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).
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Secondary diagnosis: Mild
iron-deficient anemia (D 50). Long-lasting conjugated hyper-bilirubinemia (Р
59.8). Patent foramen ovale (Q
21.8). Cholestasis (K 82.4). Carrier
state of HCVAb (P96).
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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 24th 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
