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Hurt crushing of spinal cord

Clinical diagnosis

МРТ и МРА головы

МРТ и МРА

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 by these complains:pains on the neck part,nonmovement of hands.
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. 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 tracheotomy.His condition was so serious and he consulted at professor and he was advised to be at Regional medical centre..He was output for neurorehabilitation.

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. The patient had an operation with  problems as anterior spondylosyndesis.C 5-C7 with Atlantis system,and by epicystostomy. had serious type of anemia that’s why he took 473 ml of 2 dose blood transfusion.He doesn’t have bad habits.

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.
Last: hemoglobin-134,  erythrocyte-3.8, leukocyte-6.6, monocyte-5.4, lymphocyte-35.3.
Previos:  protein-59.2, albumin-33.6, bilirubin-10,20, sugar-5,04, urea-5.1, creatinine-89.0

Treatment

After rehabilitation condition of patient is normal,but after treatment all pains such as Superior flabby Para paresis, lower paraplegia. Dysfunction of pelvis organs on central type is left.

Offers

  • 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.
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