Jelizaveta  LIZA

Clinical diagnosis:
R62.0 Delayed milestone
G83.8 Muscle dystonia

Main diagnosis:
G91.1 Closed/obstructive hydrotsefalia (bilat.)

Other diagnosis:
H47.2 Atrophia of the seeing nerve |
G83.8 Muscle dystonia
R62.0 Delayed milestone

Anamnesis
0603.2008 – a 10-months old child with hydrosefalia was hospitalized for planned research and organizing of the following treatment plan. The child was born by a planned caesarean due to malformation of the brain, after birth was examined at the Children’s Clinic of the university Hospital. Due to the child’s illnesses and social problems she is living at the Orphanage (anamnesis has gaps).

24.07.2007 has oclusive intrakr. hypertens. Venticloscopia done at the children’s surgery department due to HC after what the licuor dynamics of the brain correlated probitiously to a normally accentent HC level.   Was last at the hospital for examination in November, 2007.

Objective find

06.03.2008 – the overall condition of the child is satisfactory. Coloring is pink. The skin is dry and rough. There is not a good eye contact, the child reacts to sound, the head has an hydrosefalic shape, big fontanelle open wide, leveled surface. Cardiopulmonically ii, abdomen soft, peristatics is auscultive. Muscle tonus is close to norm, side-even, k/p reflexes appeare quite lively, without a certain side

The abstract and recommendations

01.04.2008-of the examinations the hearing screening is pathological. Repeating in dynamics is needed.

Regular physiotheraphy shows positive developments in motorical activeness, when on stomach she supports with her hands.

Still needs constant physiotheraphy.

The physiotheraphist has recommended a functional chair with a table installed in the front for the symmetry of the position of the body and for conducing the supporting of her hands.

It is recommended to attend a consultation of a tyflopedagogue in about 2 months, if possible regular teachings.

Date: 01.04.2008

back