Hospital discharge report No. 28788

Kirill Ilyich Batishchev

Date of birth: 04/30/2013

The child was cured in Department of psychoneurology for infants in State institution "Voronezh Regional Children’s Hospital No. 1” from 10/07/2013 till 11/03/2013.

 Main diagnosis: Infantile cerebral paralysis, spastic tetraplegia (G 80.8),

disorder of psychomotor development (F83) due to severe  organic lesion of Central Nervous System. Symptomatic epilepsy (West syndrome) (G 40.6).

Life history:

The child is from second pregnancy.  Recent toxicosis (7-10 weeks).  Midpregnancy ARVI (27-28 weeks).The mother was on L-thyroxine during pregnancy. Vaginal birth (oxytocia – 3 hours). Premature delivery - 32 weeks due to early discharge of amniotic fluid.  Birth weight – 2030g. Length of the newborn - 45 cm. Head circumference – 31cm.  Apgar score – 6/7.

At the present time the baby cannot hold his head up, fixes his eyes on a subject for a short time, slowly forms orientating response to sounds.

           The child has vaccination exemption.

Medical history:

The baby was born in spontaneous premature vaginal delivery on the 32nd week. He was taken immediately to neonatal intensive care unit straight from the delivery room. Due to respiratory distress syndrome (congenital pneumonia)  the baby was put on artificial lung ventilation apparatus.

After 7 days he was allowed to breathe independently and was moved to premature baby pathology department. On the 14th day he started to suckle. Since the 24^th day he is on exclusive breastfeeding.

During 6 months the child has been under 4 courses of medical treatment in Voronezh Regional Children’s Hospital.

07/05/2013 - 05/24/2013 Premature baby pathology department №3

Diagnosis:

Cerebral Ischaemia of 3rd degree, Bilateral Intraventricular hamorrhagge of 3rd degree, periventricular leucomalacia,  syndrome of pyramid insufficiency. Birth trauma of cervical spine (dislocation of vertebra C1-C2).

06/26/2013 – 07/09/2013 Premature baby pathology department №1

Diagnosis:

Motor skills disorder. Multicystic encephalomalacia. Epileptiform activity on EEG.

08/05/2013 – 08/12/2013 Department of psychoneurology for infants

Diagnosis:

Syndrome of severe bilateral pyramid insufficiency. Slowing of psychomotor development. Periventricular leucomalacia. Communicating vicar hydrocephalus.

10/07/2013 – 11/03/2013 Department of psychoneurology for infants

Diagnosis:

Infantile cerebral paralysis. Disorder of psychomotor development . Symptomatic epilepsy (West syndrome).

The child was taken to hospital to conduct anticonvulsant therapy.

Physical examination:

Weight -7400g. Length -68cm. Head circumference – 42cm. Mesosomia. Smooth skin cover. Respiratory rate 28per min. Doughy stool.

Neurological status:

Titubation. Disorder of psychomotor development:  the baby cannot hold his head up, fixes his eyes on a subject for a short time, slowly forms orientating response to sounds.

Reinforced tendon reflexes. D=S. Hyper muscle tone. Feet clonus. Disorder of development of righting reflexes.

Examination data:

 Ophthalmologist

10/20/2013:                            

Optic nerve partial atrophy. Concomitant intermittent exotropia

Speech and language pathologist

10/11/2013:                            

Spasmodic dysarthria

Orthopedist

10/11/2013:                            

Hip dysplasia

Electroencephalography (real time video)

10/03/2013:    

 Background activity of wakefulness is presented by a hypsarhythmia in which structure the discharges of multiregional epileptiform activity, such as spike - slow wave, sharp - slow wave are registered. Against mild diffuse changes of brain biorhythmic there can be registered local epileptiform activity, such as sharp waves, sharp – slow wave complex in occipital region of the head, dominating in left or right hemisphere and bilateral extension on both left and right parietal-central region, frontal region. Sleep study showed multiregional epileptiform activity with deceleration and dominating in back parts of brain hemispheres.           

MRT

07/01/2013:

Periventricular leucomalacia. Communicating internal vicar hydrocephalus. Atrophic changes of parietal, temporal and occipital lobes of alba.

Cerebellar vermian hypoplasia .

Enlargement of cerebellomedullary cistern.

Blood test of metabolic disorders

10/11/2013:

None of congenital aminoacidopathy, organic aciduria, or mitochondrial beta-oxidation defects have been found.

Treatment provided:

1. Convulex  (code ATX N03AG01  (Valproic acid))

2. Magnesia

3. Pyridoxin

4. Mexidol

5. Dexamethasone

Treatment recommended:

1.      Convulex

2.      Topamax