Name: Lucio Gonzalez
Sex: Male
Country: Argentina
Age: 2 and a half years
Diagnoses: Cerebral palsy, Hypoxic-ischemic brain damage
Date: September 8, 2014
Days Admitted to Hospital: 26 days

Before treatment:
The patient was born normally. There was no abnormalities from birth to 8 months. The patient ate cheese when he was 8 months old, then suffered from heavy vomiting. This resulted in diaphragmatic hernia. Patient suffered from viscera shift (include stomach, small intestine, colon, lungs and heart). The patient received operation for therapy. After the operation, the patient suffered from heartbeat apnea. The patient received trachea cannula and ventilator for breathing. He also received Gastrostomy. Then the patient suffered from epileptic seizure and took Levetiracetam and Sodium valproate for treatment. The patient had no epileptic seizure in recent 4 months. Before the treatment, the patient maintained the trachea cannula. He ate through Gastrostomy fistula. He suffered from asyndesis. There was no autokinetic movement in his four limbs. He could turn his head left side and right side. He was unable to turn over, sit - up, stand or walk. For further therapy, the patient came to our hospital.

From the onset of disease, the patient had normal spirit. The sleep quality was good. The defecation and urine routine were normal. There was no familial or hereditary disease.

Admission PE:
BP: 104/60mmHg, HR: 98/min, HT: 86cm, WT: 15kg. The nutrition was almost normal. Height: 74cm, weight: 10 Kg. The skin and mucosa was intact, with no yellow stains or petechia. In the middle of neck, an intubator could be observed. The incision site had no swelling, no observable secretions. There was no congestion in throat. The respiratory sounds in both lungs were rough and dry rales can be heard from time to time. The heart sounds were strong and cardiac rhythm is regular but a little faster with no obvious murmur. The abdomen was flat and soft. A filling tube can be seen in the left upper abdomen. There was no swollen or secretions around. There was no pressing pain or rebound tenderness. The liver and spleen were not enlarged.

Nervous System Examination:
The patient was alert. He didn't have any vowels. He could not cooperate with memory, orientation and understanding test. Both pupils were equal in size and round. The diameter was about 3.0 mm. Both eyes had sensitive reflex to light stimuli. Both eyes stared forward and his eyeball was unable to follow the light. The forehead wrinkle pattern was symmetrical. Bilateral nasolabial sulcus was equal in depth. He could not perform tonguing out and displaying teeth. He could not cooperate with examination for muscle strength of four limbs. Four limbs had no any autonomous movement. He was unable to turn over, maintain a sitting posture, stand or walk. The muscle tone of four limbs was higher than normal. Bilateral brachial II reflex was active, radial periosteal reflex was normal. Bilateral knee and achilles tendon reflex was active. Bilateral abdominal reflex cannot be elicited. Bilateral Hoffmann sign was negative. Bilateral sucking reflex was negative. Bilateral grasping reflex was negative. The Babinski sign was positive. He had difficulty with the examination of sensory system and coordinate movement. There was no meningeal irritation.

Treatment:
After admission, we gave Lucio Gonzalez a complete examination and the patient was diagnosed with cerebral palsy. He received treatment for nerve regeneration and to activate stem cells in the body. He was also given treatment to improve the blood circulation in order to increase the blood supply to the damaged nerves and nourishment for the neurons and. The therapy is also to helps him to restore neural function. This was combined with daily physical rehabilitation therapy. When the patient was admitted, he was found to have too many respiratory secretions. Much white sputum were gotten through the intubator and those white sputum were cultured and analyzed of which result showed A. lwoffi acinetobacter. He was diagnosed with respiratory tract infection. He was given corresponding anti - inflammatory treatment.

Post-treatment:
After treatment, the infection of lungs has been under control. The cough and phlegm are scarcely seen. There were no dry or wet rales heard from the lungs. The muscle tone of four limbs has reduced. The muscle strength of waist and back has improved and he can keep a sitting posture for about 10 minutes.