Mohamed Amin Abdullateef-Sequel of SCI-(Egypt)-Posted on May 13th, 2015

Name: Mohamed Amin Abdullateef          
Sex: Male
Country: Egypt
Age: 32 years
Diagnosis: Sequel of Spinal Cord Injury
Date: Apr. 12th, 2015
Days Admitted to Hospital: 18 days

Before treatment:
On July 22, 2013, the patient had penetrating wound at waist and abdomen. It was caused by fire arm, and that caused spinal cord injury. He had motor and sensory disturbances of both lower limbs, urine incontinence and had difficult to defecate. He had treatment in a local hospital and was diagnosed with spinal cord injury. After 2 months of rehabilitation training, he could sit day by day. His lower limbs muscle were depauperated. He couldn’t care himself. He wanted a better treatment so he came to our hospital and he was diagnosed with sequel of spinal cord injury.

His spirit was good. His diet and sleeping were good. He had urine incontinence and couldn’t defecate himself. He defecated with glycerin suppository 3 times a day. His weight was normal.

Admission PE:
Bp: 115/72mmHg; Hr: 77/min. Temperature: 36.5 degrees. Br: 18/min. His body type was good, and well nourished. There was no yellow stains or petechia on mucous membrane. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no obvious moist or dry rales. The heart sounds was strong, the rhythm of his heartbeat was normal. There was no obvious murmur in the valves. The abdomen was flat and soft, with no obvious masses. There was no pressing pain. There was an operative wound scar in the middle abdomen, the size was around 15 cm. The liver and spleen were normal.

Nervous System Examination:
Mohamed Amin Abdullateef was alert and his speech was fluent. His memory, calculation and orientation abilities were normal. Both pupils were equal in size and round, the diameter was 3.0 mms, both eyeballs could move freely. Both eyes had sensitive response to light stimuli. The forehead wrinkle pattern was symmetrical. The tongue was centred in the oral cavity and the teeth were shown without deflection. The neck moved almost normal. The muscle tension of both upper limbs was normal, the muscle power was at level 5. The muscle tension of both lower limbs was lower, the muscle power was at level 0. The depth feeling was normal above T1, T11-T12 was lower. The depth feeling under L1 disappeared. Both upper limbs tendon reflex was normal. Both knee reflex and achilles reflex were abnormal. Both side abdominal reflexes were reduced. Bilateral Babinski sign was neutral. The examination of coordinate movement of both lower limbs couldn’t be examined. The meningeal irritation sign was negative.

Treatment:
We initially gave his a complete examination and he was diagnosed with sequel of spinal cord injury. He received treatment to nourish neurons, improve circulation. We also gave him daily physical rehabilitation.

Post-treatment:
His endurance was better. The lower limbs’ muscle had slight contraction. He could control adduction and abduction a little when he passively flex the knees. His muscle power was at level 1. The depth feeling level declined from T12 to L4. The superficial sensibility level declined to L2.