Ivan Stojanov-Spinal Cord Injury-(Macedonian)

Name: Ivan Stojanov
Sex: Male
Nationality:Macedonian
Age:25 Years
Diagnosis: 1. Sequel of Spinal Cord Injury 2. Urinary Infection
Date of Admission:Nov. 05, 2015
Treatment hospital/period: Wu Medical Center/14days

Before treatment:
4 years ago (March 16th, 2011), the patient had cervical cystabscission, but after that, he lost his motor function completely for 3 months. After some rehabilitation training, he recovered the motor function of his left upper limb, but the other three limbs still not normal.His right side isseriouslylean. He took baclofen and tranquilizing drug because of limbs’ twists, but the effect was not good, so he stopped. The patient wasconfined to bed from then on.He had four limbs’sensory disturbance, his right upper limb could be liftedfrom the bed.His right elbow joint was not able to do back up. Left lower limb could be lifted from the bed but his right lower limb was not able to move. He wants a better life so he came to our centre and was diagnosed as Sequel of spinal cord injury.

He hasgood sleep and diet.His urination is normal.He defecates 3 times every day.He has put up about 24 kg.

Admission PE:
Bp: 118/79mmHg; Hr: 80/min. Temperature: 36.4 degrees. Br: 20/min. Height: 176cm, weight:100kg. There was no yellow stain or petechia on mucous membrane. The respiratory sounds in both lungs were clear, with no obvious moist or dry rales. The heart sounds was strong, the rhythm of his heartbeat was normal. There was no obvious murmur in the valves. The abdomen was bulge and soft, the liver and spleen were normal. There was no dropsy of his lower limbs.

Nervous System Examination:
Ivan Stojanov was alert and his speech was fluent. His memory, calculation and orientation abilities were normal. Both pupils were equal in size and round, the diameter was 3.0 mms, both eyeballs could move freely. Both eyes had sensitive response to light stimuli. The forehead wrinkle pattern was symmetrical. The tongue was centered in the oral cavity and the teeth were shown without deflection. The neck moved and shoulders shrugged were normal. The muscle power of left upper limb was at level 3, right lower limb was at level 1. The muscle tension of four limbs was normal with no muscular atrophy. The superficial sensation and deep sensation above C3 was normal, the superficial sensation below C4 decreased. Left side C4-LI haddeclined to 40%-70%. Left side L1-S1 had declined to40%-20%, right side C4-T11 had declinedto 40%-90%, and right T12-L1 had declined to 70%-10%. Right side L1-S1 was over sensitive, the deep sensation below C4 declined to 10% of the normal level. Both side biceps reflex, radial periosteal reflex, triceps reflex were abnormal. Patella tendon reflex was active. Both side ankle reflexeswere abnormal. Left upper abdominal reflex was abnormal. Bilateral Babinski sign was positive. The meningeal irritation sign was negative. Rapid rotation test was clumsy, left finger-to- nose test was normal, but right side was clumsy, left finger-to-finger test was normal, right side he could only do radial side 3 fingers, he couldn’t do heel knee shin test.

Treatment:
The patient got a fever without any reason, his temperature was 38.5 degrees.The patient was diagnosed as 1. Sequel of spinal cord injury 2.Urinary infection.The patient received 3 times of neural stem cell injection and 3 times of mesenchymal stem cell injection to activate the cells, nourishes neurons, fix the damaged cells, and improve circulation and immunity. He was also treated for urinary infection and had physical rehabilitation.

Post-treatment:
After 14 days of treatment, the patient’s urinary infection was under control, the motor function has been improved, the muscle power of right lower limb has increased to 3-, left lower limb was at level 4, right upper limb was at level 4-, all his four limbs were  more flexible than before. The superficial sensibility level recovered 20-30% below the injury S-T.

E-mails:

Date: 2015-12-14

Hello I'm Ivan Stojanov from Shtip - Macedonia, after 3 weeks this is my blood test results. For now everything is ok with medicin/pills.

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