Basic Information

Patient name: S.S.
Age: 19 years old
Gender: Female
Occupation: Student

Medical History

Anamnesis: Patient with post-traumatic spastic paraplegia presents for evaluation for HBOT. The patient has previously undergone hyperbaric therapy sessions at another location. The patient presents with a pressure sore in the thoraco-lumbar dorsal area of approximately 7 x 13 cm.
Family history: None.

CLINICAL PRESENTATION:

Symptoms: Chronic wound with local pain.
Duration: Over several months.
Aggravating factors: Paraplegia.
Alleviating factors: None.

Treatment History:

Current medications: None.
Previous treatments: Hyperbaric therapy.

Investigations:

Diagnosis:
Post-traumatic fracture state of vertebral body T 9-10.
Post-traumatic paraplegia.
Pressure sore in the posterior thoraco-lumbar area of approximately 7 x 12 cm.

Treatment Plan:

Recommended medication: None prescribed.
Therapeutic interventions: 31 sessions of hyperbaric therapy.

EVOLUTION AND PROGNOSIS:

Evolution: Favorable.
Prognosis: Wound reduced in size after the first treatment cycle to approximately 7 x 4 cm.

FINAL OBSERVATIONS:

After another treatment cycle, the wound closes completely, achieving total healing.