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Daniel Mitkov-Spinal cord injury-(Macedonia)-Posted on Apr.29th,2015

Author Zhangqi Views Posted at 2015/04/29

Name: Daniel Mitkov                
Sex: Male
Country: Macedonia
Age: 30 years
Diagnosis: 1. Spinal cord injury  2. Hyperlipemia
Date: Apr. 3, 2015
Days Admitted to Hospital: 20 days

Before treatment:
Daniel Mitkov had a car accident and injured the thoracic vertebrae on Nov. 11th, 2011. His lower limbs had motor and sensory disturbance, he developed gatism. After examination, he was diagnosed as paraplegia by a local hospital. He had 3 times implantations steel plate in his spine on Sep. 16th, 2011, Sep.23th, 2011 and March 2012, during these surgeries. He had transfusion of blood, after that, he began to do rehabilitation training and took oral drug. His condition did not improve. His lower limbs still had motor and sensory disturbance, he couldn’t walk and developed gatism. He wants to have a better treatment, so he came to our hospital. He was diagnosed as” Spinal cord injury”.
He was in good spirit. His diet and sleeping were good. He developed gatism. He had 5 times excrement each day. His weight was normal.

Admission PE:
Bp: 132/86Hg, Hr: 90/min. Temperature: 36.6 deg. Br: 20/min. His body type was good, and well nourished. There was no yellow stain or petechia on mucous membrane. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no obvious moist or dry rales. The heart sounds was strong, the rhythm of his heartbeat was normal. There was no obvious murmur in the valves. The abdomen was flat and soft, with no obvious masses. There was no pressing pain or rebound tenderness. The liver and spleen were normal. There was a 30cm long operative wound on the back.

Nervous System Examination:
Daniel Mitkov was alert and his speech was fluent. His memory, calculation and orientation abilities were normal. Both pupils were equal in size and round, the diameter was 3.0 mms, both eyeballs could move freely. Both eyes had sensitive response to light stimuli. The forehead wrinkle pattern was symmetrical. The tongue was centered in the oral cavity and the teeth were shown without deflection. The neck moved normal. The muscle tension of upper limbs were normal, and the muscle power was at level 5. The muscle tension of lower limbs was higher sometimes accompanied with convulsion, the muscle power was at level 0. The depth feeling was normal above T7 of segments of spinal cord. The depth feeling decreased between T7-T8. The depth feeling disappeared below T8. The tendon reflex of both upper limbs was normal, both lower limbs was over active. The achilles reflex was normal. The ankle reflex was positive. Both side abdominal reflexes was abnormal. Bilateral Babinski sign was positive. The patient was not able to do coordinate movement examination of both lower limbs. The meningeal irritation sign was negative.

Treatment:
We diagnosed him with” Spinal cord injury, Hyperlipemia” He received treatment to nourish neurons, improve circulation and adjust the lipid of blood. We also gave him daily physical rehabilitation.

Post-treatment:
The muscle power of both lower limbs improved by level 1. He had muscular contraction. The deep feeling was lower to T9. The muscle tension was lower. Convulsion was less. Both side ankle reflex was better than before. The treatment plan have been completed, the discharge has been permitted.

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