Name: Albert
Sex: Male
Country: England
Age: 13 months
Diagnosis: Sequela of ischemia oxygen deficiency brain damage
Admission Date: 2011-06-27
Days Admitted to Hospital: 31

Albert is a 13 month old male. His development was delayed beginning with complications during the 36th week of his mother's pregnancy. He was born by cesarean section. The Apgar score was 9 at birth. At the hospital, the baby suffered a cardiac arrest. The cardiac arrest lasted several minutes and soon after it ended the vital signs returned to normal and he was soon discharged from the hospital. At 3 months old, Albert experienced convulsions and when his parents brought him to the local hospital, he was diagnosed with epilepsy. His symptoms improved soon after being prescribed antiepileptic medication for treatment. At the time that Albert was admitted to our hospital he was suffering from frequent epileptic seizures again, which mainly occurred while he was awake. His vision was impaired and the cognitive development was delayed, and there were also problems with speech development. Genaro also had difficulty raising his head. He was unable to sit up, turn over or crawl by himself.

Admission PE:
Bp: 80/50mmHg; Hr: 103/min, Br: 22/min. Height: 69cms, weight: 9.5Kgs. There were no obvious abnormalities with the mucous membrane. The facial skin was presented as a dull yellowish color. The thorax was symmetrical. The respiration in both lungs was clear, with no dry or moist rales. The heart rate was faster than normal and the heart rhythm was regular. There was no obvious murmur in the valves. The abdomen was soft with no palpable masses. The liver and spleen were normal.

Nervous System Examination:
Albert was conscious, and has mental retardation. There was no response when others called his name. He could cry and smile. The speech development was delayed. He could only speak simple words and had difficulty with swallowing. Both pupils were equal in size and round, the diameter was about 3.0mms. Both pupils were slow to respond to light stimuli. The eyeballs were not able to follow moving objects and Genaro had difficulty with the examination of the vision and visual field. He did respond to the sound of voices. The ability to raise his head was poor and he was unable to sit up, stand or walk independently. All four limbs had some movement ability. The left hand couldn't grasp things and the left arm could not be lifted off the surface of the bed. The right hand was able to grasp things and the right arm could be lifted off the surface of the bed. Albert couldn't cooperate with the examination of the muscle strength. The muscle tone of four limbs was almost normal. The tendon reflexes of all four limbs were normal, the sucking reflex was negative, the bilateral palm jaw reflex was negative, and the bilateral Babinski's sign was negative.

Treatment:
Albert received a complete examination, and he was diagnosed with sequela of ischemia oxygen deficiency brain damage. He received treatment to control the epileptic seizures, improve the blood circulation, and nourish the neurons. He also received neural stem cell activation treatment. This was accompanied with physical rehabilitation.

Post-treatment:
Albert's condition has improved gradually. His height is now 73cms, the epileptic seizures have decreased, and the length of the time of loss of consciousness has decreased. The seizures still affect the left arm. The clenching of the teeth has almost disappeared. The muscle strength in the neck has increased. He can turn and raise his head more freely. The left hand can grasp objects and both lower limbs can move more flexibly and are stronger. He can maintain a four-point support with his arms and legs with some assistance. While sitting up, he can turn to the left side and right side 90 degrees.

2011-09-14

"DR Tian,

Albert general condicion is good, hi has good color, but only two days ago he can not do poop good, only with suppository.

thanks."

2011-11-23

Good Morning Dr. TIAN

I am writing to you again, because in this week Albert is making seizures whith his teehs, i check the sodium valproato in blood and this is the resoult , what do you think???

rango terapeutico: 50.0 - 100.0 ug/ml

vallor hallado: 89,00 ug/ml

i told you that Albert is strong whith the legs, but he can not even hold his head. And his his eyes, he is better whith movement an i say thanks God, thanks thanks to you.

2012-03-22

DR. Tian, hello
 

We get in contact to tell you Albert's situation:

- Medication: Regarding the medication he is still taking the medications and dose as you have prescribed. He is taking flunarizina from Monday to Friday. We want to know how long more should take Albert?

- Albert's evolution: he has grown 5 cm, and his weighs by 9 kgs. He can sit alone for only a few seconds, he don´t have head and trunk control yet, he can stand up and walk few steps. I send you a video.

- Vision: We have not see any advance yet. Sometimes, seems that he responds to light but at other time nothing

- Cognitively, responds to commands but he don't play alone.

- Epilepsy: We have not made any new study. We noticed that when he sleep makes movements with his legs like a whip, sometimes wakes up and other doesn't.

2012-12-31

Hello Dr. Tian
I have de result of the blood exam from Genaro, i am not sure how to traduce it so i send to you in spanish, can you read it ?

Genaro is better than the last time i send this email. althoug the epilepsy dose not disappear and in the morning he is tired.
He is more attentive. He can stand a bit stronger.

i will wait for your answer, thans a lot.


Best Regards
gabriela

Date: 2013-02-28

HELLO. Doctor Tian,

I have de result of the blood exam from Genaro, This month.
Genaro is better than the last time i send an email. althoug the epilepsy dose not disappear and in the morning he continues been tired.
He is more attentive. may be He is stronger.

I ask the doctor´s genaro here, to see the exam, he said that all is good.

i am sending to you this exam and when i have the new one, i will contact you again.

i will wait for your answer about this axam and what you think, thans a lot.


Best Regards
gabriela