebellar Ataxia

                     2 Asympomatic Bacteriuria

                     3 Angiosclerosis of Both lower limbs

 

Treatment outcomes:    Much Improvement

 

Discharge Advices:     1 Keep physiotherapy rehabilitation

                     2 Continue the ST treatment in 6 months.

                                               

 

 

Entry Filed under: ataxia,Uncategorized

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