h*****1
发帖数: 429 | 1 主诉： 酒饭后右脚麻木，话语轻微不灵活2小时
现病史：男，47岁，2小时前酒饭后行走时突然感觉右脚麻木，讲话时对个别词语的表达
感觉舌头不灵活流利。
过去史：无特别疾病。
家族史：直系亲属有高血压病史。
体检： 神志清晰，反应正常。个别字发音不流畅。血压180/130， 体温37，右脚感觉轻
度减轻，健反射正常。眼底无水肿出血。
检测： 血常规正常。血钾3.45 mmol／L。 CT 显示脑部轻微出血性阴影。
诊断： 高血压，轻度血管破裂性脑出血。
住院治疗：
《1》 厄贝沙坦氢氯噻嗪分散片(Irbesartan and Hydrochlorothiazide）。
《2》 可乐定（Clonidine）
《3》 硝苯地平片 （Nifedipine）
《4》 甲钴胺片 （Mecobalamin Tablets）
《5》 盐酸纳洛酮注射液（Naloxone Hydrochloride）
《6》 吡拉西坦片（脑复康片， Piracetam Tablets）
《7》 氯化钾缓释片（Potassium Chloride Sustained-Release Tablets）
治疗一周后：血压早上睡醒后180/120； 服药后145/85。尿不多。
问题：
《1》 诊断方面还要考虑什么？
《2》 治疗用药上有什么缺陷或需要改进？
《3》 还要做那些检查？
各位有什么高见？ |
z****o
发帖数: 368 | 2 did the patient have recent blood pressure reading before the incident? 180/
130 is very high. Any work-up for possible cause of 2nd HTN? |
h*****1
发帖数: 429 | 3 The patient has been healthy and exercises regularly. There is no known
recent blood pressure reading before the incident. A CT scan has been
scheduled for adrenal gland.
180/
【在 z****o 的大作中提到】
: did the patient have recent blood pressure reading before the incident? 180/
: 130 is very high. Any work-up for possible cause of 2nd HTN?
|
A*******s
发帖数: 9638 | 4 This patient most likely suffered from an ischemic infarct with hemorrhagic
transformation based on the initial presentation.
So elevated BP is from the stroke not the other way around.
The workup should include a MRI/MRA to establish a diagnosis of acute
infarct and rule out anurysm/AVM, respectively.
Treatement would be to moderately lower the BP, like 140/90. Too low would
worsen the stroke, whereas too high would make bleeding more.
I have no knowledge regarding the treatment mentioned by LZ except
antihypertensive and potassium. We use IV antihypertensive meds in NICU. |
h*****1
发帖数: 429 | 5 This is actually a patient currently being treated at a hospital in China.
It is interesting to compare the treatment in two different countries on a
disease like this.
BTW, his current BP is 153/94. Such a BP shall be OK according to your view.
hemorrhagic
【在 A*******s 的大作中提到】
: This patient most likely suffered from an ischemic infarct with hemorrhagic
: transformation based on the initial presentation.
: So elevated BP is from the stroke not the other way around.
: The workup should include a MRI/MRA to establish a diagnosis of acute
: infarct and rule out anurysm/AVM, respectively.
: Treatement would be to moderately lower the BP, like 140/90. Too low would
: worsen the stroke, whereas too high would make bleeding more.
: I have no knowledge regarding the treatment mentioned by LZ except
: antihypertensive and potassium. We use IV antihypertensive meds in NICU.
|
A*******s
发帖数: 9638 | 6 That is correct.
If you understand the concept of penumbra, you will know the perfusion to
the area is so important in stroke management. Because of bleeding, he is
not a candidate for tPA. What affects cerebral perfusion? BP.
view.
【在 h*****1 的大作中提到】
: This is actually a patient currently being treated at a hospital in China.
: It is interesting to compare the treatment in two different countries on a
: disease like this.
: BTW, his current BP is 153/94. Such a BP shall be OK according to your view.
