Translated from Russian
KURORTNY ADMINISTRATIVE DISTRICT
CASE RECORD
Yakovleva Kristina Andreevna (date of birth 04.10.1995.) has undergone a course of rehabilitation
treatment at the Medical rehabilitation department for patients with disorders of central nervous system №2
from 08.10.14. till 21.11. 14.
Blood tests: hemoglobin – 126, erythrocytes – 4.47, leucocytes – 5,66, bands – 0, segments – 53.5?
eosinocytes – 3, lymphocytes – 30, monocytes – 13, ESR – 11.Creatinine – 48, Urea – 2.6, Uric acid –
0.276. Activated partial thromboplastin time – 34. INR – 1.03. Prothrombin time – 95 %. TB – 17.
Fibrinogen – 2,7. Alkaline phosphatase–- 257. LDH – 310. C-reactive protein – 0,8.
MR is negative of 26.06.14.
Urine analysis: specific gravity, acidic, protein 0,526, pavement epithelium 1-2 per HPF, leucocytes
– high amount, erythrocytes 10-12 per HPF.
Urine inoculation: Е coli. 1 million per 1 ml. Sensitivity to ampicillin, ceftazidime, cefoperazone,
cefotaxime, nitrofuran.
Ultrasonic examination of kidneys, urinary bladder of 20.10.14: right and left kidneys are normal.
Projection of adrenals is normal. Bladder: low filling, volume up to 30 ml. It is hard to assess walls, lumen,
and openings of the ureters due to low filling.
Electrocardiogram – sinoatrial rate. Heart rate - 63 per minute. Electrocardiogram is normal.
Consultation by urologist: Neurogenic bladder. Chronic retention of urine. Chronic cystitis, latent
course.
Recommended: intermittent catheterization with lubricated catheters "EasiCath" 12-6 times a day
(180 times pieces per month). Daily urine control (2-2.5 l a day). Urologic herbal medicine (decoction of
dogrose, bearberry leaves, horsetail leaves etc.) – courses.
Treatment received: Individual remedial gymnastics with walking training. Remedial gymnastics at
the pool, robotized mechanic therapy using training system «Korvit», Lokomat Pro, Manual
massage/massage of extremities, magnetic therapy «Polymag-101», «Polus-4». D'arsonvalization of lower
extremities, ozokeritotherapy, SMT, general thermal influence, vacumed, intracutaneous administration of
oxygen ozone mixture, polyreceptor SPA capsule, LKM to the lower extremities, B group vitamins IM,
cyston, cardiomagnyl, midocalm IM and per os, baclosan, pentoxifylline tablets, axamon (neuromidin) IM,
omeprasole.
Status: cranial innervation and upper extremities are normal. The lordoses are flattened, thoracic
kyphosis is moderately smoothed. Spine dynamics is up to 2-3 points. Abdominal are absent. Lower deep
spastic paraparesis up to plegia in the distal parts of the legs. Knee reflexes are low, Achill reflexes are
moderately vidid. Hypesthesia from D10 level – conduction type. Pelvic function disorder in the form of
spinal automatism , urination is periodic with incontinence and periodic catheterization, defecation is
normal.
She has independent living skills – in a bed, in a wheelchair with assistance, she is able to move
using a wheelchair. She is able to walk with Canadian crutches with the help of instructor and her mother.
Diagnosis: Concomitant head and spine injury of 25.05.14: Closed craniocerebral injury. Brain
concussion. Closed backbone-spinal injury. Instable dislocation-fracture of Th8 vertebra, compression
fracture of Th9 vertebra with spinal cord contusion and compression.
State after the surgery of 25 05.14.: laminectomy at Th 8-9-10-11 level using XIA Styker system.
Lower deep spastic paraparesis up to plegia. Neurogenic urinary bladder. Chronic urine retention. Chronic
cystitis, latent course. Combined contracture of the left hip joint. Ossification in the area of the upper third
of the left hip.
-------------------------------------------End of translated document----------------------------------------------------------------------------------Конец перевода документа---------------------------------------
I, the undersigned certified translator Yurov Stanislav Igorevich, fluent in both Russian and English,
confirm that the above is a true, accurate and complete translation of the attached document.
Я, дипломированный переводчик Юров Станислав Игоревич, владеющий русским и английским
языками, подтверждаю, что выполненный мною перевод приложенного документа является
правильным, точным и полным.
Тranslator Yurov Stanislav Igorevich
Переводчик Юров Станислав Игоревич
I hereby confirm the signature of the translator Yurov Stanislav Igorevich
Подпись переводчика Юров Станислав Игоревич подтверждаю
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