Case Stusies
Liu Hao
Gender: Male
Age: 8 years and 10 months
Admission Summary:
The child experienced hypoxia and ischemia at birth. At the age of 1, it was noticed that the child couldn't sit or walk independently. After seeking medical attention, the diagnosis was cerebral palsy, and no specific treatment was administered. The child has been undergoing self-rehabilitation since returning home. Currently, the child has a slightly diminished intellectual capacity, unclear speech with 5-6 syllables, and increased muscle tone in all limbs, particularly pronounced in the left upper limb and right lower limb. When lifted, the right foot shows inward turning. To further diagnose and treat the condition, the child has been admitted to our hospital. Since the onset of the condition, the child has maintained clear consciousness, good mental well-being, normal eating and sleeping habits, and regular bowel and bladder function. There is no significant change in weight. The child is unable to walk independently and shows no signs of leg swelling.
Admission Diagnosis: Cerebral Palsy.
Treatment Process:
After admission, a comprehensive examination was conducted, ruling out any surgical contraindications. Due to symptoms of cerebral palsy, the patient underwent a robot-assisted stereotactic brain surgery on December 23, 2021, under combined inhalation anesthesia. The surgical procedure went smoothly, with approximately 3 milliliters of blood loss during the operation. Postoperatively, the surgical site was locally sutured and subjected to pressure dressing. A follow-up head CT scan revealed no apparent bleeding, confirming accurate targeting of the surgical site. The patient returned to the ward smoothly after the surgery and received routine intravenous fluids, oxygen supplementation, and cardiac monitoring. No adverse reactions or complications have occurred to date.
Discharge Summary:
The current physical examination of the patient reveals clear breath sounds in both lungs, with no audible crackles, wheezing, or pleural friction sounds. The heart rate is normal, with a regular rhythm, and no murmurs are detected in any of the valve auscultation areas. The patient is alert and oriented, with normal muscle strength in all four limbs, and there is no swelling observed in the lower extremities.
Discharge Instructions:
1. Rest is essential, strengthen protection, avoid vigorous head movements.
2. Keep warm, prevent infections, continue rehabilitation training, and avoid head vibration, acupuncture, or electrotherapy during rehabilitation treatment for one month.
3. Seek prompt medical attention if any discomfort arises.