Overview of medical reports (neurologists), sorted by date, as of: 03/27/2023

December 16, 2020, Mannheim, Germany – Radiology, MRI

Magnetic resonance imaging of the skull in T1- and T2-weighted images

sequences; transverse, coronal and sagittal incisions

Clinical indications:

Left corporal movement disorder, discrete tremor and left hand hypokinesis

and left leg, excluding structural lesion or degenerative process.

Findings:

Proper position of centerline structures. Regular demarcation of Mark and

Bark. Age-appropriate width of the inner and outer liquor spaces.

The basal ganglia, internal capsule and both thalami are unremarkable.

The brainstem and cerebellum show proper conformation and signaling.

Mucosal swelling of the maxillary sinus on the right. Unobtrusive representation of

Orbitae and petrous bones on both sides. The pituitary is not enlarged, the

Pituitary stalk is medial.

Judgement:

Normal visualization of the brain parenchyma. mild maxillary sinusitis on the right.

Investigation:

MR angiography of the skull in time-of-flight technique (TOF)

Findings:

Dominant vertebral artery on left compared to right, otherwise normal

Flow signal of the detected portions of the ACI, ACA, MCA, PCA, BA . No evidence for

Stenoses, occlusions or aneurysms.

Judgement:

Normal TOF of the intracranial arteries.

January 21, 2021, Mannheim, Germany – Radiology – DatScan

Clinical information: Clarification of an increase in tone in the left arm DD

Parkinson's syndrome. Dopa test was negative

SPECT study of striatal dopamine reuptake

Injection of 184 MBq Iodine 123 FP-CIT

Indication: Parkinson's syndrome.

Visual Findings:

There is a strong storage in the Caput nuclei caudati on the left, less in the

side comparison on the right. Bds. shows an amputation regarding the

Nuclide storage in the putamen where the occipital part is more obvious on the left than

right shows missing nuclide storage. Storage in the thalamus as an indication of

advanced disease.

Semi-quantitative evaluation:

Ratio striatum/occiput left = 1.8

Judgement:

right = 1.7 (rough normal value 2.5-2.7)

Both the visual aspect and the standardization with reduction of the

Dopamine transporter in the right Caput nuclei caudati and in the putamen on both sides: here is one

slight left emphasis, indicate a neurodegenerative

disease such as Parkinson's disease.

March 18, 2021, Hattingen, Germany – Clinic for Neurology

Dear Mrs,

dear colleague,

We report on the above-mentioned patient, who is here on March 18, 2021 in

presented to our outpatient clinic.

Mr. P. reported that he had one for the first time around spring 2020

Noticed changes in the motor function of the left half of the body, including in

form of cramping of the toes on the left side. In the summer of 2020

there was also a left-sided fine motor impairment. As part of

a neurological consultation, the diagnosis is a probable one

Parkinson's disease has been placed, which ultimately includes a

I have confirmed the DATScan that has been carried out. He also has LDopa for a few days

taken, but this ended again due to ineffectiveness.

Upon closer enquiry, it turns out that the dosage

was only 2 x 50 mg levodopa.

In addition, there have been problems sleeping through the night for a long time

also a slight depression, he takes 2 mg Circadin for this

in the evening. The smell is good, the bladder and intestinal motor skills

stated as undisturbed.

Relevant previous illnesses are denied.

Current medication: Circadin 2 mg in the evening, as well as various dietary supplements

such as vitamins Bund D and on the part of the

Substances prescribed by naturopaths, among other things, to strengthen the mitochondrial

Function.

Mental Findings: Alert, conscious and oriented. mnestic

and cognition intact. Mood and drive balanced. No clue

for content or formal thought disorders. No indication of current

Danger to self or others.

Neurological findings: no hypomimia, no dysarthria, no evidence of cranial nerve disorders.

Discreet postural tremor on the left. Bradydysdiadochokinesis on the left, reduced tapping on the left. left side

rigor. Slightly bound posture on the left side, brisk walking, reduced arm swing on the left, also subjective

not as fluid and loose on the left as on the right. No indication of paresis, no indication of sensory disturbances.

Assessment: Taking into account the anamnestic information and the current clinical-neurological impression, Mr. P. has Parkinson's syndrome with left-sided motor symptoms as mentioned above. Today's understanding of the disease was detailed

discussed with a focus also on the premotor disorders and the importance of gut and

microbiome. In this context, the special complementary concept of our

Department discussed and ultimately the implementation of inpatient complex therapy and drug

Setting recommended to achieve the best possible symptom reduction and achievement

a good quality of life and a favorable long-term prognosis. Mr P. wanted this

first think again and then, if necessary, come back to make an appointment

report us.

April 30, 2021, Tübingen, Germany – University Clinic for Neurology

We report on the presentation of the above patient.

