Heavy spinal cord trauma. Unstable fracture dislocation of body. C6. Hurt crushing of spinal cord. Superior flabby Para paresis, lower paraplegia. Dysfunction of pelvis organs on central type. Condition after posterior and anterior spondylosyndesis. Condition after tracheostomy, epicystostomy. Sepsis. Septic shock on background of bilateral infiltrate pneumonia. Serious degree of anemia.
The patient was brought to Regional Medical Centre after car crash with spinal cord trauma
Patient’s complains: Pains of the neck, pains during the movement, paraplegia.
Anamnesis morbi: According to information received from relatives the patient was crashed by crash. He was brought to regional Medical Centre, to reanimation.
Anamnesis vitae: According to information received from mother he didn’t have any skin diseases, never has derma to venerologik,tuberculosis.he doesn’t have genetic disease.
Status praesense communis: Condition of patient is so hard,dysfunction of spinal cord.Body structure is normosthenic.Colour of skin is normal,clean,body temperature is 36 C,wetty. Condition of eyes are clean.Shape of nose is not changed, breathing is normal.Type of breathing is mixed.,rhythmical. Breathing is 18 time per minute.Vesicular breathing on lungs’ auscultation,there is not any vibration while breathing. On heart auscultation the sound of heart is normal,rhythmical. The colour of oral cavity is pink,clear. The shape of tongue is normal,dry. Inside is soft,there are n’t any peritonitis symptoms.
Status nevrosus: He answers all questions very adequate. He has an orientation. Photoreaction is saved.D=S.Tongue’s position is by central stripe.The function of teeth is normal.Tetraplegia. Lower part of chest is nonsense to any medicine.Dysfunction of pelvis organs on central type.Pains on spinal cord.
Result of analysis:unstable discolation,crushing spinal cord.
It was an operation by intubation.After operation there was problems with vertebra,C-6-C5 vertebras are fully dislocated.All problems was received to neurosurgery and suggested to do an operation. The patient had an operation with problems as anterior spondylosyndesis.C 5-C7 with Atlantis system,and by epicystostomy. After X-ray all problems are solved which he had before. The patient breaths by instrument. He can’t breath himself that’s why they did an operation by putting tracheostomy.On auscultation part of lungs there is vibration,pneumonia. There is purulent liquid by tracheostomy instrument,body temperature is 37-39 C.On status nevrosus there is superior flabby paraparesis,lower paraplegia,dysfunction of pelvis organs on central type.
The history of patient was informed and suggested to invite other neurosergeons and neureanimations to other Medical Centre.
The patient was at professor. He advised to continue antibacterial theraphy,vitamin theraphy,eating by probe,to find out sensibility to antibiotics.
The patient was again at professor. He found out the vibration on the right side of auscultative lungs.
By analysis his hemoglobin was 75 g\litre,that’s why doctor advised to do bloodtransfusion,and change all antibiotics because he has reaction to them.
Blood to sterility – Blood is sterility.
Nowadays the condition of patient is feet and can breath himself.
Nevrosus status is clear,but superior flabby paraperesis,lower paraplegia,dysfunction of pelvis organs are left.
The patient was output for rehabilitation.
- Must be on the observation of neurologist,urologist.
- Breathing gymnastic,acupuncture,massage.
- Renal tea.
- Doesn’t have complication of lungs.
- To continue rehabilitation at Regional Medical Centre,neurosurgery section.