Victoria Castro - Anoxic encephalopathy Before treatment: The patient was born through a cesarean at the 27 weeks of gestation because her mother had pregnancy-induced hypertension. Her weight was 850kg at time of birth; this was lighter than normal baby. The baby had no autonomous respiration. She received trachea cannula operation. She also needed oxygen uptake and ventilator for breathe. 5 weeks later, the patient had autonomous respiration. The four limbs had abnormal activities. The position of both eyes was abnormal. The patient suffered from developmental retardation of intelligent and motor function. She was diagnosed with anoxic encephalopathy. The patient received operation to adjust her abnormal eyes position when she was 1 year old. After operation, the patients eyes had better motor function. About two years ago, the patient suffered from higher fever. Her left face and limbs was twitching. She took Fanobarbital morning 22.5mg, evening 30mg. Then the patient epileptic seizures were gone. The patient took baclofen 2.5 mg BID to treat high muscle tone. Before the treatment, the patient’s muscle tone was almost normal. She still couldnt turn over, sit-up or maintain sitting position by herself. Her comprehension was still good. She could utter fewer words than normal baby and only could send out simple words. From onset of the disease, the patients nutrition was normal. The sleep quality was poor. She started to take Clobazam 5 mg to improve sleep. She had semi-liquid diets and about 1800ml each day. She had gatism. Admission PE: Bp: 94/70mmHg; Hr: 130/min. Br: 32/min. Temperature: 37.6degree. Weight: 10Kg. She suffered from developmental retardation and poor nutrition. The skin and mucosa was intact, with no yellow stain or petechia. The mouth and lips were ruddy. No congestion was found in her throat. No swollen was found in her tonsil. The thorax was symmetrical. Through auscultation, the respiration in both lungs was rough, with no dry or moist rale(s). The heart sound was strong. The rhythms of cardiac rate were irregular and there was no pathological murmur in the valves. The abdomen was soft, with no mass. There was no pressing pain or rebound tenderness. The liver and spleen were not touched. Nervous System Examination: Victoria Castro was alert. Her spirit was weak. The family said she had a few autonomous language, only could speak few words. The patient couldn’t cooperate with the examination of language. Her comprehension was almost normal. She couldnt cooperate with memory, calculation ability or orientation examinations. Both pupils were equal in size and round. The diameter of both pupils was 4.0mms and both pupils were sensitive to light stimulus. Both eyes could follow objects. The movement of ocular muscles was not coordinated. Both eyes was slightly outwards frequently. She couldnt cooperate with the examination of cranial nerve. The ability to swallow was normal. She had semi-liquid diets. There was no cough when she swallows. The neck was soft and weak. The muscle tone was low. She could turn her head and raise her head in horizontal position. Her four limbs had automatic action. She couldnt turn over, sit-up, stand or walk. The muscle tone of the four limbs was almost normal. The tendon reflex of both upper limbs was normal. The abdominal reflexes couldnt be elicited. The tendon reflex of both lower limbs was active. The Achilles tendon had hyperreflexia. Bilateral sucking reflex was negative. The Babinski sign was negative. She couldn’t cooperate with the sensory examination or coordinate movement examination. The meningeal irritation sign was negative. Treatment: Victoria Castro received a complete examination and she was diagnosed with anoxic encephalopathy. The patient received nerve regeneration treatment and stem cell activating treatment. She received treatment to improve the blood circulation and also to nourish her neurons. She also received nutritional treatment for strength. This was accompanied with physical rehabilitation. Post-treatment: The patients nervous system function has improved. The spirit and appetite are better. The food-intake has increased. Weight: 10.5Kg. The muscle strength of neck, waist and back has increased. The ability to balance the trunk has increased too. She can control her head better. She can control her trunk better in sitting position with some assistance. The right upper limb has gained more active exercises. Right hand has achieved grasp action. wumedicalcenter/article/PatientStories/Others/11201412852.html
Posted on: Mon, 16 Jun 2014 01:21:30 +0000
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