Sex: Male
Age: 4 years
Birthplace: Russia
Admission Time: 2012-08-16
Discharge Date: 2012-11-11
Admission: The vertical head less stable, can rise his hands bed, stand up to, would belly crawl, can pose a four-point support, sitting alone for up to 10 minutes, when the lower limbs protective kick set up, sharp enough, not a cross Obviously, a lot of hands can grip, fine poor, children with poor eyesight, hearing, chasing sound responsive, able to say, "Dad, Mom, grandfather, uncle," others will not, dysarthria less clear, Shenshe flexible, can chew, no drooling, no drinking cough, poor comprehension.
Physical examination: T: 36.3 ℃, P: 98 beats / min, R: 25 beats / min, clear mind, spirit can, poor eyesight, light reflex. Examination uncooperative, upper limbs IV level, bilateral muscle tension Class I, Class III lower extremity muscle strength, muscle tone II level, adductor angle: 40 °, hip angle: 30 ° / 30 °, popliteal fossa angle: 110 ° / 110 °, dorsiflexion angle: 105 ° / 105 °, knee tendon hyperreflexia, double Pakistan's sign positive, ankle clonus not elicited.
Admission diagnosis: cerebral palsy (hybrid, severe) mental retardation, optic atrophy
Hospitalization program: admission-round 360 ° meticulous assessment, using Kang minimally invasive surgical needle Stubbs, Kang Chinese medicine balance therapy, rehabilitation therapy combined with Kang 4T.
Discharge conditions: children vertical head basically stable, flexible stand than before, sitting cross-legged pose longest 50 minutes, belly crawl increased awareness, reflex spasm improved significantly, decreased muscle tone.
Discharge Instructions: Continue the family rehabilitation.
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