Case Stusies
Gao Yizhe
Gender: Male
Age: 3 years old
Admission Details
The patient experiences difficulties in independent walking due to delayed language and intellectual development. Currently, the patient's intellectual and language development lags behind peers. Speech expression is not very clear and fluent, and independent standing appears unstable. Walking independently is also challenging, with a tendency to walk on tiptoes during assisted walking. Fine motor skills in both hands are limited, preferring a gross grasp when holding objects. Despite these challenges, the patient's cognitive understanding remains at a relatively good level. Since the onset of the condition, the patient has maintained clear consciousness, a generally good mental state, normal eating and swallowing functions, occasional drooling, and awareness of the need for assistance in toileting.
Admission Diagnosis: Cerebral Palsy, Brain Maldevelopment.
Treatment Process:
The patient underwent comprehensive examinations upon admission, including the three major routine tests, liver, gallbladder, pancreas, spleen, kidney, heart color ultrasound, electrocardiogram, electroencephalogram, etc. No surgical contraindications were identified based on the examination results, and the patient met the conditions for surgery. On June 21, 2021, at 14:00, the patient underwent a robot-assisted frameless stereotactic brain procedure under general anesthesia. Postoperative head CT revealed no significant bleeding, and the target was accurately reached. After the surgery, the patient returned to the ward in a stable condition, received routine intravenous fluid therapy, and was provided with oxygen and cardiac monitoring. The patient's vital signs are being closely monitored.
Discharge Summary:
The patient is currently in good mental condition, and their language is clearer than before the surgery. The muscle tone in the lower limbs is reduced compared to pre-surgery. General condition is still acceptable, with normal sleep and diet, and no abnormalities in bowel and bladder function. The patient is alert, mentally stable, with a regular heart rhythm, and no abnormal sounds have been detected. The surgical incision has been sutured and is healing well, with no signs of bleeding or swelling.
Discharge Instructions:
1. Rest, strengthen protection, avoid vigorous head movements, ensure wound dryness.
2. Commence rehabilitation training based on the patient's language and motor recovery.
3. Follow-up appointments regularly after discharge.