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Abstract: IT Brother came to the clinic with recurrent dizziness, high blood pressure and dizziness after a long night at work due to recent exertion and was found to be cerebral ischemia. He was given medication to improve brain metabolism and nourish brain cells, such as Danshen Chuanxiongzin injection, cerebroprotein hydrolysate tablets and betahistine mesylate tablets, and the patient’s condition improved after treatment.
Basic information】Male, 44 years old
Disease Type】Cerebral ischemia
Hospital】Shandong Provincial Third Hospital
Date of consultation】July 2021
Treatment plan】Medication (Danshen Chuanxiongzin Injection + Brain Protein Hydrolysate Tablets + Betahistine Mesylate Tablets)
Treatment period】Outpatient treatment, follow-up after 1 week, follow-up by phone after 1 month
Treatment effect】Stable condition, no special discomfort
I. Initial consultation
The patient is a senior IT worker who needs to be in high intensity brain work for a long time and sleeps for about 6 hours a day. Recently, he has been feeling overwhelmed with work, dizzy, unsteady walking, slow reaction, and easy to forget things. Because I was a bit worried about my health, I came to the hospital for a complete cranial MRI examination, which indicated cerebral ischemia. Outpatient diagnosis of cerebral ischemia, neurological examination suggests: closed eyes difficult to stand sign (+), the rest of the positive signs are not obvious. It was suggested to further improve the relevant examinations to exclude any high-risk factors of cerebrovascular disease and see if intervention was needed. The patient expressed understanding and actively cooperated with the examination.
II. Treatment history
The patient was given a blood test and the related tests mainly included blood routine, liver and kidney function ion, blood lipids, blood glucose, cardiac enzymes, stool routine and urine routine, and the test results indicated high uric acid, but no other significant abnormalities were seen. The cranial magnetic resonance angiography suggested multiple ischemic infarct foci in the brain, and the foaming test was negative. Considering that the patient currently has no obvious high-risk factors and is young, the possibility of simple cerebral ischemia associated with prolonged and high-intensity brain work is high. Treatment is to give Danshen Chuanxiongzin injection, cerebral protein hydrolysate tablets, betahistine mesylate tablets to improve circulation, nourish brain cells, and anti-dizziness medication. It is recommended to arrange working hours reasonably, ensure enough sleep, enhance physical exercise, and follow up with neurology outpatient clinic in 1 week.
III. Treatment effect
The patient has no obvious high-risk factors in the examination, and the uric acid is high. After 1 week of treatment, the patient reported that his dizziness was significantly relieved and he had no special discomfort. 1 month later, the patient was followed up by phone and his condition was stable without special discomfort.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment, but during the treatment of cerebral ischemic focus, we should also remind the patient to pay attention to blood pressure, blood sugar, blood lipid, blood uric acid, homocysteine, if there are indicators high, pay attention to active control, usually diet should pay attention to low salt, low fat and low purine diet, pay attention to increase physical exercise to avoid blood sugar rise, if there is an increase in blood sugar, you can give adjustment If blood sugar is elevated, you can adjust your diet and eat more coarse grains. During the medication period, attention should be paid to the presence of dizziness, headache, unstable walking, abnormal sensation and other symptoms. If there are signs of neurological dysfunction, you should actively visit the neurology department and improve the cranial MRI to assess the ability. Medications need to be taken on time, and if skin petechiae and gum bleeding occur after taking anti-platelet aggregation medications, they need to be discontinued. If elevated liver function indicators occur with lipid-lowering medications, they also need to be discontinued. Regularly visit the hospital every year to assess the cerebrovascular condition to avoid aggravation of the disease.
V. Personal insight
Cerebral ischemia refers to the ischemic degeneration of brain cells, which is usually caused by cerebrovascular lesions. By understanding the situation of the patient in this case, we can know that the various functions of the body in the 40s begin to gradually decline, and chronic diseases may begin to appear, such as hypertension, hyperglycemia, hyperlipidemia, cerebral arteriosclerosis, cardiovascular sclerosis, etc. You should develop good living habits and have regular checkups to avoid diseases. If there are high-risk factors, doctors should actively communicate with patients, carry out reasonable control and regular review, early intervention can effectively reduce or delay the occurrence of the disease and improve the quality of life. Do not think that no special treatment is needed because of cerebral ischemia, but should actively look for the presence of high-risk factors and whether intervention is needed.