Jack Mautral - Cerebral palsy (United States) Posted on April 17, 2013
Name: Jack Mautral 
Sex: Male
Country: United States
Age: 2
Diagnoses: Cerebral palsy, Optic atrophy, Epilepsy
Admission Date: 2013-03-10
Days Admitted to Hospital: 27 days
Medical History:
Jack Mautral as born when his mother was 29 weeks pregnant. His weight was 1.2kg when he was born. The patient's condition was normal after birth. 1month later, the patient received 2 operations to treat ileus. After being kept in ICU for 10 months, the patient kept the gastrostomy for nutritional support. In the meanwhile, he suffered a epileptic seizure. Then the patient had developmental retardation of intelligent and motor. The EEG in the local hospital showed abnormal electroencephalogram. He was diagnosed with Cerebral palsy and Optic atrophy. The patient received rehabilitation every day. Before the treatment, the patient still couldn't turn over, crawl or walk. He had a speech disorder and could only speak "A". He had poor vision.
Admission PE:
Bp: 80/50mmHg; Hr: 90/min, Br: 22/min. Height: 77cms, weight: 11kgs. He suffered from developmental retardation. The nutrition was normal. The skin and mucosa was normal with no hemorrhaging spots or yellow stains. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no dry or moist rales. The heart sound was strong. The cardiac rhythm was regular, with no obvious murmur in the valves. The abdomen was smooth. There were surgical scars in the epigastrium and right lower quadrant. There was tympanitic sound when tapping the abdomen. There were no masses in the abdomen. The liver and spleen were not palpable under the ribs. There were scars in the left lateral thigh from post skin grafts. There was muscle contracture in the left leg's far end. There was swelling in the left foot. The left lower limb was shorter than the right lower limb.
Nervous System Examination:
Jack Mautral was alert and had a speech disorder. He could only say "A". He couldn't cooperate with the examination of orientation, memory or calculation. He had poor comprehension and could only communicate simply with his parents. Both pupils were equal in size and round, the diameter was about 3.5mms. Both pupils were sensitive to light stimuli. The forehead wrinkle pattern was symmetrical. The nasolabial sulcus was equal in depth. He could move the neck to the left and right side in supine position. His head had poor support in the sitting position. The head was liable to sag or fade sideways. The muscle strength of the back and waist was weak. He couldn't turn over or maintain sitting position independently. Both hands had hand grasp action, but the hold power was poor. Both lower limbs had involuntary movement and could lift off the bed surface. His four limbs couldn't cooperate with the examination of muscle strength. The muscle tone of both upper limbs was normal. The muscle tone of both lower limbs was slightly higher than normal. The abdominal reflexes were normal. The tendon reflex of both upper limbs was normal. The patellar tendon reflex of both lower limbs was slightly active. The left Achilles tendon reflex had disappeared. The right Achilles tendon reflex was active. The bilateral ankle clonus was not elicited. The bilateral sucking reflex was positive. Both palm jaw reflexes were positive. Bilateral Hoffmann sign was negative. The Rossolimo sign of both upper limbs was negative. The bilateral pathological reflex was negative. He couldn;t cooperate with the examination of deep sensation and shallow sensation examination. He also couldn't cooperate with the coordinate movement examination.
Treatment:
After admission, Jack Mautral received the relevant examinations. The patient received treatment to improve the blood circulation in order to increase the blood supply to the damaged nerves, to nourish the neurons and strengthen immunity. He also received treatment for nerve repair and nerve regeneration.
This was combined with physical therapy.
Post Treatment:
The patient's intelligence, vision and muscle strength has improved. The patient smiled when the attending doctor called his name. The patient has some resistance to the nurse before the infusion. He has conscious support or tries to stand up to cooperate with the therapist's exercises. The eyeballs are more sensitive to following light and sound. The right eye is more sensitive. The muscle strength of the four limbs, waist and back are improved. He has better control of his head and the time of raise head is longer. He can turn over by himself.
Email:
Date: 2013-07-12
Good Afternoon Dr
I am sending this e-mail to let you know that my son ran out of folic acid along with calcium.
He's stronger and healthier, and we do not give milk and the change has been better.
We still have not seen big changes in my son, but we are planning our next visit.
I need you could give me the dose of folic acid and calcium, so I can ask for the recipe to doctors here.
Thank you very much I hope all are well
Date: 2013-09-04
Dr. Like Wu, Dr.Liu
Good morning and greetings to all. Hope all are well and their families also.
I would like to inform you that Jack is doing well and is more alert than before, stronger and is recognizing more things. And he is also very bratty. His care plan continues with his daily therapies. With respects to his eating habits, they are much better, he is having only one bowel movement a day and it comes out pasty.
The medications from China are finishing and I wonder if we should continue with the treatment of the medicines.
Please send me the blood tests I should get for Jack in order to send you the results to see if we need to continue
Thank you for everything, I anticipate your response.
Henry
Date:2015-6-9
Good Morning, Susan
Bellow you will find all the details;
87cm - Height
25Lbs - Weight
72/48 - Blood Pressure
70/80s ( Day ) - 50 ( night sleep ) - Heart Rate
30oz - Daily Food intake
8-9 Diaper urine - urine & Stool
2 BM Daily -
Gurgles and gunts - Comunication
Delayed, imitates - Learning
Minimal - Concentration
Peripheral - Visual
Rigid ( hypotonia ) - Movement
Sorry for the delay, I will wait for an answer
Henry Beltran