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Abstract: This patient recently underwent a physical examination organized by the unit. The physical examination revealed high blood lipids and glucose, and cranial magnetic resonance suggested multifocal cerebral infarction, and the patient felt worried and came to the hospital. After further improvement of cerebrovascular examination, he was clearly diagnosed with multifocal cerebral infarction and the glucose tolerance test indicated type 2 diabetes.
Basic information】Male, 50 years old
Disease Type】Multifocal cerebral infarction
Hospital】Shandong Provincial Third Hospital
Date of consultation】February 2022
Treatment plan】Oral medication (aspirin enteric solution tablets, ginkgo biloba extract tablets, butalbital soft capsules, oracetam tablets, metformin hydrochloride tablets)
Treatment period】Outpatient treatment, follow-up after 1 month
Treatment effect] The disease was controlled, no special discomfort
I. Initial consultation
The patient came to our hospital with a physical examination report, complaining of a recent physical examination organized by the unit, which revealed high blood lipids and blood glucose, and came to the outpatient clinic to view imaging pictures suggesting multiple small focal infarcts distributed in the brain, and the patient currently has no special symptoms. Because the patient had high-risk factors such as high blood lipids and high blood glucose, further improvement of cerebrovascular examination was suggested to assess the cerebrovascular condition, and the patient expressed understanding and actively cooperated with the examination to clarify the outpatient diagnosis of multifocal cerebral infarction.
In the outpatient clinic, the patient was given a review of blood routine, liver and kidney function, ion, lipids, blood glucose, and glycated hemoglobin. The patient was found to have persistently elevated blood glucose, considering the possibility of diabetes mellitus, and further improved the glucose tolerance test to clarify type 2 diabetes. It is recommended to actively control the diet, increase exercise, and review after 1 month. The cranial magnetic resonance and angiography examinations were completed, and the results suggested cerebrovascular atherosclerosis, mild luminal stenosis and mild cerebral atrophy, which confirmed the diagnosis of multifocal cerebral infarction.
II. Treatment history
Considering the patient’s current youth and the presence of high-risk factors, it was recommended to actively control the current condition of having cerebral atherosclerosis with a high risk of late cerebral infarction, so aspirin enteric solution tablets were given to anti-platelet aggregation, ginkgo biloba extract tablets to improve circulation, butylphthalide soft capsules to promote neocapillary formation, and olanzapine tablets to improve cerebral metabolism. Regular review at the outpatient clinic was recommended. 1 week later, the patient came to the outpatient clinic for review and the blood glucose was still high and was given the hypoglycemic drug metformin hydrochloride tablets for symptomatic treatment. the patient was advised to eat mainly coarse grains and increase exercise to control blood glucose and avoid aggravation of atherosclerosis.
III. Treatment effect
The patient was rechecked after 1 month of medication treatment, and her condition was stable with no special discomfort. Blood lipids and blood glucose were controlled in the normal range. There was no further aggravation of cranial magnetic resonance infarction on re-examination. The patient was instructed to review cranial MRI, angiography and carotid ultrasound every six months to assess the vascular condition. Six months later, the patient regularly visited the neurology department for follow-up, and the condition was controlled and stable. The present early intervention was effective and further expansion of the cerebral infarct foci was avoided.
IV. Notes
I am also relieved that the patient’s condition was controlled through treatment. However, the patient should still be advised that he should go home and control his blood pressure, blood sugar and blood lipids regularly to the normal range, pay attention to quit smoking and alcohol, and should take his medication on time and not discontinue it at will. If symptoms such as bleeding gums and stomach pain occur during medication, aspirin enteric tablets should be discontinued.
At home, you should also pay attention to the presence of symptoms such as dizziness and limb immobility. If you have these symptoms, you should actively go to the hospital for treatment to avoid delaying the disease. Normally, you should have a low-salt and low-fat diet, and increase physical exercise and aerobic exercise, such as running, rope skipping, and swimming, which can be performed for about 30 minutes a day on the basis of what your body can tolerate.
V. Personal insight
The patient in this article was found to be abnormal during the physical examination, but it is good to see the doctor in time, standardized treatment, and stable disease control. Therefore, we also want to remind everyone that regular medical checkups should be arranged to clarify the physical condition and prevent the occurrence of diseases. The examining physician should notify the patient by phone if abnormal indicators are found and follow up to facilitate the prevention and control of the patient’s disease.