:
: hemorrhagic
|
h*****1
发帖数: 429 | 7 Update:
<1> adrenal gland: CT examination shows “Normal”.
<2> problem with flexible blood pressure. In the past 24 hours, the
patient has a systolic pressure ranging from 192 to 116 with diastolic
pressure from 115 to 67.He fells dizzy when the blood pressure goes down.
<3> The flexible blood pressure could be associated with the muscularly
injection of naloxone hydrochloride (an opioid antagonist) at8mg/day.
Naloxone hydroxylase is said to improve perfusion in the ischemic stroke.
This drug has been used since his hospitalization (22 days ago). The use of
this drug is associated with the raise of blood pressure.
Currently, the patient is virtually normal. He can walk, eat, talk, but felt
dizziness when the blood pressure goes down. A brain CT is scheduled for
this coming Monday.
Question
<1> How to stabilize his blood pressure?
<2> should stop using Naloxone hydroxylase?
<3> any other suggestions? |
A*******s
发帖数: 9638 | 8 You always can lower the BP, otherwsie, consult internal medicine. Like I
said before, 140/90 is OK.
Stop Naloxone. There is no clinical evidence supporting naloxone's
neuroprotective effects.
http://stroke.ahajournals.org/content/15/4/627
of
【在 h*****1 的大作中提到】
: Update:
: <1> adrenal gland: CT examination shows “Normal”.
: <2> problem with flexible blood pressure. In the past 24 hours, the
: patient has a systolic pressure ranging from 192 to 116 with diastolic
: pressure from 115 to 67.He fells dizzy when the blood pressure goes down.
: <3> The flexible blood pressure could be associated with the muscularly
: injection of naloxone hydrochloride (an opioid antagonist) at8mg/day.
: Naloxone hydroxylase is said to improve perfusion in the ischemic stroke.
: This drug has been used since his hospitalization (22 days ago). The use of
: this drug is associated with the raise of blood pressure.
|
t*********m
发帖数: 360 | 9 you need to finish the workup for hemorragic stroke, i.e. why this man bled
in his head, as A++ suggested, before playing with hypertension. get
neurosurgeons involved in this case, since patient is in China. |
h*****1
发帖数: 429 | 10 Update:
<1> Second brain CT: A second brain CT shows that the hemorrhagic shadow
shown in the first CT 4 weeks ago appeared not visible.
<2> The cause of the (ischemic) stroke remains unknown: He has not done
any MRI/MRA to establish a diagnosis of the acute stroke or to rule out
aneurysm/AVM, which makes worrisome.
It is true that he needs to talk to a neurosurgeon about it. However, the
hard part is that he is in China and he is now normal other than high blood
pressure. It would be very hard to convince him to have a neurosurgeon
involved.
According to the patient, he had an intense massage shortly before the onset
of the stroke. Could the intense massage spiked a high blood pressure
leading to a brain hemorrhage or resulted in a release of thrombus to block
a small artery of the involved portion?
<3> His current blood pressure remains hard to control, with systolic
pressure ranging from 218 to 140 and diastolic pressure from 79 to 125.
Could the recovering portion of the involved brain still play a role in the
change of his high blood pressure?
<4> Drug in use: Naloxone hydroxylasev was stopped a week ago just before he
was released from the hospital, and Clonidine, which was used to control
his blood pressure was also taken away from his list due to dizziness
affecting his driving a car. He currently uses Irbesartan and
Hydrochlorothiazide and Nifedipine to control his blood pressure. He is also
taking some traditional Chinese medicine for his illness.
<5> General condition: His feeling of numbness on his right foot improves
but not completely disappear. Occasionally, he feels a little bit tardy for
his right foot while walking. Otherwise, he is normal.
bled
【在 t*********m 的大作中提到】
: you need to finish the workup for hemorragic stroke, i.e. why this man bled
: in his head, as A++ suggested, before playing with hypertension. get
: neurosurgeons involved in this case, since patient is in China.
|
