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TBI Female, 46 years old, Jul – Aug 2018

Summary

DiagnosisSexAgeNationality
Traumatic Brain InjuryFemale46Brazil
Admission dateDischarge date
2018-07-092018-08-02

Condition On Admission

The patient’s chief complaint was of weakness in all four limbs for more than 20 years. Patient first noted he had a weakness in both his upper limbs in 1987, which was especially evident in his handwriting. The weakness progressively got worse over time. In 1994, he noticed he had problems walking up and down stairs and would trip over himself from time to time; an MRI confirmed a diagnosis of Ataxia. On physical assessment upon hospital admission he was found to have low muscle tone in all limbs with muscle power of 5/5. Coordination tests such as finger-to-nose and heel-to-tibia showed poor coordination and the patient was unable to walk heel-to-toe. Routine examination showed no other abnormalities.

Treatment Schedule

NumberDateCell TypeDelivery MethodSide Effects

Condition 1 month after treatment

Condition 1 months after treatment: ​The patient reported significant improvements at one month after his treatment. He stated, “[I] can walk heel to toe, can do the balancing exercise for longer periods of time, can go up and down stairs with no hands.” He also made comments about the importance of continuing to do daily exercise and how it is becoming easier but also feels that the exercises are essential to aiding his continued improvements.

Condition 12 months after treatment

Condition 12 months after treatment: ​At the 12 month follow up point the patient reported that he was satisfied with the outcome of his treatment which has improved his quality of life and given him moderate improvements overall in his physical condition.

Symptom

Parents’ Assessment of Improvement

Balance

Moderate improvements

Coordination

Moderate improvements

Fine hand movements

Small improvements

Tremors

Not applicable

Control of movement

Moderate improvements

Muscle stiffness

Not applicable

Speech

Moderate improvements

Walking

Moderate improvements

Fatigue

Small improvements