Shanghai First Hospital

Admission records

Name:Xin-Hua gender:female age:65 Age Department:internal medicine Bed No:0013 Medical record number:100153

Name:Xin Xiuhua | Address: Handan Tianheyuan, Xiangdu District, City
gender:female | employer:--
age:65 | Admission time:2023-07-15 15:44:07
Marriage:Married | Recording time:2023-07-15 17:54:07
nationality:Han nationaliy | History Narrator:I am
Profession:Freelance | reliability:reliable

Chief complaint:Left limb weakness accompanied by slurred speech and right corner of the mouth for 6 hours.

History of present illness:The patient had left limb weakness with slurred speech, right corner of the mouth, walking left deviation, unconscious disturbance, no dizziness, no deafness, tinnitus, no blurred vision, no urination and defecation due to no obvious cause 6 hours before admission The incontinence did not improve significantly after rest, and now she came to our hospital urgently for treatment, and was admitted to the hospital for treatment as "cerebral infarction".
Since the onset of the disease, the patient had no cough, sputum, and nocturnal paroxysmal pink foamy sputum, no convulsions, no chest pain, and no radiating pain. There were no symptoms of frequent urination, urgency, or dysuria, and no abnormalities were found in the appearance of urine and stool.
Past history:The previous history of "hypertension" was 5 years, the highest blood pressure was 200/120mmHg, and antihypertensive drugs were not used regularly; 4 years ago, he was cured after surgery for "right upper limb fracture"; "acute upper respiratory tract infection" for 7 days, with runny nose Mainly symptoms such as cold, symptoms relieved after oral administration of cold medicine; denied history of diabetes. He denied any history of drug allergy. No history of hepatitis, tuberculosis and other infectious diseases. Vaccination history was ominous, and the systematic review was unremarkable.

Personal History:Born in the original place, lived in the local area for a long time, never been to the epidemic area or pastoral area, no venereal disease and travel history, no smoking and drinking habits.

Marriage History:Married at the right age, with 1 son and 1 daughter, both spouse and children are in good health.

Menstrual history:
Usually menstruation is regular, natural menopause at the age of 51.

birth history: 2-0-0-2, with 1 son and 1 daughter, both of them are healthy.

Family History:There was no history of bleeding or genetic disease in the family. There is no history of cancer in the family.

physical examination

T:36.5℃ P:112 times/min R:20 times/min BP:140/80 mmHg

generally:Normal development, clear mind, slurred speech, cooperation in physical examination.
Skin and mucous membranes:The skin has no yellow stain, no bleeding point, blood stasis and ecchymosis.
Lymph nodes:Superficial lymph nodes around the body were not palpably enlarged.
Head and facial features:No skull deformity. There was no edema in both eyelids, no hyperemia in the conjunctiva, no jaundice in the sclera, bilateral pupils were large and equi-circular, and were sensitive to light reflex. The ear and nose were normal, the left nasolabial fold became shallower, the corners of the mouth deviated to the right, the tongue deviated to the left, the lips were not cyanotic, the pharynx was not congested, and the tonsils were not enlarged.

neck:The neck is bilaterally symmetrical and no jugular veins are seen
. Neck:Both sides of the neck are symmetrical, no jugular vein engorgement
neck:Both sides of the neck are symmetrical, no jugular vein engorgement
neck:Both sides of the neck are symmetrical, no jugular vein engorgement
neck:Both sides of the neck are symmetrical, no jugular vein engorgement
neck:Both sides of the neck are symmetrical, no jugular vein engorgement

neck:The neck is bilaterally symmetrical and no jugular veins are seen . Neck:
Both sides of the neck are symmetrical, no jugular vein engorgement
neck:Both sides of the neck are symmetrical, no jugular vein engorgement
neck:Both sides of the neck are symmetrical, no jugular vein engorgement
neck:Both sides of the neck are symmetrical, no jugular vein engorgement
neck:Both sides of the neck are symmetrical, no jugular vein engorgement

neck:The neck was symmetrical on both sides, no distended jugular veins and abnormal carotid pulses were seen, and the hepatic jugular reflux sign was negative. The ne ck was soft, no resistance, the trachea was in the middle, the thyroid gland was small, and no vascular murmur was heard.
Chest:There was no deformity of the thorax, and both sides were symmetrical, the respiratory rate was consistent on both sides, and the verbal tremors on both sides were equal, without enhancement or weakening.
lungs:On percussion, the relative dullness of the lung and liver is located in the fifth intercostal space on the right midclavicular line. The breath sounds of both lungs are clear, and dry and wet rales and pleural friction rub are not heard in both lungs.
heart:There was no prominence in the precordial area, no obvious apical beat, no palpable tremor, small heart circle, heart rate 112 beats/min, regular heart rhythm, no murmur heard in the valve auscultation area, no pericardial friction rub and pericardial percussion sound.

abdomen:Flat and soft abdomen, no intestinal pattern and peristaltic wave, no abdominal wall varicose veins, no tenderness, no rebound tenderness and muscle tension, no palpation of liver and spleen, abdominal percussion drum sound, no moving dullness, no liver and kidney area Percussion pain, bowel sounds are normal.
Anus, external genitalia:Anus and external genitalia were normal.
Spine limbs:There was no tenderness in the spine and vertebral bodies, no deformity in the limbs, pitting edema in both lower limbs, muscle strength of the left limb was grade 4, muscle strength of the right limb was grade 5, and the muscle tone of the limbs was normal.
nervous system:Bilateral biceps tendon and Achilles tendon reflexes were normal, left Babinski sign was positive, right Babinski sign was not elicited, and bilateral Kernig sign was negative. Bilateral Hoffmann sign, Chvostek sign and Trousseau sign were not elicited.

Auxiliary inspection

Electrocardiogram: sinus tachycardia, extensive lead ST-T abnormalities suggest myocardial ischemia.
Head CT showed: left basal ganglia and right corona radiata small ischemic lesi ons; cerebral white matter demyelination; senile brain changes; combined with clinical practice, MRI examination is recommended. Chest CT showed: the anterior segment of the right upper lobe and the lingual segment of the left upper lobe fibrous cords and calcified plaques in the right lower lobe; calcification of the aorta and coronary arteries; local thickening of the right pleura.
Random glucose: 7.26 (mmol/L). The five items of blood lipids showed: triglyceride: 3.01 (mmol/L), total cholesterol: 5.52 (mmol/L), low-density lipoprotein cholesterol: 3.45 (mmol/L), and the rest was normal. Routine blood test showed: white blood cells: 10.34 (10^9/L), and the rest had no obvious abnormalities. C-reactive protein, electrolytes, liver function, kidney function, myocardial enzymes, troponin, five items of blood coagulation, and five items of hepatitis B showed no obvious abnormalities.

Discharge diagnosis: | initial diagnosis:

1. Carotid artery stenosis and cerebral infarction (acute stage)
carotid atherosclerosis Carotid artery stenosis
Vertebral
artery stenosis
2. Hypertension grade 3 very high risk
3. Hyperlipidemia
4. Acute upper respiratory tract infection
Xu Jingjiang
2023-07-15

1. Cerebral infarction (acute phase)
2. Hypertension grade 2 very high risk
3. Hyperlipidemia
4. Acute upper respiratory tract infection
Xu Jingjiang revised diagnosis on
July 25, 2023 : 1. Carotid artery stenosis cerebral infarction (acute phase) carotid artery Atherosclerotic carotid stenosis Vertebral artery stenosis 2. Hypertension grade 3 very high risk 3. Hyperlipidemia 4. Acute upper respiratory infection Xu Jingjiang 2023-07-28