Shahad - Sequelae of brain injury (Saudi Arabia) Posted on June 1, 2012
Name: Shahad Saleh Al Hamdan 
Sex: Female
Country: Saudi Arabia
Age: 20
Diagnoses: 1.Sequelae of brain injury 2. Low pigment-small-cell anemia
Admission Date: April 14, 2012
Days Admitted to Hospital: 29
Shahad was involved in a car accident in 1996. After going to the hospital she was diagnosed with a brain injury. She also suffered an abdominal injury and a fracture to the right humorous. Two days after being treated at the hospital, Shahad fell into a coma. The CT of the head revealed a hemorrhage. Shahad received an exploratory laparotomy and the results showed a transverse colon and damage to the spleen and appendix. So she underwent a transverse colon resection, anastomosis, splenectomy, appendectomy and gastrostomy. During the treatment, Shahad suffered a severe lung abscess, hydrothorax and septicemia. After the 2 and a half month treatment, the Glasgow score was between 10 and 11 points. One month after being discharged from the hospital, Shahad was able to open her eyes as well as cry, but she had difficulty controlling her emotions. Her speech was impaired. Seven months after the trauma, the language ability was restored to normal. Shahad was able to eat normally and participated in a regular physical rehabilitation training program. One year after the trauma her condition had greatly improved and she was able to walk one or two steps. After falling and injuring herself, she was not able to walk again. At present, Shahad is alert and in good spirits as well as having good cognitive abilities, but she still has movement impairment in the arms and legs.
Admission PE:
The skin and mucosa were normal, with no stained yellow spots or petechia. There were superficial lymph nodes throughout the body, but there were no swollen lymph nodes found. There were several surgical scars on the left forearm, right upper limb and abdomen. The movement of the right shoulder joint was limited and could only extend outward to 60 degrees. The movement of the right elbow joint was limited and could only extend to 90 degrees. The movement of the right wrist joint and finger tips were limited. With passive movements, the left hand could open slightly. There were no yellow stains in the sclera. There was no cyanosis in the lips. The respiratory sounds in both lungs were clear with no signs of dry or moist rales. The heart sounds were strong, and the heart rhythms were regular. The abdomen was smooth and soft, with no obvious masses. The liver and spleen were not palpable under the ribs.
Nervous System Examination:
Shahad was alert and responsive. The speech was normal. The memory, orientation and calculation abilities were normal. The diameter of the left pupil was 4.0mms and had slow responses to light stimulus. The diameter of the right pupil was 3.0mms, and was sensitive to light stimulus. The left shoulder shrugging ability was strong. The right shoulder had weak shrugging ability. The muscle strength of the left upper limb was level 5; the muscle strength of the right upper limb was level 2. The holding power of the left hand was level 4+, the holding power of the right hand was level 2. The muscle strength of both lower limbs was level 2. The muscle tone of the left upper limb was normal. The muscle tone of the right upper limb and both lower limbs were increased. The bilateral radial periosteal reflex, biceps reflex, triceps reflex and patellar tendon reflex were active. The bilateral Achilles tendon reflex was not elicited. The bilateral abdominal reflexes were normal. The bilateral palm jaw reflex was negative. The bilateral Hoffmann's sign, Rossolimo's sign and Babinski's sign were negative. The bilateral shallow sensation and deep sensation were almost normal. The left side was able to finish rapid rotation test, digit opposition test and finger-to-nose test, but in clumsy manner. The right side had difficulty with the rapid rotation test, digit opposition test and finger-to-nose test. Both sides had difficulty with the heel-knee-shin test. Shahad had difficulty with the Romberg`s sign test.
Treatment:
We initially gave Shahad a complete examination, and she was diagnosed with: 1.Sequelae of brain injury 2. Low pigment-small-cell anemia. She was then given treatment in order to expand the blood vessels, nourishment for the neurons and anti-anemia treatment. This was combined with physical rehabilitation training.
Post-treatment:
After the treatment, the range of motion of the right shoulder joint and elbow joint increased. The right shoulder joint can be extended outward to 90 degrees and the right elbow joint can extend to 135 degrees. The shrugging strength of both shoulders has increased. The holding power of the right hand increased. The muscle strength of the right limbs has increased and has now reached level 3-. In horizontal position, the right lower limb can be raised off the bed surface 5-8cms. And the patient's right lower limb can stretch better and straighter than before. The muscle tone of the right upper limb and both lower limbs has decreased.
