Mohsin Islam-Spinal Cord Injury-(Pakistan)

Name: Mohsin Islam
Sex: Male
Nationality: Pakistani
Age: 35Y
Diagnosis: Spinal Cord Injury

Before treatment:
The patient went to hospital 19 months ago due to a fall and his head hitting a cabinet. His limbs were unable to move so he was taken to hospital and diagnosed with a spinal cord injury. He had  surgery and did rehabilitation training but 27 days later his condition was not improved. He can only lie in the bed and can’t take care of himself. He can move part of his arms but not his legs so he was unable to move. There is no sensation function below C5 and he also had gatism.
His spirit is normal, his diet and sleep are normal. He has gatism, defecates once in 2-3 days and has catheterization for urination.

Admission PE:
Bp: 133/85mmHg, Hr: 54/min, breathing rate: 25/min, body temperature: 36.0 degrees. He has normal physical development and nutrition status. The skin and mucosa do not have yellow stains or bleeding points. There is a bedsore on his buttock with a diameter around 1.5cm. There is an 8cm scar tissue post surgery on the neck. Chest development was normal, the breathing sounds of both lungs were clear with no rales. Heart beat was powerful and regular with no murmur. The abdomen was soft and bulging with no tenderness, liver and spleen were in the normal position.

Nervous System Examination:
Patient was alert, his mental status was good and he had clear speech. The memory, calculation and orientation abilities were normal. Both pupils were equal and round with a diameter of 3mm and react well to light. The eyeballs can move freely. The forehead wrinkle is symmetrical, showing teeth and tongue extending out were normal.  His neck can move freely and he can turn his neck and shrug as normal. The arm deltoid muscle power was 5 degrees, the proximal side cannot lift up off the bed. The distal flexor muscle power was 4 degrees, extensor muscle power was 3 degrees and he can touch his head. The grip force was 0 degrees, his left hand fingers had contracture and cannot open at all. The arm muscle tone was normal, muscle power of the legs was 0 degrees, with high muscle tone. Patient had normal sensory response up to the C5 level. There was obvious hypaesthesia between C5-T4 level, no deep sensory response below T4 level. The tendon reflex of the arms was normal, the knee jerk and Achilles tendon reflex was active. Ankle clonus was positive. Bilateral abdomen reflex cannot be induced by examination. His right side Rossilimo sign, Hoffmann sign were positive and left side Rossilimo sign and Hoffmann sign were negative. The bilateral Babinski sign was positive. The 4 limbs coordinated movement test cannot be performed because of weakness. The meningeal irritation sign was negative.

After the admission, he received related examinations and received 3 times nerve regeneration treatment to repair his damaged nerves, replace dead nerves, nourish nerves, regulate his immune system and improve blood circulation. This was done with rehabilitation training.     

After 14 days treatment his bedsore was better, the muscle power of the arms  increased, he was able to raise his arms above the bed. Some fingers can now start to move again and he can grasp better. Both legs muscle tone decreased and the time of his post exercise muscle spasm reduced. His joints were more flexible.

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