Diagnoses:

1. Sporadic parkinsonian syndrome of the equivalent type, first manifestation: 2020, first diagnosis:

2021, emphasized on the left

MRI: unremarkable

DaTSCAN 01/2021: presynaptic dopaminergic deficit right> left

Anamnese:

Mr. P. introduces himself to me for the first time. He reports that in 2020 he initially had cramps during sports training

of the left foot to have noticed. In the course of this, the fine motor skills will also gradually improve

left hand and fingers have been increasingly restricted. He noticed an aggravation of the symptoms

under cold and stress. He would feel more comfortable, especially when it was warm. In the course then also be a

Tremor at rest on the left side.

With regard to non-motor symptoms, he reports problems sleeping through the night. Also his mood

be partly restricted. The cognition is normal. No evidence of REM sleep behavior disorder. discrete

hyposmia. No constipation. No urge to urinate.

A cMRI had been unremarkable with no structural evidence for a secondary genesis. The DaTSCAN examination

from January 2021 showed - matching a sporadic Parkinson's syndrome - a presynaptic one

dopaminergic deficit right> left with emphasis on the putamen.

The family history is positive. The paternal aunt also suffers from Parkinson's syndrome.

So far no Parkinson's-associated medication.

Non-medicinally, he carries out Traditional Chinese Medicine as well as curative practical exercises. Also

he was active in Qigong.

Clinical-neurological examination findings:

Alert, well-oriented patient. Friendly towards. No meningism. No aphasia. No dysarthria.

Discreet hypomimia. Cranial nerve status downright. No manifest or latent paresis. Under

Co-nervation slight rigidity on the left side. slight hypobradykinesis on the left side. Discreet rigor with aggravation

during concentration exercises. No dystonia. Muscle reflexes can be triggered medium-lively on the same side.

Getting up from the chair is smooth. Gait pattern fluent with discreetly propulsive posture as well

reduced swinging of the left arm. No postural instability. standing and gait tests.

Surface sensitivity stated intact on same side.

Further additional examinations:

Montreal cognitive assessment {MoCA): 26/30 points, normal findings

Beck's depression inventory (BDl-2): 5 points, normal findings

Assessment and procedure:

In the synopsis of the anamnesis and the clinical-neurological examination findings, a sporadic one appears

Equivalence-type Parkinson's syndrome emphasized on the left. Secondary causes arose in the structural

supplemental cMRI imaging does not. Consistent with a neurodegeneratively associated Parkinson's disease

Syndrome shows a slight hyposmia. The presynaptic dopaminergic deficit is also right >

on the left in the DaTSCAN examination supporting diagnosis.

In terms of therapy, we discussed the possibility of therapy with AZILECT 1 mg 1-0-0. Mr P wanted

are still considering when exactly they want to start medication. We discussed the concept

that in the context of Parkinson's disease, especially in the case of clinically relevant limitations

Medication as early as possible can make sense to support the dopaminergic system.

In addition, we discussed the importance of regular, self-motivated physical activity,

as in the context of current Qigong activities, but also gladly supplemented by ergotherapy and physiotherapy

to promote mobility and fine motor skills, especially with regard to the long-term course of the

Illness.

Due to the positive family history and the young age of onset, we discussed the indication

for human genetic testing for possible gene variants that are causal or associated

with present Parkinson's disease. This can certainly result in new cause-specific

Therapy options result.

July 26, 2021 - Findings of molecular genetic diagnostics (Practice for Human Genetics, Tübingen)

No evidence of variants that, on the basis of the current data, the disease of your

Confirm patients molecularly.

However, this does not mean that a genetic disease is present

excluded.

e No genomic gains or losses were found which, according to today's

state of knowledge as likely to be the cause of your patient's disease

can become.

Suspected one caused by pathogenic changes in the studied genes

Parkinson's disease could not be confirmed molecularly in your patient.

Variants in unexamined areas of the analyzed genes (e.g. introns, untranslated regions

(UTRs), promoter or enhancer), in regions with multiple copies of high sequence homology, repeat

Expansions and copy number changes of individual exons or of an entire gene cannot

reliably recorded and therefore cannot be ruled out. Furthermore, mosaics with low

Frequency component cannot be reliably recorded and therefore cannot be ruled out either. variants that

classified as benign or probably benign based on current data are not

listed. Although unlikely, it is also possible that new

scientific knowledge, the assessment of the pathogenicity of variants at a later date

time could change.

If you would like further diagnostics for your patient, you are welcome to contact us

to contact.

According to § 1 O Gen DG, every diagnostic genetic examination should be accompanied by the offer of a genetic

accompanied by advice.