The second treatment:
Name: Shahad Saleh Al Hamdan
Sex: Female
Country: Saudi Arabia
Age: 21
Diagnoses: 1.Sequelae of brain injury 2. Secondary epilepsy
3. Low pigment-small-cell anemia
Admission Date: 2013-03-04
Days Admitted to Hospital: 26 days
Before treatment:
Shahad was involved in a car accident in 1996.After the accident, she was alert. She was sent to hospital and diagnosed with a brain injury. She also suffered an abdominal injury and a fracture to the right humorous. Two days after being treated at the hospital, Shahad's diasease was aggravated and fell into a coma. She was went over big hospital and the Glasgow score was 7. The CT of the head revealed a hemorrhage of cerebral hemisphere and encephalocoele. The patient received ventrideperitoneal cavity and right humeral fracture. Shahad received an exploratory laparotomy and the results showed a transverse colon and damage to the spleen and appendix. So she underwent a transverse colon resection, anastomosis, splenectomy, appendectomy and gastrostomy. During the treatment, Shahad suffered a severe lung abscess, hydrothorax and septicemia. After the 2 and a half month treatment, the Glasgow score was between 10 and 11 points. One month after being discharged from the hospital, Shahad was able to open her eyes as well as cry, but she had difficulty controlling her emotions. Her speech was impaired. Seven months after the trauma, the language ability was restored to normal. Shahad was able to eat normally. Her spirit was good and the intelligence was almost normal. She continue with a regular physical rehabilitation training program. But she still couldn't walk. She couldn't open fingers or grasp objects. She took carbamazepine to control epilepsy.
Admission PE:
Bp: 133/90mmHg; Hr: 85/min, Temperature: 36 degrees. The skin and mucosa were normal, with no stained yellow spots or petechia. There were superficial lymph nodes throughout the body, but there were no swollen lymph nodes found.There were several surgical scars on the left forearm, right upper limb and abdomen. The movement of the right shoulder joint was limited and could only extend outward to 90 degrees passively and extend outward to 60 degrees actively. The movement of the right elbow joint was limited and could only extend outward to 180 degrees passively and extend outward less than 135 degrees actively. The movement of the right wrist joint was limited completely and only extended outward to 10 degrees actively. The movement of the right fingertip joints was limited completely. The fine motor skill of right fingers was poor. The movement of the left upper limb was not flexible. The fine motor skill of left fingers was poor. There was no hyper-anemia or paleness in the conjunctiva. There were no yellow stains in the sclera. There was no cyanosis in the lips. The respiratory sounds in both lungs were clear with no signs of dry or moist rales. The heart sounds were strong, and the heart rhythms were regular. There was no obvious murmur in the auscultatory valve areas. The abdomen was smooth and soft, with no obvious masses. The liver and spleen were not palpable under the ribs. There was tympanitic sound when the doctor knock it. The bowel sounds were normal through auscultation. There was no edema in the lower limbs.
Nervous System Examination:
Shahad was alert and responsive. The speech was normal. The memory, orientation and calculation abilities were normal. The diameter of the left pupil was 4.0mms and had slow responses to light stimulus. The diameter of the right pupil was 3.0mms, and was sensitive to light stimulus. Both eyeballs could move freely, with no diplopia. The vision in both eyes was almost normal. The forehead wrinkle pattern was symmetrical. Both eyelids had strong closing ability. The bilateral nasolabial sulcus was equal in depth. The tongue was centered in the oral cavity. The soft palate could be raised strongly. The neck could be turned in both directions flexibly. The left shoulder shrugging ability was strong. The right shoulder had weak shrugging ability. The muscle strength of the left upper limb was level 5; the hold power of the left hand was level 4. The muscle strength of the left lower limb was level 2. The muscle strength of the right upper limb was level 3+. The muscle strength of the right lower limb was level 3-. The muscle tone of the left upper limb was normal. The muscle tone of the right wrist joint and both lower limbs' adductor was slightly higher than normal. The bilateral radial periosteal reflex, biceps reflex, triceps reflex and patellar tendon reflex were active. The bilateral Achilles tendon reflex was not elicited. The bilateral abdominal reflexes were normal. The bilateral palm jaw reflex was negative. The bilateral Hoffmann's sign, Rossolimo's sign and Babinski's sign were negative. The bilateral shallow sensation and deep sensation were almost normal. The left side was able to finish rapid rotation test, digit opposition test and finger-to-nose test. The right side had difficulty with the rapid rotation test, digit opposition test and finger-to-nose test. Both sides had difficulty with the heel-knee-shin test. Shahad had difficulty with the Romberg`s sign test. There were no signs of meningeal irritation. The labortory test showed the hemoglobin:105g/L,the level was low.
Treatment:
We initially gave Shahad a complete examination, and she was diagnosed with: 1.Sequelae of brain injury 2. Secondary epilepsy 3. Low pigment-small-cell anemia. She was then given treatment in order to expand the blood vessels, nourishment for the neurons and anti-anemia treatment. She also received treatment for nerve repair and nerve regeneration. This was combined with physical rehabilitation training.
Post-treatment:
After the treatment, the anemia is disappearred. The range of motion of the right shoulder joint and elbow joint increased. The right shoulder joint can be extended outward to 100 degrees passively and extended outward to 70 degree actively. The range of motion of the right elbow joint has increased and reached 135 degrees. The range of motion of the right wrist joint has increased about 15 degrees. The movement of the right fingertip is better than before and had slight movement. The movement of the left upper limb is flexible. The fine motor skill of the left hand has increased.The muscle strength of the right lower limb is improved and reached level 3+. The right lower limb can lift off the bed surface 10cm. The patient's blood pressure was higher than normal during the hospital stay about 138/90mmHg. The patient received treatment to adjust the blood pressure. She also took carbamazepine for anti-epileptic. The dose of carbamazepine has reduced to 100mg, 2 times a day.
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