Lucas Pastorino - Cerebral palsy (Argentina) Posted on October 25, 2012

Name: Lucas Pastorino      
Sex: Male
Country: Argentina
Age: 7
Diagnoses: 1.Cerebral palsy 2. Hydrocephalus post ventriculoperitoneal shunt  3. Secondary epilepsy
Admission Date: September 10, 2012
Days Admitted to Hospital: 28

Before treatment:
The patient was born prematurely by caesarean section. He was delivered by caesarean section at the 29th week of pregnancy. He was the fourth born quadruplet and was diagnosed with hydrocephalus at birth. The patient had hydrocephalus after birth. The patient was presented with mental retardation, motor disorder and development delay when he was 1 year old. At the same time, this was accompanied with epileptic seizures. He went to the local hospital for a ventriculoperitoneal shunt and took related medication to control the epilepsy. The development of intelligence and motor skills was slower than a normal baby after the operation. At present, the patient has no epileptic seizure. He can understand the family member's simple language and could turn over by himself. With some assistance, he could sit up and stand. But he couldn't maintain a sitting or standing position. 

Admission PE:
Temperature: 36.6 degree. Br: 26/min; Bp: 85/45 mmHg, Hr: 89/min, Height: 111.5cms, weight: 15 kgs. The patient was kept in bed. His left upper limb was bending slightly and both lower limbs were bending slightly to the right side. The vertebral column was bending slightly to the right. The movement of left hip joint was limited and outreach was insufficient. The head had no deformity. The respiratory sounds in both lungs were clear, with no dry or moist rales. The heart sound was strong. The cardiac rhythm was not regular, with no obvious murmur in the valves. The abdomen was smooth and soft. The abdominal muscle was slightly tight. The liver and spleen were not touched under the rib.

Nervous System Examination:
Lucas Pastorino was alert and his spirit was slightly weak. Oligophrenia. He was unable to cooperate completely with the physical examination. He had no language ability and could only make simple sounds. He could understand the family member's simple language. His pupils were unequal in size, the diameter of the right was about 4.0mms and the diameter of the left was about 3.5mms. Both pupils were slow reacting to light reflex. The movement of the eyeballs was not flexible. There was no blepharoptosis. The bilateral nasolabial sulcus was unequal in depth. The left side was shallower than the right side. The tongue was centered in the oral cavity. The soft palate could be raise normally. The uvula was in the center. The pharyngeal reflex existed. There was obvious gum hypertrophy. There was facial paralysis of left side. He couldn't cooperate with other cranial nerve examination. Neck had no resistance. The neck move flexibly. He needed great efforts to raise head. The muscle strength was weak and the left side was more severe. Both upper limbs had active movement and right upper limb was more flexible. The grasp ability of right hand was normal, but the left upper limb was poor. He had evasive action if he suffered from pain stimulus. He couldn't cooperate with the examination of muscle strength. He could turn over by himself. With the assistance of a family member, he could sit up and stand. But he couldn't sit up or stand by himself. The muscle tone of both upper limbs was almost normal. The muscle tone of both lower limbs' outside was normal. The adduction muscle tone of both lower limbs was higher than normal. The tendon reflexes of four limbs were almost normal. Bilateral ankle clonus was negative. Bilateral abdominal reflexes was elicited slightly. Bilateral palm jaw reflex was positive. Bilateral Hoffmann sign was negative. Bilateral Babinski sign was negative. He couldn't cooperate with coordinate movement and sensory system examination. The meningeal irritation was negative.

Treatment:
After admission, Lucas Pastorino received the relevant examinations and was diagnosed with Cerebral palsy. The patient received treatment to improve the blood circulation in order to increase the blood supply to the damaged nerves and to nourish the neurons. This was combined with neurological rehabilitation treatment. 

Post Treatment:
The patient's comprehension and response are improved. Both pupillary reflexes are more flexible. He can raise his head more easily. Left upper limb has more flexible movement. He has lifting action consciously. Bilateral abdominal reflexes are more flexible. The muscle strength of left upper limb and both lower limbs are increased and the movement is more flexible. The muscle strength of left upper limb has reached level 3. The muscle strength of right lower limb is obviously increased. The right lower limb can lift off the bed surface and the muscle strength reached level 3-.

Lucas's family member email to us:

2012-11-21

Dr Susan Chu

HOLA DR WU SOY LA MAMÁ DE LUCAS PASTORINO,LE ENVIÓ LOS ESTUDIOS BIOQUÍMICOS .
LUCAS ESTA BIEN CON LOS TRATAMIENTOS DE REHABILITACIÓN.

SALUDOS MARÍA ROSA

2013-01-14

Hello doctor,
I'm sending you the results of Lucas Pastorino's medical studies.
He's finishing the medicine he's been taking for 3 months, that's folic acid, pantoprazole, mosapride. Does he have to go on taking any of these medicine?
He's improved his hip and his muscular mass, he can now sit cross-legged for a whil.

saludos
MARÍA ROSA

Date: 2013-05-28

Hello Dr Peng,
Dr Wu has sent you Lucas' last medical record.
He's much better: his attention, He's developed his muscles, his trunk is better too.
His sight is better, he can fix his eyes and he can control his head, he can sit for a while and his hip is better.
He's taken the prescribed medicine for 6 months. We'd like to know if he has to go on taking any other medicine.
saludos
Maria Rosa