Name: Adam Niyaz
Sex: Male
Nationality: Maldivian
Age: 46Y
Diagnosis: Amyotrophic Lateral Sclerosis (ALS) 
Discharge Date: 2019/06/28

Before treatment:
A year and a half ago the patient had no inducement to have unclear speech, low voice and a weakened swallowing function which gradually aggravated within two months. Therefore he went to a hospital in India and found there was no abnormality after the examinations of a brain CT, MRI and so on. The doctor did not give a definite diagnosis. A year ago he began to develop tremors in the scapular muscle, intercostal muscle, chest muscle and right arm muscle bundle so he went to South Korea to see a doctor. He was treated with acupuncture and moxibustion. The swallowing function was slightly improved and the progress of muscle atrophy of the right limb was accelerated before 2 months so he then went to Thailand to see a doctor. After various tests it was clearly diagnosed as "amyotrophic lateral sclerosis". Weakness began to appear in the right leg a month ago. After an intravenous injection of Edaravone 10 days ago the patient could not complete the fine movement of the right hand and the muscle atrophy was more obvious.
He has good sleep and mental condition, his urination and defecation functions are normal. He has had a  weight loss of about 8kg.

Admission PE:
Bp: 137/86mmHg, pulse rate: 83/min, breathing rate 19/min, height 168cm, weight 62.5kg, body temperature: 36.3 degrees. The patient has good nutrition status and normal physical development. There was no ecchymosis of the skin or mucosa, no congestion of the throat and no swelling of the tonsils. He had a symmetrical chest, clear respiratory sounds of both lungs, no dry or moist rales heard, regular heart sounds, regular heart rhythm, a heart rate of 83/min and no obvious murmur heard in valves. He had a soft abdomen with no tenderness and masses, normal liver and spleen and no edema of the legs.

Nervous System Examination:
The patient was alert, had good spirit, slurring of speech, normal memory,  calculation and orientation abilities. Both pupils were round and equal in size, with a diameter of 3 mm and reacting sensitively to light. There was free eyeball movement, no nystagmus, poor convergence of the left eye and strong eyes-closing. He had symmetrical forehead wrinkle and nasolabial fold, disabled cheeks-bulging, the tongue can only reach to the lips with atrophied muscle and inflexible movement. There was weak soft palate-lifting power, right deviation of the uvula, weak pharyngeal reflex, weak shrug and weak neck-turning. Muscle power: left arm 5-; left gripping power 4+; proximal end of right arm 3; distal end of right arm 3-; adductor 3+; abductor 3-; right gripping power 3-; right leg 4; left leg 5-. There was normal muscle tone of the 4 limbs, mild muscle atrophy in biceps brachii, triceps brachii, deltoid, ulnar muscle groups, hypothenar, thenar and interphalangeal muscle groups. Normal tendon reflexes of the 4 limbs, positive Hoffmann sign and Rossilimo sign bilaterally, negative Babinski sign bilaterally, normal deep and shallow sensation by gross examination. He had unremarkable fast alternate and finger to nose movement on the left, finger to finger movement only accomplished with little finger on the left and only the index finger and middle finger on the right. Finger to nose and fast alternate movement cannot be done due to muscle power problems. Normal heel-knee-tibia test was performed bilaterally and there was a  negative meningeal irritation sign.

Treatment:
After the admission he received 3 nerve regeneration treatments (neural stem cells and mesenchymal stem cells) to repair his damaged nerves, replace dead nerves, nourish nerves (ganglioside, nerve growth factors and neurotrophic factors), improve body environment (Edaravone and Riluzole ), regulate his immune system and improve blood circulation. This was combined with rehabilitation training.   

Post-treatment:
After 14 days treatment his respiratory function got better- br: 17-20/min,
oxyhemoglobin saturation is 97-99%. His swallowing and tongue extension movement got better, choking when drinking reduced and articulation got clearer.The muscle power of the right limbs increased, he could grasp easier and raise his right leg easier, his legs were more flexible and he could walk better, his exercise tolerance was improved and he now walked longer.