Outpatient service diagnosis：Acute accident of blood vessel of brain: cerebral infarction？
Diagnosis upon hospitalization：Headache and faint to be checked: accident of blood vessel of brain? cervical spondylosis? Vascular headache?
Discharge diagnosis：Attack by temporary cerebral ischemia Multiple Lacunar Cerebral Infarction, cervical spondylosis, lumbar vertebra disease, infection of urinary tract; J respiratory tract infection, constipation of aged people
Sickness course and treatment result (indicating operation name, operation date, blood transfusion and rescue situation )
After hospitalized, relevant examinations are further made to the patient to clarify the diagnosis, and blood pressure measurement, oxygen absorption is provided. As cerebral infarction is determined via head CT, Ginkgo Leaf Extract and Diphyridamole Injection is applied to reduce stasis and improve blood circulation against agglutination of blood platelets; and Flunarizine to reduce spasm of blood vessel of brain; NOBEX (growth factor of rat nerve); GM1,Monosialotetrahexosylganglioside to provide nutrition to nerves. The routine urination examination prompts infection of urinary tract, so combined with clinical physical features, levofloxacin is provided for anti-infection. Later, the patient got cold when walking outside, she suffered angina, nasal mucus, dry cough, then thymopeptide is provided for increasing immunity. Bufferin Cold (Paracetamol) is used to improve Coryza symptom. Mosapride is used to impulse enterokinesia of intestinal tract; Changtai Mixture is used to adjust function of intestinal tract; Tongtai (Glucomannan) and Glycerine Enema are used to lubricate the intestines and ease constipation. Since multiple plaques are found at neck artery, Lipitor is used for plaque treatment. During treatment, the patient suffered sudden faint on the next day after hospitalized, and lost consciousness for several seconds. After treatment, no headache and faint appear again. The pain at neck and shoulder disappear basically. The Coryza symptom disappears, Frequent and urgent urination disappears.
Situation at discharge (symptom and physical features)
Right now, the patient has no obvious uncomfortable complaint. Sleep well, eat well, smooth urination and faeces. Physical check: T:37°C, BP: 120/70mmHg, clear minded, smooth respiration, equal round and big pupils, normal reflection to light; no limited vibration, bland neck. Noise in blood vessels can be heard at the left neck artery. Tenderness at neck and shoulder (-); arm lifting test (-);corner of mouth a little inclined to right. The tongue locates in the center when extended. Clear respiratory sound of both lungs; no rale is heard. HR: 738 PM; with good rhythm, bland and soft abdomen; no tenderness; no mass is touched. Peristaltic sound 3 times/min.; mobile sonant (-); normal muscle tension of four limbs; muscle force of four limbs V°; symmetrical; negative for Hoffman sign (-);Babbitt sign; Kernig’s sign; Oppenheim sign; Gordon’s sign
Treatment after discharge and recovery instructions
Continue to receive active treatment in Hospital, avoid spirit excitement, avoid lifting heavy objects, pay attention to personal hygiene and wear enough clothes to keep warm.
Treatment result：Turned better
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