(Disclaimer: This article is for general science purposes only. To protect Mr. Zhao’s privacy, the relevant information in the following content has been processed)
Abstract: Mr. Zhao visited the hospital for dizziness, blurred vision, and double vision. Examination of head CT showed brainstem hemorrhage and bilateral lacunar cerebral infarction, with no significant worsening of symptoms and normal limb movement during hospitalization. Vital signs monitoring was given, and medications such as cerebral protection, hemostasis, and dehydration were administered.
Basic information】Male, 34 years old
Disease Type】Brainstem hemorrhage
Hospital】The Second Hospital of Harbin Medical University
Date of consultation】February 2022
【Treatment plan】Medication (wake-up call injection, glycerol fructose injection, spearhead viper hemagglutinase for injection, ceftriaxone sodium for injection, tetrahexose monosialate ganglioside sodium for injection, pantoprazole sodium for injection, amlodipine benzoate tablets)
[Treatment period] 10 days of inpatient treatment
Treatment effect】Dizziness and double vision have been relieved, and the condition is stable
I. Initial consultation
Mr. Zhao came to our hospital one day before admission with no obvious cause of dizziness with double vision, a feeling of spinning, vomiting three times, vomit with coffee-colored stomach contents, blurred vision, free movement of arms and legs, and normal speech. Mr. Zhao and his family agreed to be admitted to the hospital, and were informed that the brainstem hemorrhage was very dangerous and that any further bleeding or increased bleeding would be life-threatening at any time. Mr. Zhao and his family agreed to be admitted to the hospital immediately. He was admitted to the outpatient clinic with “brainstem hemorrhage” and was informed that Mr. Zhao had been hypertensive for many years, irregularly controlled by oral antihypertensive drugs and smoked for years.
II. Treatment history
After admission, physical examination showed: consciousness, fluent speech, body temperature of 36.3℃, blood pressure of 170/110mmHg, heart rate of 79 beats/min, respiration of 16 breaths/min, limited internal retraction of the right eye, and movable limbs. Blood was collected for routine blood tests, coagulation, homocysteine, liver function, renal function, ion and blood gas analysis. We explained to Mr. Zhao and his family that his condition was critical and needed close observation and regular review of head CT, and they were well informed and cooperative. He was given cerebral protection with wake-up call injection, dehydration treatment with glycerol fructose injection, hemostasis treatment with spearhead viper hemagglutinase injection, anti-inflammatory treatment with ceftriaxone sodium injection, nerve nutrition with tetrahexose monosialate ganglioside sodium injection, gastric mucosa protection with pantoprazole sodium injection, and blood pressure control with amlodipine benzoate tablets.
(Cephalometric CT-primary diagnosis)
III. Treatment effect
After 10 days of inpatient treatment, Mr. Zhao’s symptoms were not further aggravated and his condition was controlled. During the treatment, blood pressure was well controlled, with high pressure fluctuating at 140-150 mmHg and low pressure fluctuating at 85-95 mmHg, and the symptoms of dizziness and double vision were relieved, and the brainstem hemorrhage was absorbed on re-examination of head CT. No significant fluctuation of the disease, 1 month review, dizziness, visual double vision disappeared, the disease is stable, Mr. Zhao expressed great satisfaction with the treatment.
(Cephalometric CT-review)
IV. Notes
I am glad to see that Mr. Zhao’s dizziness and double vision have been relieved after treatment. Due to his prolonged bed rest, sputum is not easily coughed out and is prone to secondary lung infection. In terms of diet, attention should be paid to timely supplementation. Since the patient’s gastrointestinal tract peristalsis differs from that of normal people, it is necessary to prevent esophageal reflux when feeding food. After discharge, it is recommended to have a quiet and comfortable environment and minimize visits, especially within 2 weeks after the disease, Mr. Zhao only had dizziness and double vision, and after discharge, it is also necessary to pay attention to whether there is numbness and weakness of the limbs and clumsy speech, and if there are symptoms of appeal, seek medical attention in time to avoid coma, respiratory and cardiac arrest, and even life-threatening.
V. Personal insight
Mr. Zhao’s dizziness and double vision, combined with the head CT, is considered brainstem hemorrhage, brainstem hemorrhage in this patient’s performance is considered light, serious can show limb numbness, weakness, clumsy speech, even coma, respiratory and cardiac arrest, life-threatening. The main thing is to control blood pressure to prevent cerebrovascular rupture and bleeding, and also need regular physical examination to clarify whether there are hematologic diseases, such as thrombocytopenia, coagulation abnormalities and other bleeding disorders, and to pay attention to the patient’s consciousness, pupils and vital signs during hospitalization.