ADDITIONAL INFORMATION

examined

regions

methods

CHCHD2, GBA, LRRK2, SNCA, VPS35 (Parkinson's disease, autosomal dominant)

ATP13A2, DNAJC6, FBXO7, PARK7, PINK1, PLA2G6, PRKN,. SLC30A10, SYNJ1, VPS13C (Parkinson

disease, autosomal recessive)

ATP13A2, ATP1A3, C19orl12, CHCHD2, DCTN1, DNAJC12, DNAJC6, FBXO7, FTL, GBA, GCH1, GRN,

LRRK2, MAPT, PANK2, PARK7, PINK1, PLA2G6, PRKN, PRKRA, SLC30A10, SLC39A14, SLC6A3, SNCA,

SPG11, SPR, SYNJ1, TH, VPS13C, VPS35 (Parkinson's disease)

Sequencing: The coding regions and the adjacent intron regions were identified using in-solution hybridization

Technology enriched and then using high-throughput sequencing on the lllumina

Analyzed HiSeq/NovaSeq System. At least one rare variant has been identified using traditional Sanger

Sequencing post-sequenced and in this way in an independent approach by a second method

confirmed.

NGS-based CNV calling: CNVs (copy number variations) were based on sequences that were unique

could be assigned to a genomic position using an internally developed method

calculated based on the depth of the sequer. Reference samples were used to model the

expected· coverage that includes both possible deviations in laboratory process and variation

generally reflected between samples. CNV calling was performed by normalizing the

Coverage of each sample and its deviation from the expected coverage were calculated. genomic

Regions are designated as variant if they deviate significantly from the expected coverage.

Please note that next-generation sequencing-based detection of

· Copy number changes have a lower sensitivity/specificity than· MLPA, for example.

Whenever possible, all reported CNVs were validated using a second method. As part of the

Findings that do not report CNVs ultimately do not guarantee the general absence of CNVs.

Bioinformatics: The sequencing data were processed with lllumina bcl2fastq2. co-sequenced

Adapter sequences were removed with the skewer and the resulting sequences with the Burrows Wheeler

Aligners aligned against the human reference genome (hg19). Sequences that are not unique to a genomic

position have been removed, as have duplicate sequences likely due to the

are due to amplification. The remaining sequences were high quality

Sequence variants (single nucleotide substitutions and short insertions/deletions) determined. These were with

annotated in various internal and external databases.

Genetic data analysis: The classification of variants is based on the. ACMG/ACGS-2020v4.01

Guidelines (Richards et al., 2015, PMID: 25741868, https://www.acgs.uk.com/quality/best-practice-guidelines/).

Only variants (SNVs/Small lndels) with a population frequency (MAF) < 1.5% within the

coding regions as well as in flanking intronic regions (±8 bp). Known disease triggers

Variants (according to HGMD) are scored in flanking regions up to ±30 bp and up to a MAF < 5%.

Population frequencies are based on public databases (e.g. gnomAD) and an internal database

determined. Our quality criteria require an informative sequencing depth by means of non-achievement

High-throughput sequencing local re-sequencing using conventional Sanger technology.

All CNVs relevant to the given case and identified according to the above procedure are manually

evaluated. Potentially pathogenic results may be evaluated with a second diagnostic method, such as

e.g. MLPA, validated.

In the present case, a sequencing depth of at least 30X for> 99.9% was achieved using high-throughput sequencing

of the coding areas. Clinical information was used to assess the variants

used, which were available to us at the time of the evaluation. Only variants that

were not classified as benign or probably benign according to the current data. In the

si/ico prediction of the variants listed in the table is based on the individual results of the programs

Mutation Taster, fathmm, Mutation Assessor, SIFT, fathmm-MKL coding, LRT and PROVEAN calculated as follows:

100% agreement = "pathogenic" or "benign"; 2c 75% agreement = "predominantly pathogenic" or

'predominantly benign'.', agreement < 75% or no prediction possible= 'inconsistent'. For classification

the effect of a variant on splicing, SpliceAI is used (cutoff 0.8-1 "splice effect", 0.6-0.8

"Possibly splicing", <0.6 "No splicing"; Jaganathan et al., 2019, PMID: 30661751). For the

Prediction of splicing effects with missense changes only values >0.8 are taken into account. In individual cases

this prediction can be supplemented by additional in silico predictions.

The nomenclature of found variants follows the guidelines of the HGVS, but without taking into account the

allelic assignment of individual variants, since this is usually not known.

The sample has the quality criteria that apply to us after the sample has been received and the respective analytical

processing steps in the laboratory are complied with.

The procedure described above is an in-house developed and validated test

(Laboratory developed test; LDT).

July 21, 2021, Munich, Germany – Clinic for Neurology on the right side of the Isar

We report on your presentation in our outpatient clinic on July 21, 2021.

Diagnoses: Left-biased idiopathic parkinsonian syndrome of the equivalent type (EM

2020, ED O1 /2021)

- Diagnostic certainty according to modified MDS criteria 2015: clinical

probably

- Hoehn and Yahr Stadium currently: 1.

