Case Stusies
Tan Qingling
Gender: Female
Age: 11 years and 10 months
Hospitalization Information:
About 8 years ago, the patient visited the hospital due to an inability to walk and was diagnosed with cerebral palsy, exhibiting an abnormal walking posture. The patient had sought treatment at multiple hospitals and underwent over a year of rehabilitation training at a local hospital. Currently, the patient still demonstrates an abnormal walking posture with the left foot toe-walking and stiffness in the left lower limb. The upper limbs show no abnormalities, and the patient can engage in verbal communication with normal comprehension skills. The patient is currently in the fifth grade of elementary school. In order to undergo further diagnosis and treatment, the patient was referred to our hospital with a diagnosis of "cerebral palsy" through outpatient services. Since the onset of the condition, the patient has maintained clear consciousness, good mental status, normal eating and drinking habits, regular bowel and bladder movements, and no significant change in weight.
Admission Diagnosis: Cerebral Palsy.
Diagnostic and Treatment Process:
After admission, a comprehensive preoperative examination was conducted. The head magnetic resonance imaging (MRI) on October 23, 2021, revealed multiple punctate T1-weighted low signals in the bilateral basal ganglia and corona radiata, along with irregularly shaped dilatation of the lateral ventricles. No significant abnormalities were found in other auxiliary examinations, and there were no surgical contraindications. On October 25, 2021, at 14:00, a robot-assisted frameless stereotactic brain surgery was performed under general anesthesia. The surgical procedure went smoothly, and postoperative head CT showed no apparent bleeding with accurate targeting. Routine intravenous fluid administration was administered postoperatively to prevent infection. The surgery was successful.
Discharge Summary:
Currently, the patient's condition is stable, normal communication, normal comprehension, no headaches, nausea, vomiting, good appetite, the wound stitches have been removed, healing well without bleeding or swelling. No abnormalities in bowel movements or urination, normal diet and sleep. Regular heartbeat, no abnormal sounds heard. Improved mobility in the left lower limb.
Discharge Instructions:
1. Rest, strengthen protection, and avoid vigorous head movements.
2. Keep warm, avoid infection, continue rehabilitation training.
3. Seek medical attention if any discomfort arises.