Clinical diagnosis

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.

Full information of diagnoses

Paraparesis and lower paraplegia

Heavy spinal cord trauma. Unstable fracture dislocation of body. C6. Hurt crushing of spinal cord. Superior flabby paraparesis, 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,spinal cord trauma,paraplegia.

Anamnesis morbi

Carcrash on 16.12.12.Operation on 18.12.12. On 18.12.12 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 on 24.12.12 by putting tracheostomy.

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 nevrosus

Level of consciousness of 15 points on a scale of Glasgow. Photoreaction is alive, symmetrical face, swallowing and phonation are not violated. urinating by epitsistostome. muscle strength in the legs and in the bones is 0. Dysfunction of pelvis organs.

Local

Injury without signs of inflammation with sluggish granulation and fibrin coating in the area of ​​the scar in the area of ​​the projection of the vertebral.C4-Th1.

Survey

Indicators of laboratory and instrumental examinations for admission to the respective lists of hospitalization at Scientific Medical Centre. fracture-dislocation of the spine, chronic bronchitis, blood negative for HIV, hepatitis B negative blood, some reduction in the size of the left kidney;
Conclusion urologist: disruption of the pelvic nitrogen bladder, cystitis secondary.
Operation 1: Front access parafaringialny left, the removal of metal, resection of the body.
Operation 2: rear access, spinal fusion neurological status in the dynamics unchanged, there is not any active movement of the lower limbs.Was output home in a satisfactory condition. recommended: observation by a neurologist, avoid colds and physical activity, occupational therapy courses at the neuropathologist.

Rehabilitation treatment

Some reduction in the size of the left kidney;

Course of rehabilitation treatment is completed, the patient is discharged home in a satisfactory condition. during treatment with positive dynamics. improved overall health. stable hemodynamics, pain in the cervical vertebra.
When you receive a complaint: pain in the cervical spine, enhancing when turning the head. Weakness  and violation sensibility in the limbs, limitation of movement in the hands, disruption of the pelvic weakness.

Physiotherapy

A laser-projection of the bladder: magneto-on the distal upper and lower extremities. bladder to the distal upper and lower extremities: mineral wax on the distal lower extremities massage of the lumbosacral spine of the lower extremities.
postural exercises in neck braces, dosed.