Epicrisis/Procedure:

The first presentation in our outpatient clinic for movement disorders

took place with regard to possible participation with regard to process-modifying

Studies in known Parkinson's syndrome.

They reported that earlier this year the Va on a

Parkinson's syndrome had been asked, a DAT scan had a match

showed presynaptic dopaminergic deficit (right > left), had a cMRI

showed an unremarkable finding. Because of the boy

Age of onset was recently a blood sample for human genetic

Investigation is ongoing, results are pending. initial

did you initially have increasing cramps in the area of the left

foot after a long period of exertion as well as in the course also one

Impaired fine motor skills in left hand noted. in the course

I've also noticed a tremor in my left hand in places

made. You would have taken L-DOPA for 3 days (dose 150mg/d), with

discontinued due to lack of effectiveness. Last was rasagiline

been recommended, which you had been taking for 2 days initially

but didn't want to take it any further. Currently you would several

Preparations (Mannitol, PS128 (intestinal bacteria), Reishi mushrooms (Linghzi)), to

which studies regarding a course-modifying effect in the

Parkinson's disease would be conducted outside of clinical trials

take in. You wouldn't do physiotherapy at the moment, you

be very active in sports (including qigong, rowing, cycling,

Yoga). Evidence of autonomic symptoms or REM sleep behavior disorder

did not arise. They expressed that temporary

a slight depressive mood existed, the diagnosis as well

You continued to worry about future prospects. Further

Previous illnesses are not known, there is no previous medication.

Physical examination showed a left-sided accent

Akinetic-rigid syndrome with transient mild tremor at rest (MDS

UPDRS III current: 18 points). Stigmata of an atypical

Parkinson syndromes were not found.

In summary, we also go from an idiopathic

Equivalence-type parkinsonian syndrome, indications of an atypical one

Parkinson's syndrome was not found overall. Regarding one

drug therapy, we recommend starting therapy with

Rasagiline according to the schedule below. The use of a dopaminergic

Medication in the early course of the disease is not at an increased rate

associated with side effects or a faster progression. Regarding the

Use of study drugs outside of clinical studies and

thus missing monitoring of side effects, we see this extremely

critical, as severe side effects can occur in places. From

an uncontrolled intake of preparations outside of clinical

Overall, we strongly advise against studies.

With regard to the study drug Fasudil, a corresponding

Reservation made.

We thank you for the idea and are happy to answer any questions

Disposal.

Procedure:

- Attempted therapy with rasagiline 1mg 1-0-0. Please regarding MAO

, inhibitor interactions and contraindications in case of addition

other medications (esp. SSRI, SNRI, tri-, tetracyclics,

other MAO inhibitors, St. John's wort preparation, pethidine).

- Regular physiotherapy with the implementation of large-scale exercises

Movements, for example, as part of the BIG therapy

- See you again in 6 weeks for follow-up and, if necessary,

Participation in the DESCRIBE-PD and DiFUTURE observational studies.

if desired. Corresponding information material was handed out.

- Inclusion in the list of interested parties for clinical studies

Anamnesis: For longer distances currently on the road with a folding bike in case of cramps

of the left foot when walking longer distances. So hiking works

not anymore, he is currently doing a lot of sport.

A few years ago with flip-flops on the south coast of France with an infection

of the left foot, since then always something interfering with

Cramping of the left foot on exertion. Since last summer

there would be more cramps in the left foot and less

Motor skills of the left arm. V he foot is already starting to cramp

a few hundred meters. Increased postural tremor of the left side

upper extremity noted. In the course of symptoms overall slowly

progressive. Rasagiline discontinued after 2 days in spring. L-DOPA

taken as a test, this did not happen after 3 days (dose 150mg).

struck so that it was discontinued. In the course of DAT scan for

confirmation of the diagnosis.

I received the diagnosis in January and was initially very burdened by it

been, but have now dealt with the situation better.

Qigong, rowing, cycling, yoga currently carried out.

Psychiatric: Suicidal thoughts denied, but mood over time

slightly deteriorated, temporary slight depressive mood.

in places a feeling of trepidation, inner contemplation. in places

Crying fits, Mental situation improved over the course of the

Time.

Sleep: trouble staying asleep, trouble falling asleep. no ha REM sleep

behavioral disorder

autonomous: no autonomous symptoms

Falls: no

Smell: slight hyposmia subjectively for several years.

Premedication:

Currently taking mannitol teaspoons evening and morning, PS128

(intestinal bacteria), Reishi mushrooms (Linghzi), outside of clinical trials

one, a stool transplant is being considered.

Family history: Parkinson's disease in her paternal aunt at an advanced age.

