慢性Case1
2022-03-27 13:09:12 0 举报AI智能生成
慢性脑梗
作者其他创作
大纲/内容
Laboratory examination
D - D dimer
0.94 2022-2-18
0.49 2022-3-1
0.26 2022-3-18
TT
23.7s 2022-2-18
16s 2022-3-1
ALT
19 2022-2-18
60 2022-3-18
AST
28 2022-2-18
39 2022-3-18
ALP
67 2022-2-18
148 2022-3-18
GGT
13 2022-2-18
70 2022-3-18
Special examination
MRI
Top left frontal temporal lobe and left basal ganglia region of hemorrhagic cerebral infarction.2022-2-24
Bultrasound
showed patent oval-foramen.2022-3-21
CT
a little fiber focal left lower lobe.2022-3-25
Treatment
Oral
Rivaroxaban 10mg qm
Anticoagulant drugs can reduce blood viscosity and prevent heart thrombosis from regenerating
2、Risk for bleeding
Butylphthalide soft capsule, 0.2tid
Improve cerebrovascular circulation
Atorvastatin calcium
20 mg Qn
20 mg Qn
Stabilize plaque and reduce low density blood lipid
Butyl phthalide soft capsule 0.2g tid
Improving brain metabolism
Rehabilitation Treatment
aerobic training
exercise therapy
balance function training
Acupoint regulation therapy
Ordinary acupuncture
low frequency pulsed electrical stimulation
Intermediate frequency pulsed electrical stimulation
transcutaneous electrical nerve stimulation
functional electrical stimulation
General history
General：Female
Age :46y
Educational status: high school level
Occupation:housewife
Marital status :Married
Family
Two son,Health,21y and 14y,student
Her husband is a businessman and has a good financial condition；
The patient's parents, siblings are in good health.
Present history (PI)
Past history (PH)
No history of hypertension,diabetes, hepatitis, tuberculosis and other infectious diseases,
No history of food and drug allergy,no history of major surgical trauma
Health behavior
No smoking
No drinking
Like greasy food
Activities daily living
DO not exercise
Diagnosis
Hemiplegia on the right side
Convalescence of cerebral infarction (left frontotemporal lobe, lateral paraventricular region, basal ganglia region)
Movement disorders
Speech disorders
Dysfunctions of daily living
Left internal carotid artery occlusion (postoperative)
Left middle cerebral artery occlusion (postoperative)
Chief complaint (CC)
Right limb movement disorder for half a month.
Present history (PI)
After thrombectomy for cerebral infarction, the patient could not move his right limb, could not understand the problem, could not nod and respond correctly, could control his urine and feces by himself, felt depressed and had no fever.
Physical examination
General Appearance and Mental
Status
Status
Clear mind and anxious mood
Vital Signs
Body temperature: 36.8degrees
Pulse :86 beats/min
Blood pressure :112/81mmhg
Respiratory rates: 21 times/min
Height 165cm , weighs 58kg,BMI 17
Scale
Water swallow test:1 lever
GCS score:11
Barthel index:20 points
Brunnstrom:Right upper limbⅡ lever,right hand Ⅰ lever, right lower limb Ⅱ lever
Ashworth:0 lever
Balance function:Sitting balance 3 lever, standing balance 2 lever,Holden class 0lever
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