Danilo Marinozzi-#SCI Before treatment: Danilo Marinozzi is a 28 years old male. He was presented with a movement disorder and sensory disorders in both lower limbs post-trauma for the past 4 years. He was diagnosed with spinal cord injury. The patient was healthy before the onset of the disease. There was no history of diabetes mellitus, hypertension or tuberculosis. There was no history of blood transfusion or food allergies. The patient always smokes 5 ~ 6 cigarettes each day, since last year they were increased gradually to now about 50 cigarettes per day. He drank small amount of wine occasionally. In recent months, the patient had poor diet and the food intake had reduced. He had no sense of hunger. He ate one meal a day only. His defecation is influenced by abdominal massage. He urinated through catheterization every several hours. He had urine discharge about 6 times each day. Admission PE: Bp: 110/70mmHg; Hr: 62/min. Mild malnutrition. The skin and mucosa were normal, with no ecchymosis, petechia or yellow stains. There are surgery scars at the center of the neck and back, the scars are about 20cm each. The scar which was resulted from an operation healed well, with no ulceration. There was a scar resulted from a bedsore on the sacrococcygeal region and it had healed. The surface of the skin was not smooth, with no ulceration or exudation. There was no congestion in the pharyngeal. There was no enlargement of the tonsils. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no dry or moist rales. The cardiac rate was normal and the heart sound was strong. The heart rate was 62/min. There was no obvious murmur in auscultatory valve areas. The abdomen was soft and sunken, with no obvious masses. The liver and spleen were normal during palpation. The borborygmus was presented normally through auscultation. The temperature and color of both heels were normal. The dorsal artery of the acrotarsium was beating strongly. Nervous System Examination: Danilo Marinozzi was alerted. His speech was fluent. His memory, calculation and orientation abilities were normal. The pupils were equal in size, the diameter was 3.5 mm and the pupils reacted normally to light stimulus. Both pupils move freely. The forehead wrinkle pattern was symmetrical. The tongue was centered in the oral cavity and the teeth were shown without deflection. Danilo’s neck could move flexibly. He could shrug shoulders normally. The muscle tone of both upper limbs was normal. The muscle tone of both lower limbs was low. The muscle strength of both lower limbs was level 0. The tendon reflex of both upper limbs was normal. Bilateral abdominal reflexes could not be elicited. The tendon reflex of both lower limbs could not be elicited. The touch sensation and pain sensation below thoracic vertebra 3 segments were lowered down. The pain sensation below left thoracic vertebra 4 has disappeared. The pain sensation below right thoracic vertebra 5 has disappeared. The sense of vibration was lowered down from both thoracic vertebra 3 to the first lumbar segment. The sense of vibration below both lumbar vertebra 1 has disappeared. Bilateral Hoffmann sign and Rossilimo sign were negative. Bilateral palm jaw reflex was negative. Bilateral Babinski sign was negative. Bilateral ankle clonus was negative. The pathological reflex of four limbs were negative .The coordinate movement examination of both upper limbs was normal. The patient was unable to finish coordinate movement examination of both lower limbs. Treatment: We initially gave Danilo Marinozzi a complete examination and he was diagnosed with spinal cord injury. Then we proceeded with the treatment to nourish his nerves and improve the blood circulation to increase the blood supply to the damaged neurons. He also received treatment to activate his own neural cells. This was combined with daily physical rehabilitation training. Post-treatment: The patient has better diet. He has normal sense of hunger. He can eat three meals a day. The food intake is almost normal. Both side’s dysalgia planum is down one segment. The pain sensation of left was 5 thoracic vertebra, and the pain sensation of tight was 6 thoracic. The waist continuously appear some feelings, sometimes he can feel the pain of sacral tail or lower limbs, There is muscle contraction in both lower limbs, the muscle strength is between levels 1-2, he can keep his bended legs from falling off and his knees are able to move outward in a small range. wumedicalcenter/article/PatientStories/sci/3120141281104.html
Posted on: Tue, 09 Dec 2014 01:25:28 +0000
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