Tox: Phased consumption of multiple drugs (party drugs) from 25-35

Age. Nicotine stop 15 years ago, alcohol recently in phases

more, currently 2 beers a day.

Social anamnesis: self-employed in the real estate sector

neurologist Investigation:

Patient awake, oriented, cooperative. At best, slight neck rigidity,

no cervical deformity. certain hypomimia

Cranial nerves: pupils isocor, pupillo- and oculomotor function intact, none

vertical gaze paresis, saccades normal, visual field

finger perimetry free, facial sensitivity and motor skills downright,

Caudal cranial nerves without pathological findings.

Motor function: no indication of latent or manifest paresis, no sinking

in the holding attempts, mild intermittent tremor at rest

left oEx and slight postural tremor on the left, left-sided rigidity,

reinforced under ground.

Reflexes: own muscle reflexes can be triggered medium-lively on the same side,

Babinski sign negative.

Coordination: finger-nose test metric, knee-heel test metric,

left-sided bradydiadochokinesis.

Attachments to the doctor's letter from 29.07.2021

Gait/stand: smooth gait with normal step length and

Number of turning steps with reduced swinging of the left arm, toe,

Heel and tightrope walking as well as monopedal hopping inconspicuous,

Romberg standing attempt, admittedly, no postural in the pull attempt

Instability.

Sensitivity: intact for touch on both sides, normal palesthesia on the

upper extremities and lower extremities (big toe joint on both sides

8/8).

MDS UPDRS 3

3.1 Language: 0

3. 2. Facial expression: 1

3. 3a neck rigor: 1

3. 3b/ c Rigor right/left arm: 0/2

3. 3d/ e Rigor right/left leg 0/2

3 .4a/b fingertips right/left: 0/2

3.5a/b hand movements right/left: 0/1

3.6a/b Pro/supination right/left hand: 0/2

3.7a/b Forefoot tap right/left: 0/2

3.8a/b leg mobility right/left: 0/1

3. 9 getting up from the chair: 0

3.10 Gait: 1

3.11 Blockage when walking: 0

3.12 Postural Stability: 0

3 .13 Posture: 0

3 .14 Global spontaneity of movements: 1

3 .15a/b Posture tremor hand right/left: 0/ 1

3 .16a/b intention tremor hand right/left: 0/0

3 .17 a/b Rest tremor right/left arm: 0/1

3.17c/d Tremor at rest right/left leg: 0/0

3 .17 e Resting tremor lips/jaws: 0

3.18: Constancy of resting tremor: 1

Total: 18 points. No dyskinesia, no dopaminergic therapy

December 5th, 2022, Havana, Cuba – Prof. Dr. Ivonne Pedroso

SYNTHESIS OF THE ESSENTIAL ASPECTS

OF CLINICAL HISTORY

GENERAL DATA

Name: Mr. P
Age: 52 years

German nationality
Entry date: October 15, 2022
Completion: December 5, 2022
Clinical history: E-11378
Stay: 21 days

BACKGROUND OF INTEREST.

a) Significant history of your illness:

This is a male patient with a history of presenting 3 years ago with a mild tremor in the left upper extremity and a cramping sensation in the lower extremity of the same hemibodies. Among the non-motor symptoms, he reports having had depression. He doesn't take levodopa so we don't know what the answer is. He has no insomnia.

b) Other personal history:

nothing to emphasize

c) Family history:

nothing to emphasize

PHYSICAL EXAMINATION ON INCOME.

Generally:

mucous membrane. Wet and normally colored.
ACV: rhythmic heart sounds. No noise HF: 80´.

Blood pressure: 110/70 mm Hg.

RA: Normal breath sounds. No rattles. HR: 20'.
Carotid pulses present. don't blow

Abdomen: Declining, not painful. No hepatomegaly. No visceromegaly. RHA present and normal

TCS: Not infiltrated
SOMA: Normal

b) Neurological:

Slight facial hypomimia
normal language
normal memory
regular care
Stiffness in pinion 1 on the left
Hypokinesia 1 left
Resting tremor 1 left
Action tremor and position 1 left
Preserved postural reflexes
no cerebellar signs
no pyramid signs
Hypometric eye movements. No vertical gaze paralysis

COMPLEMENTARY STUDIES PERFORMED AT THE CENTER

Hematological Studies:

b) Electrophysiological studies:

EEG: Functional wakefulness in which adequate organization of basic activity is observed. Presence of a predominantly right-sided mild bilateral temporal slow anomaly.

Imaging Studies:

Chest X-ray: normal cardiothoracic index. No mediastinal abnormalities. Enhancement of the bilateral lung diagram with the presence of a 5.8mm calcium micronodule in the right lung base.

Neuropsychological assessment:

Orientation: Preserved worldwide in person, time and place.

Attention: Vigilance is adequate and there are no changes in executive attention and selective attention.

