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Abstract: The patient in this case was 67-year-old Master Li. In the morning, the family found that Master Li had slurred speech, unclear spitting, choking and coughing when drinking water, and a history of hypertension and diabetes mellitus for many years, but had been actively controlled. The family sent Master Li to the hospital and perfected the cranial MRI examination suggesting ischemic stroke, and was discharged in stable condition after giving medication.
Basic information】Male, 67 years old
Disease type】ischemic stroke
Hospital】Shandong Provincial Third Hospital
Date of consultation】May 2020
Treatment plan】Medication (nifedipine extended-release tablets, glimepiride tablets, ginkgo biloba extract injection, aspirin enteric solution tablets, atorvastatin calcium tablets, butalbital soft capsule, olanzapine injection)
Treatment period】Inpatient treatment for 10 days, outpatient follow-up after 2 weeks
Treatment effect】Stable condition, symptoms have improved
I. Initial consultation
The family members found that when they got up in the morning and communicated with the family members, the family members found that Li had slurred speech, slurred vomiting, choking and coughing when drinking water, normal muscle strength of the limbs, no other discomfort, and dizziness in the previous days. moncler outlet online, the past history of hypertension, diabetes for many years, has been actively controlled.
Neurological examination: clear consciousness, slurred speech, difficulty in spitting out words, hypopharyngeal reflex, tongue extension centered. The muscle strength of the extremities is grade 5 and the muscle tone is normal. It was recommended to further improve the intracerebral examination to clarify the diagnosis of ischemic stroke, which required hospitalization. Subsequently, hospitalization was arranged, and communication was made with Master Li and his family, who expressed their understanding and active cooperation with the examination and treatment.
II. Treatment process
After admission, relevant laboratory tests were completed, including routine blood, urine, stool, liver and kidney function, blood lipids, blood glucose, glycosylated hemoglobin, and cardiac enzymes. The examination suggested that the blood glucose and lipid were high, and glycosylated hemoglobin was high, so he was given drugs to adjust the glucose and blood pressure, and nifedipine extended-release tablets and glimepiride tablets were added. After 1 week of treatment, Master Li’s condition was stable and his slurred speech symptoms were better than before, and he could express short sentences clearly, and was discharged from the hospital after 10 days of treatment with improved condition.
(Report)
(Cranial magnetic resonance)
III. Treatment effect
Ischemic stroke is common in middle-aged and elderly patients. It is caused by ischemic damage to brain cells due to cerebrovascular atherosclerosis or thrombosis, which leads to signs of neurological dysfunction, which can manifest as limb paralysis, abnormal sensation, and slurred speech. After medication was given to Master Li, his condition was stable for about 1 week, and the symptoms of slurred speech were not further aggravated, and he could express short sentences without limb immobility. After 10 days of hospitalization, his condition was stable and he was discharged with medication. Outpatient follow-up is recommended in 2 weeks and regular review at the neurology department to assess cerebrovascular condition and control high-risk factors. In conclusion, Master Li’s condition was basically stable, and his slurred speech improved, and the treatment effect was good.
IV. Notes
We are glad that Master Li’s condition is under control after treatment. Before discharge, he was informed of the high-risk factors for cerebrovascular disease, including hypertension, hyperglycemia, hyperlipidemia, smoking and alcohol consumption, etc. Therefore, he was instructed to take his medication on time, monitor his blood pressure, and make sure to quit smoking and alcohol consumption after going home. Daily should pay close attention to whether the signs of neurological dysfunction have worsened, and if symptoms such as slurred speech, limb immobility and dizziness worsen, they need to be actively reviewed. After discharge from the hospital, develop good lifestyle habits, a low-salt, low-fat diet, increase physical exercise, including running, rope skipping, swimming, etc., and regularly visit the neurology department every year to improve the intracerebral vascular assessment.
V. Personal insight
Ischemic stroke is a serious health hazard for middle-aged and elderly people, with a high mortality and disability rate, and needs to be given high priority. Early intervention and active prevention of ischemic stroke can improve the quality of life and well-being of the elderly. Doctors should also promote ischemic strokes and follow up on a regular basis with people who are at high risk, as in the case of Mr. Li. It is also important to pay attention to one’s own health condition and have regular checkups to assess whether there are any high-risk factors that can help prevent the disease.