Case Stusies
Sun Jiahui
Gender: Female
Age: 4 years and 10 months
Admission Details:
The patient experienced complications during birth, including the umbilical cord around the neck and murky amniotic fluid, necessitating resuscitation in the intensive care unit. Developmental delays have persisted compared to typical children. To date, the patient is unable to sit, walk, or stand independently. There is increased muscle tone in all four limbs, with curled fingers and difficulty in straightening them. Fine and gross motor skills are impaired. There is no history of seizures, fever, dizziness, or headaches. The patient can communicate verbally, possesses adequate cognitive understanding, and maintains stable emotions. Normal eating and sleeping patterns are observed. Seeking further diagnosis, the patient was admitted to our hospital with the provisional diagnosis of "cerebral palsy." Since the onset of the condition, the patient has remained clear-minded, in good spirits, with normal eating and voiding habits, and no significant weight changes.
Admission Diagnosis: Cerebral Palsy.
Diagnostic and Treatment Process:
After admission, comprehensive examinations were conducted. On July 31, 2020, at 09:30, the patient underwent a robot-assisted frameless stereotactic brain surgery under general anesthesia. The surgery proceeded smoothly. Postoperatively, routine intravenous fluids were administered, and oxygen supplementation and cardiac monitoring were provided. No specific discomfort occurred, and the patient is scheduled to be discharged today.
Discharge Summary:
The patient's condition is currently stable. Emotionally stable, the surgical wound shows no signs of bleeding or swelling. Muscle tension has decreased compared to before, no abnormal lung sounds or pleural friction rubs detected. Heart rate is 102 beats per minute, regular rhythm, and no abnormal sounds.
Discharge Instructions:
1.Rest and avoid vigorous head movements after discharge.
2.After discharge, inspect and change the dressing of the surgical wound daily, ensuring it stays dry. Remove the stitches after 5 days postoperatively.
3.If any discomfort arises, seek medical attention promptly.