Memory: In the verbal modality, the ability for short-term fixation and recall is preserved. In the word learning test, he achieved an average of 7.5 in three repetitions. Working memory with no changes was observed on the digit retention task, where he could inversely recall up to 5 digits. The explicit semantic and episodic memory subsystems do not show changes shown in the semantic fluency task. On the other hand, in the learning test it shows a productive serial position curve with an increasing trend, which shows that the learning process for auditory-verbal information has been preserved. Over the long term, he was able to evoke 6 out of 10 elements in this modality. In the visual modality he showed no difficulty in short-term retention as demonstrated in the SKT where he was able to evoke 9/12 elements. In the long term he was able to evoke 70% of the elements in this modality. With the help of cues in recognition tasks, he managed to recover 100% in both modalities, expressing the integrity of bilateral temporomesial structures.

Language: Expressive: without changes. Repetitive: conserved and denominative: without changes

Impressive: Shows no difficulties in understanding - when carrying out instructions or when coding sentences with complex logical-grammatical structures

He showed slight difficulty in phonological fluency tasks, while preserving the semantic variant:

TASK

Score F 3

CATEGORY RIVER

score

SEMANTIC 18

Thinking: Normal course Content: It is observed that the ability for abstraction and conceptual thinking is retained, showing a tendency to think of an abstract type.

Practice: Received Visoconstructiva is manifested in the ability to perform three-dimensional figures. Without graphomotor, ideational and ideomotor changes. For tasks that require visuo-motor coordination and manipulation of visuo-spatial material, no changes detected when running the clock test are observed.

Executive Functions: He received a score of 16/18 on the FAB (Frontal Assessment Battery) observing only a change in mental flexibility.

Arithmetic: Mental arithmetic operations are preserved.

Writing: dysgraphia

Reading: Received

Affective and behavioral sphere: She does not report any emotional or behavioral changes and reports good emotional state, although she admits that two years ago when she was diagnosed with Parkinson's disease it caused sadness, depressive episodes and trouble sleeping, among those she was able to recover without pharmacological treatment. He received a score of 4 on the Hamilton scale, which corresponds to normal without depression.

Cognition: Global: Conserved. MMSE from 29./30.

Conclusions:

In general, in the neuropsychological examination carried out, no significant changes in higher mental functions were observed, noting only a slight decrease in tasks requiring cognitive flexibility, while maintaining the rest of the cognitive domains assessed. From a cognitive point of view, there is no impairment. (MMSE: 29). No emotional involvement or behavioral changes were reported. _cc781905-5cde-3194 -bb3b-136bad5cf58d_

EVOLUTION

During the current admission, the patient was evaluated clinically and complementary, at the end of this and previous discussions within the group of the Clinic for Movement Disorders and Neurodegeneration, the conclusion is that his diagnosis in Parkinson's disease stages Hoehn I and Yahr

The patient underwent a two-week treatment program of intensive and personalized rehabilitation based on neurological recovery. In addition, he was treated as a compassionate subject with good tolerability in the NeuroEPO clinical trial in Parkinson's disease.

The patient reports that his sense of smell has improved and abnormal movements have been controlled.

The molecule is provided free of charge to continue treatment for the next six months. At this point, you must return to the center for re-evaluation and continue your hospital treatment.

DIAGNOSTIC CONCLUSIONS.

Hoehn and Yahr Stage I idiopathic Parkinson's disease

RECOMMENDATIONS.

Medical treatment in the attached document

Neurorehabilitation Maintenance Program
The next consultation in our center is proposed in the month of June/2023,

Havana City, December 5, 2022

MOVEMENT DISORDERS ATTENTION CLINIC

AND NEURODEGENERATIONS

Patient: Mr. P

Release date: December 5, 2022

dr Ivonne Pedroso

Physician

2nd degree specialist in neurology

Masters in Clinical Neuroscience

Senior Professor of Neurology. Masters Neuroscience

Clinical Trial Leader: Efficacy and Safety ofNeuroEPOin patients with Parkinson's disease.

Head of the Clinic for Movement Disorders and Neurodegenerative Diseases

RECOMMENDATIONS FOR REHABILITATION

Summary of rehabilitation treatment

Patient who has a good motor condition and shortly after the diagnosis of the disease, in addition to the daily exercises in his country, after the motor examination was carried out, was able to detect a slight decrease in the mobility of the MSI, which makes the arm swing, with this arm in relation is lower on MSD and occasional discrete hypokinesia. He does not take any medication and is included in the treatment with NEUROEPO. The neurorehabilitation lasted two weeks, so the objectives proposed for the phase were aimed at the following aspects.

Maintain general physical abilities.
Promote posture correction.
Improve mobility, hemibody joint width and affection.
Improve movement coordination.
Reeducate gait patterns.

Significant improvements were observed in the following aspects.

