Case Study – Juan Martinez

Patient Background:

Patient, Juan Martinez, a 32-year-old man was involved in a car accident in the US. Allista connected Mr. Martinez with the long-term medical care he needed with Americas Hospital in Guadalajara, Mexico.

Patient’s Medical Record:

The patient was involved in a car accident in the U.S. in May 28th, 2006. After his admission into a hospital in the U.S., his diagnosis was a basilar fracture and intra-ventricular hemorrhage, bilateral hemo-thoraces, spinal injury with fractures from T1 through T3, and fractures of each the T12, L1, and L2. All these were revealed in a C.T. scan. An M.R.I placed on May 30th, 2006 and an I.V.C. and P.E.G on June 05th, 2006, noted swelling of the spinal cord from C7 toT1. A fusion from C6 to T1 with posterior wiring was conducted to treat the fractures.

Physical Examination:

BP: 110/70 mmHg, HR= 70x´ rhythmic, R.R.= 18x´, Temp. 36.1º C.

Appears alert, oriented in person, place, and time. Follows commands and answers questions asked. Normal pupil eye response to light, eye movements are found normal, as well as reflects, fundoscopic eye examination appears normal, no nystagmus, and gag reflex is normal. Lung exam is found with normal ventilation, no rales or wheezing. Heart sounds are rhythmic; without murmur or S3. Abdominal sounds of bowel movement normal, no hepatomegaly, no pain found at palpation, and surgical scar in the left flank.

No evidence of abnormality in cranial nerve examination. There is symmetrical and good strength in upper extremities. There is no voluntary movement of lower extremities. There is only spinal reflex in both lower extremities when pain stimulated, but without sensation. Muscle tone of lower extremities is diminished. He stated he felt stimulation when not being touched during Sensation test. Otherwise, the sensation is above T3. (Probably T1). There is a pressure sore in the coccygeal area covered by a patch, without evidence of infection.

Diagnosis and Treatment:

The patient has a diagnosis of paraplegia from spine and brain injury due to medullar section T1-3, ABP instability due to dysautonomia secondary to medullar section, and a history of recurring UTI. He is in a wheelchair, semi-autonomous, and has a permanent nurse to help him in his everyday activities. At first, the patient was irritated most of the time, had problems communicating, had problems doing things on his own, and even had suicide attempts. Nowadays, the patient is capable of doing many things on his own, such as eating by himself and moving around in his wheelchair and has a cooperative attitude towards his physical and psychological therapies.

The patient has had several complications such as constipation, bleeding hemorrhoids, and recurrent urinary infections. In these instances, the patient has been admitted as an in-patient, if necessary, to Americas Hospital, and given the most adequate care and treatment. The patient receives his physical therapy at Americas hospital as well.

The patient refers to Americas Hospital as his “savior”.

After the accident happened, he suffered from severe depression. He remembers having no life expectations, being in denial, not being communicative, and hopelessly lying in bed. After the first few rounds of psychological and physical therapies, the patient started noticing results. He was convinced that he could do better than just lying in bed, so he started moving around on a wheelchair and overall semiautonomous. The patient’s physical condition remains delicate due to his condition. Nevertheless, The patient is grateful, has an optimistic attitude towards his treatment, and looking forward to his fullest recovery.

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