 |
| |
ANA MARIA
|
First name: Ana-Maria
Last name: Lautaru
Birth date: 07 September 2002
Hospital entry date: 25 June 2006
DIAGNOSTIC:
1. Brain paralysis – mix form (extra pyramidal system)
2. Psycho-motor retardation
3. Convulsive crises straight focal secondary generalized
The patient, aged 3 years and 10 months, was born prematurely and required resuscitation maneuvers. She was transferred from the “Grigore Alexandrescu” Hospital for clinical, sub clinical and therapeutic evaluation.
The patient is know to have the Spastic Paraplegia disease from the age of 8 months. She followed this treatments: Eacephanol (?), Cerebrolysiu, Tanakan, Vitamin B Complex and Kinesitherapy.
Convulsive crises straight focal secondary generalized appear when she was 2 years old. She had a total of 4 crises with the first 3 of them producing small fever and with the 4th one entering in status epilepticus.
The pacient is now under close observation of Dr. Ciocea and is receiving a treatment based on Timonil (4 + 4 + 6.5ml per day).
CT cerebral was taken at the age of 8 months. Cortical atrophic.
Clinical exam when the patient arrived: average health condition, weight = 13Kg, P.C = 47 ?, pale teguments, equilibrated cardiopulmonary and digestive.
Neurological exam when the patient arrived: it’s looking with the eyes inconstantly, left eye strabismus. Spastic paraplegia observed mostly as spastic diplegic. Keeps the head inconstantly and doesn’t stay in the sit position. Looks like doesn’t have any sensibility disorders, it’s conscious and sometimes it’s able to pronounce complete words like “mom”, “dad” and “bye, bye”. |
|
|
|
