Name: Linn Holmedahl;

Gender: female;

Age: 12

Date of admission: Oct 31st, 2006.

Date of discharge: Nov 15th, 2006.

REASON FOR TREATMENT:

She was hospitalized with “unconsciousness for 1 days since head injury”. This girl who tripped and fell down from The Great Wall suffered from head injury in Oct. 30th, 2006. She had a persistent unconscious with vomiting and upset after the injury, a cranial CT scan was done in the Peking Union Medical College Hospital several hours later, which showed brain contusion of right front lobe. A right eye-bow skin wound was cleaned and stitched. The next day (Oct 31st), she was transferred to our hospital and had another cranial CT scan which showed no new bleeding. But the patient’s condition was still unconscious and upset with GCS of 9, she could not ate and drank herself and did not cooperate with her parents and medical staffs.

DIAGNOSIS ：

Acute brain injury (GCS 9), diffuse axonal injury (DAI), cerebral contusion (right front), skin wound (right eye bow); Multiple skin and soft tissue bruise.

TREATMENT：

After her admission, the patient had been given TAT, mannitol, nimotop, dexamethasone, famotidine, replilase, intravenous fluid and nutrition support (fat emulsion and amino acid), neuro-protective medicine (GM-1, sodium cytidine triphosphate, cerebrolysin and oxiracetam), and antibiotics (ceftriaxone).

When she discharged, her condition was stable. She was alert and cooperative. The pupils were equal and round, reactive well to light. No stiff neck. The stitches had been taken out. The wound healed well. Her limbs could move freely. The Babinski’s sign was negative.

Cranial CT scan showed:

       right front lobe contusion and laceration                                     no positive findings

       (2006-10-30, 2006-10-31, 2006-11-2);                                       (2006-11-13).