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Tony Buley - Cerebral palsy (USA) Posted on May 15, 2014

Author Julia Views Posted at 2014/05/15

Name:Tony Buley

Sex: Male

Country: USA

Age: 3 years

Diagnoses: Cerebral palsy, Optic atrophy, Epilepsy

Date:March 10, 2013

Days Admitted to Hospital: 27 days

Before treatment:

Tony Buley is a 2 year old boy. He was presented with an intellectual developmental delay and motor developmental delay for the past 2 years. He was diagnosed with cerebral palsy and optic atrophy. Past medical history: he had an intestinal obstruction operation when he was 1 month. Post operation, the patient had bowel movement 4-5 times each day and the defecation was diluted. The patient also had nausea and vomit. He took erythrocin to promote gastrointestinal motility for the long term. He suffered one epileptic seizure in March 2011. After taking oxcarbazepine, he had no epileptic seizure.

Admission PE:

Bp: 80/50mmHg; Hr: 90/min, Br: 22/min. Height: 77cms, weight: 11kgs. He suffered from developmental retardation. The nutrition was normal. The skin and mucosa was normal with no hemorrhaging spots or yellow stains. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no dry or moist rales. The heart sound was strong. The cardiac rhythm was regular, with no obvious murmur in the valves. The abdomen was smooth. There were surgical scars in the epigastrium and right lower quadrant. There was tympanitic sound when pat the abdomen. There were no masses in the abdomen. The liver and spleen were not palpable under the ribs. There were scars in the left lateral thigh from post skin grafts. There was muscle contracture in the left leg's far end. There was swelling in the left foot. The left lower limb was shorter than the right lower limb.

Nervous System Examination:

Tony Buley was alert and had a speech disorder. He could only say "A". He couldn't cooperate with the examination of orientation, memory or calculation. He had poor comprehension and could only communicate simply with his parents. Both pupils were equal in size and round, the diameter was about 3.5mms. Both pupils were sensitive to light stimuli. The forehead wrinkle pattern was symmetrical. The nasolabial sulcus was equal in depth. He could move the neck to the left and right side in supine position. His head had poor support in the sitting position. The head was liable to sag or fade sideways. The muscle strength of the back and waist was weak. He couldn't turn over or maintain sitting position independently. Both hands had hand grasp action, but the hold power was poor. Both lower limbs had involuntary movement and could lift off the bed surface. His four limbs couldn't cooperate with the examination of muscle strength. The muscle tone of both upper limbs was normal. The muscle tone of both lower limbs was slightly higher than normal. The abdominal reflexes were normal. The tendon reflex of both upper limbs was normal. The patellar tendon reflex of both lower limbs was slightly active. The left Achilles tendon reflex was not elicited. The right Achilles tendon reflex was active. The bilateral ankle clonus was not elicited. The bilateral sucking reflex was positive. Both palm jaw reflexes were positive. Bilateral Hoffmann sign was negative. The Rossolimo sign of both upper limbs was negative. The bilateral pathological reflex was negative. He couldn't cooperate with the examination of deep sensation and shallow sensation examination. He also couldn't cooperate with the coordinate movement examination.

Treatment:

After admission,Tony Buley received the relevant examinations. The patient received treatment to improve the blood circulation in order to increase the blood supply to the damaged nerves, to nourish the neurons and strengthen immunity. This was combined with neurological rehabilitation treatment.

 

Post Treatment:

The defecation routine at admission: white blood cells 4-6/HP. The mould could be see in it. The patient still had diarrhea and vomiting. After symptomatic treatment, the patient's condition was improved. At present, he has 3-4 bowel movements each day. The defecation was restored to normal. Height: 77cms, Weight: 11kgs. The patient's intelligence, vision and muscle strength has improved. The patient smiled when the attending doctor called his name. The patient has some resistance to the nurse before the infusion. He has conscious support or tries to stand up to cooperate with the therapist's exercises. The eyeballs are more sensitive to following light and sound. The right eye is more sensitive. The muscle strength of the four limbs, waist and back are improved. He has better control of his head. The patient has improved.

The patient received treatment in our hospital last year. After that treatment, the patient's condition improved. The patient's height increased. The intelligence, vision and muscle strength of limbs increased too. For consolidating the effect and make further progress, the patient came to our hospital again.

Admission PE:

Bp: 90/60mmHg; Hr: 100/min, Br: 22/min. Height: 83cm, weight: 11kgs. He suffered from developmental retardation. The nutrition was normal. The skin and mucosa was normal with no hemorrhaging spots or yellow stains. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no dry or moist rales. The heart sound was strong. The cardiac rhythm was regular, with no obvious murmur in the valves. The abdomen was smooth. There were surgical scars in the epigastrium and right lower quadrant. There was tympanitic sound when pat the abdomen. There were no masses in the abdomen. The liver and spleen were not palpable under the ribs. There were scars in the left lateral thigh from post skin grafts. There was muscle contracture in the left leg's far end. There was swelling in the left foot. The left lower limb was shorter than the right lower limb.

Nervous System Examination:

Tony Buley was alert and had a speech disorder. He could only say "A". He couldn't cooperate with the examination of orientation, memory or calculation. He had poor comprehension and could only communicate simply with his parents. Both pupils were equal in size and round, the diameter was about 3.5mms. Both pupils were sensitive to light stimuli. The forehead wrinkle pattern was symmetrical. The nasolabial sulcus was equal in depth. He could move the neck to the left and right side in supine position. His head had poor support in the sitting position. The head was liable to sag or fade lean back. The muscle strength of the back and waist was weak. He couldn't turn over or maintain sitting position independently. Both hands had grasp action, but the grasp power was lower than normal. Both lower limbs had involuntary movement and could lift off the bed surface. His four limbs couldn't cooperate with the examination of muscle strength. The muscle tone of both upper limbs was normal. The muscle tone of both lower limbs was slightly higher than normal. The abdominal reflexes were normal. The tendon reflex of both upper limbs was normal. The patellar tendon reflex of both lower limbs was slightly active. The left Achilles tendon reflex was not elicited. The right Achilles tendon reflex was active. The bilateral ankle clonus was not elicited. The bilateral sucking reflex was negative. The bilateral pathological reflex was negative. He couldn't cooperate with the examination of deep sensation and shallow sensation examination. He also couldn't cooperate with the coordinate movement examination.

Treatment:

After admission, Tony Buley received the relevant examinations. The patient received treatment to improve the blood circulation in order to increase the blood supply to the damaged nerves, to nourish the neurons and also to strengthen his immune system. This was combined with neurological rehabilitation treatment.

Post Treatment:

Height: 84cms, Weight: 11kgs. The patient's intelligence, comprehension, vision and muscle strength of limbs has improved. The patient greets doctors and nurses when induced by a family member. He can say "A", smile, swivel or turn eyeballs to find a sound. He can cooperate with the physical therapist when asked to do exercises, such as conscious support. The patient's eyes can follow spot and sound better than before. The left eye has more significant reflex. The muscle strength of his four limbs, waist and back are stronger than before. He can control his head better. The grasp ability of hands has increased. He can turn over by himself partly. He can maintain sitting position for a short time. He do more actions, such as lift leg, abduction and internal rotation.


 

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