He has assimilated the gradual increase in loads, which is reflected in the increase in his physical performance and improvement in his breathing capacity.
It creates coordination and balance exercises with greater safety and complexity.
The gait is more fluid, stable and coordinated, with greater involvement in changing arms and better posture.

Recommendations.

Continue to perform the Yoga and Chigon techniques that you practice daily, combined with the exercises aimed at counteracting the symptoms of the disease at this stage, in order to have a better quality of life.

Treatment Policy.

Mobilizations of wrists, elbows, knees, ankles and feet.
Flexion and extension of the neck.
Lateral twists of the neck.
Forward and backward bending of the neck.
Arm circles front and back.
Bend and stretch the arms in front, above, to the side and obliquely behind.
bent towards the chest, opening and closing simultaneously and alternately.
Arms bent forward to open and close them.
Touch the opposite ear with your arm behind your neck.
Alternate bending of the legs from a sitting position.
Move from the seated position to the standing position.
While sitting, open and close your legs alternately with your arms.
Seat dribbling, front and side
Throwing balls with one and both hands.
Alternating starts with two and three balls.
Turn in both directions alternately with walking.
Perform stretching on the trellis.
Stand in front of the trellis with support on toes and heels
Step forward in front of the trellis, bring your arm back and touch your bent knee with your other hand.
To the side of the trellis make pendulums.
Go up and down stairs and insist on alternating arms.
March between obstacles from the front, side and back.
March with changes of rhythm and direction.
Walking on uneven terrain, increasing distances, and insisting on correcting posture while walking.
Walking with sticks
coordinate bike.
mechanical mat.
breathing exercises

FINAL REPORT OF THE TREATMENT OF DEFECTOLOGY

Goals.

Increase muscle strength, mainly at the distal level of the left upper limb.
Stimulate higher thought processes.
Improve general and manual coordination of active movements in terms of precision, rhythm and speed.

Results

The neurorestorative, multifactorial, intensive and personalized treatment he received in our institution included the defectology in which the above objectives were proposed with the appropriate skills.

The general and manual dynamic coordination of active movements was favored, he can do the exercises simultaneously, in different directions, alternately and sequentially and combined with the legs, makes the assembly of small pins, works with the psychomotor boards and tuned to the quality required , reproduced figures in the mosaic, with and without model, performs the upper distal clamping, high-quality threading, correlation activities (remove-set, screw-unscrew, open-close) etc. basically with the arm through the left, where there are slight difficulties in executing finer movements there.

Work to maintain muscle strength was done with the right upper limb and this ability was favored in the left where the patient reported showing greater muscle fatigue when performing exercises.

The stimulation of the psychic processes was carried out, especially the higher thought processes, where the patient's ability to assemble puzzles quickly and with quality was demonstrated.

We recommend continuing maintenance therapy according to the proposed goals.

GENERAL DEFECTOLOGICAL RECOMMENDATIONS

Massage therapy in the upper extremity has an effect.
General active mobilizations in the upper extremities.
Stretching.

Shoulder : lift and relax. Alternating and simultaneous movements. Front and back. Alternating internal and external rotation; adduction and abduction.

Elbows: Perform flexion-extension, hands crossed, palms outward, chest forward. Ibid of the thorax on both sides, Ibid of the neck upwards.
Wrist: flexo extension and move sideways.
Finger: carry out flexo-extension and tweezers with all (place and remove thin and thick pins, carry out threading, place and remove pyramids, etc.); lacing and lacing.

4. Coordination exercises

Alternating movements of the arms stretched forward up and down.

page ibid.

Bend and stretch the arms in front, alternating at shoulder level. page ibid. Ibid above.

Movements of outstretched arms crossing them up and down four times.
Mimicking the arm movement exaggerating the movement.
Put your hands on the table, your right hand in the form of a fist, hit and at the same time perform friction with your left hand as instructed by the therapist, switch movements.

Put your hands on the table: the right hand in the form of a fist to punch, and at the same time make prone supination with the left hand at the therapist's direction to switch movements.
Supine prone with left hand while opening and closing right hand as instructed by therapist, alternating movement.
Open and close your hands simultaneously and alternately, combining both movements as instructed by the therapist.
Simultaneously and alternately connect and separate the fingers and combine both movements as instructed by the therapist.
Digital clamping with all fingers from the index finger to the little finger and vice versa with both hands at the same time.
Digital clamping with all fingers, starting right from the index finger to the little finger and left from the little finger to the index finger at the same time.

5- Coarse and fine precision exercises.

Psychomotor and precision boards.

prescribe dashes. With excessively large beats and gradually decreasing until normality is reached.

Repetition of letters, syllables. With exaggeratedly large font and gradually decreasing until reaching normality.

Writing words, sentences and texts. Same as the previous one.

