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Abstract: Stroke is a common and frequent disease in neurology. It is a sign of neurological dysfunction caused by ischemic and hypoxic necrosis of brain cells due to cerebrovascular lesions, and should be treated actively with early intervention. The patient had a sudden onset of limb immobility and chopstick instability 1 week ago, and was diagnosed with stroke and cerebral infarction by cranial magnetic resonance examination. After hospitalization, he was given drugs to improve circulation and nourish brain cells, and his symptoms were relieved.
Basic information】Male, 66 years old
Disease Type】Stroke – cerebral infarction
Hospital】Shandong Provincial Third Hospital
Date of consultation】March 2022
Treatment plan】Medication (butylphthalide soft capsule + aspirin enteric dissolved tablets + atorvastatin calcium tablets + hemosiderin tablets) + rehabilitation training + acupuncture and physiotherapy
Treatment period】10 days of inpatient treatment, 1 month of outpatient follow-up
Treatment effect】Stable condition, adhere to the limb rehabilitation training
I. Initial consultation
The patient is relatively old, lives alone, has a long history of hypertension and diabetes mellitus, and has a history of smoking and alcohol consumption. When he came to the clinic, the limb weakness had been present for more than 24 hours, and the thrombolysis period was missed. The child was anxious that her care was not enough to delay the treatment of the patient’s disease. After evaluation, it was recommended to hospitalize the patient for infusion therapy, and later to improve the relevant, assess the cerebrovascular condition and standardize the drug treatment plan for cerebrovascular disease.
II. Treatment after
The most common cause of cerebral infarction is cerebrovascular atherosclerosis. High-risk factors leading to cerebrovascular atherosclerosis include age, smoking, alcohol consumption, hypertension, hyperglycemia, hyperlipidemia, hyperuricemia, homocysteinemia, etc. The patient was admitted to the hospital to complete relevant examinations, blood sampling and laboratory tests of routine blood, liver and kidney function, ion, lipid and blood glucose, etc. The examination results indicated hypertension, diabetes mellitus, hyperlipidemia and hyperhomocysteinemia, and cranial magnetic resonance indicated acute cerebral infarction and cerebral atherosclerosis. After admission, the patient was given butylphthalide soft capsule, aspirin enteric solution tablet, atorvastatin calcium tablet and hemosiderin tablet to improve brain circulation, nourish brain cells, antiplatelet aggregation, improve brain metabolism and promote neovascularization. After that, the rehabilitation department was arranged to give rehabilitation training to the patient, together with acupuncture and physiotherapy to promote recovery.
III. Treatment effect
The onset of cerebral infarction within 6 hours is in the acute stage, and thrombolytic therapy can be considered, but the onset of cerebral infarction in this patient was already more than 24 hours, and the patient could only be treated with conservative medication in internal medicine after arrival at the hospital. Fortunately, the vascular atherosclerosis was not particularly severe and the infarct area was small. The patient’s symptoms were relieved after the administration of butylphthalide soft capsules, aspirin enteric-coated tablets, atorvastatin calcium tablets, and hemosiderin tablets. After 10 days of treatment, the patient was discharged from the hospital in stable condition. 1 month later, rehabilitation training was arranged according to the functional assessment of the hand at the follow-up outpatient clinic, and the condition was stable without further aggravation of symptoms.
IV. Notes
We are glad that the patient’s symptoms were relieved after treatment. We suggest that the patient should have a low salt and low fat diet after treatment, quit smoking and alcohol, maintain good lifestyle habits, avoid staying up late and straining, avoid emotional excitement, regularly monitor blood pressure, blood glucose, lipids, blood pressure and other high-risk factors, actively control them to the normal range, and regularly evaluate the vascular situation in the brain to improve cranial magnetic resonance and myovascular imaging. After discharge from the hospital, take medication on time, follow up regularly at the outpatient clinic, and adhere to rehabilitation training is beneficial to the recovery of the disease. Once the signs of neurological dysfunction appear, you should go to the hospital immediately to avoid delaying the treatment and missing the golden 6 hours, which may lead to sequelae and no recovery once missed.
V. Personal insight
The elderly living alone is a group that we should care for. The elderly are prone to diseases when they live alone and are not treated in a timely manner. Fortunately, the patient was treated promptly and was lucky enough not to have any significant sequelae. Therefore, it is essential that family members should contact the elderly regularly and take them to the hospital regularly to improve their checkups, assess their health and give them drug interventions if necessary. Usually, one should develop good habits to help avoid the occurrence of diseases, learn health science knowledge regularly and actively identify their own problems, which is conducive to early detection and early treatment, and should not be blindly careless.