6.- Training activities and stimulation of cognitive processes.

Read newspapers, magazines and books and then comment on the topic read. (start with short and simple texts that arouse interest in the patient).
Watch TV shows and comment on what you watch.
Perform activities found in hobbies aimed at training memory, attention, orientation, thinking, and executive functions to the best of their ability.
Get outside help if needed
Pay more attention to anything you need to store in your memory.
Constantly repeat anything you need or want to remember until you achieve it.
Make associations that help remember specific information.
Memorize texts, phrases, poems and others that arouse the patient's interest.
Look at pictures, maps, figures, etc., and then, without seeing them, try to represent them in a drawing.
Remember lists of related and unrelated words, include words with no meaning.
Remember synonyms and antonyms of selected words.
Selective crossing out of letters, syllables, numbers, figures etc.
Remember to repeat digits from 4 left to right and vice versa, increasing up to 10 digits. Example: 3-4-5, 9-6-4-2, 5-4-3-2, 8-3-6-7, increase in complexity as accepted.
Memory game in different categories.
calculations.
Simple and complex math problems.
Sequential ordering of cards or sheets.
Assemble jigsaw puzzles from 10 pieces and increase the complexity of body figures, animals, things, characters, landscapes, etc.
Reproduction of Mosaics.
Create stories using given words that have a specific context
imitation of usual gestures.
I work with the psychomotor boards.
object exclusion
Complete sentences and numbers.
Puzzle.
Comparison of concepts. Similarities and differences .

SUMMARY REPORT OF LOGOPETIC TREATMENT

Diagnosis: No speech pathology.

Patient with Parkinson's disease, dysarthric disorder has not yet occurred, we have developed a prophylactic speech therapy treatment. (health education)

SUGGESTED WORK GOAL:

Prophylaxis of speech disorders, phonobreathing and facial mimicry.

GET RESULTS:

Patient who comes to therapy for a short time (10 days) with great enthusiasm and interest, very cooperative, in terms of orientation and preparation for speech therapy care, despite the short treatment time, the exchange was beneficial:

- Learn and practice orolinguofacial gymnastics based on the amplitude, speed, precision and coordination of movements with total independence

- Practiced facial expressions and facial expressions with very good results

- Does the costodiaphragmatic breathing pattern work. The inspiratory and expiratory capacity has been slightly increased.

-He worked on better phono-respiratory coordination with an emphasis on voice intensity.

- He worked on the basis of better intonation, expressiveness and rhythm and fluency of the emission.

RECOMMENDATIONS:

Maintain the therapy in a targeted manner, taking into account the progressive course of the disease.

07.03.2023, Munich, Germany

I report on her outpatient examination on March 7, 2023 at the Institute for EEG

Neurofeedback (IFEN) in Baldham.

They reported that they had suffered from mild Idiopathic Parkinson's Syndrome for years

suffering, which led to a slight tremor and fine motor dysfunction in the left hand

has. The diagnosis was confirmed by a DATSCAN examination. You are currently in therapy

multimodal with various drug and non-drug procedures without

Use of dopamine or classic dopamine agonists. Underneath it is rather closed

moderate improvement in symptoms.

The neurological finding shows a slight postural and action tremor

left hand, the gait is fluid, the alternating movements of the left hand show a

Brady and dysdiadochokinesis. The accompanying movement of the left arm when walking is evident

reduced. Cognitive limitations could not be verified in my investigation

become.

At rest, the EEG shows a well-developed, stable and well-modulated alpha

Basic rhythm with a frequency of 8 Hz and amplitudes around 30 myV. the visual

Blocking reaction is sufficient. Hyperventilation was not performed. No

Signs of increased cerebral excitability. As a result, the EEG is considered normal too

assess, in particular no general change, no focus findings, no indications of

epileptic changes.

The derived late visual evoked potentials (P 300) show normal

Latencies around 400 ms. it is striking that with normal amplitudes in the occipital, temporal and

central area the frontal amplitudes especially under fpl and fp2 atypical

are diminished. A side difference could not be determined with certainty.

The frontal reduction could be related to Parkinson's disease in that

the implementation of actions or ideas could be delayed

(Parkinsonian bradyphrenia). Another observation of this

The results of the investigation could therefore be useful in the course.

Judgement:

Clinically, there is a slight manifestation of Parkinson's disease, which was confirmed in the DATSCAN

with slight tremor and fine motor dysfunction of the left hand.

It is noteworthy that you have had a very good course so far without the use of dopamine-containing drugs. It cannot be said with certainty which of the alternative therapy methods they used contributed significantly to this.

From a neurological point of view, I recommend repeating the electrophysiological one

Investigations in about half a year to see a deterioration or a

to determine an improvement in the findings obtained.

You will receive the evaluation of the QEEG collected by Mr. F. separately.