Detailed Treatment Process
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Male, 53 years old Discharge Summary Department: Neurology Date of admission: February 22, 12:03 Date of discharge: March 31, 09:00 Outpatient diagnosis: Obstructive sleep apnea syndrome Admission diagnosis: Vocal cord polyp; Obstructive sleep apnea syndrome Discharge diagnosis: Acute multiple cerebral infarctions (right temporal lobe, basal ganglia region, bilateral occipital lobes); Moyamoya disease?; Grade 2 hypertension (very high-risk group); Impaired glucose tolerance; Hypokalemia; Hyponatremia; Obstructive sleep apnea syndrome; Vocal cord polyp; Urinary tract infection Main symptoms and signs on admission Main symptoms: The patient was admitted to the otolaryngology department with a history of recurrent throat pain for more than 6 months. He underwent vocal cord polyp resection followed by uvulopalatopharyngoplasty plus bilateral tonsillectomy (laser). Postoperatively, he developed blurred vision in both eyes. Head MRI revealed large areas of fresh infarction in the right temporo-occipital and left occipital regions. He was then transferred to the neurology department for further management. Physical findings on admission to otolaryngology: T 37℃, P 88 beats/min, R 22 breaths/min, BP 120/70 mmHg. The patient was alert and oriented, with steady breathing, appropriate responses to questions, clear speech, and full cooperation during examination. No jaundice or hemorrhagic spots on the skin or mucous membranes. No enlarged superficial lymph nodes. Neck supple without resistance. No jugular vein distension. Trachea midline. Normal chest contour. Clear percussion note over both lungs. Symmetric respiratory movements. Clear breath sounds bilaterally with no crackles or wheezes. Heart rate 88 beats/min, regular rhythm, no murmurs. Abdomen soft and nontender, no rebound tenderness. Liver and spleen not palpable below the costal margin. No lower limb edema. Negative pathological reflexes. After transfer to neurology: T 36.5℃, P 85 beats/min, R 18 breaths/min, BP 140/80 mmHg. Alert, slightly unsteady gait, slowed movements, mildly blunted responses. Oriented to time, place, and person. Answers generally appropriate. Reduced memory and calculation ability. Cooperative with examination. Symmetric frontal wrinkles. Normal palpebral fissures. Grossly reduced visual acuity in both eyes. Extraocular movements essentially normal. Pupils equal and round, 4 mm in diameter, with intact light reflexes. Symmetric hearing. Symmetric nasolabial folds. Tongue midline. Present gag reflex. Neck supple. Normal muscle tone and power (Grade V) in all limbs. Steady finger-nose and heel-knee-shin tests. Symmetric tendon reflexes (++). No obvious sensory abnormalities. No pathological reflexes elicited. Negative meningeal signs. Patchy ecchymosis noted on the right buttock with mild local tenderness. Hospital course and key investigation results February 23 blood routine: WBC 6.22 × 10⁹/L, RBC 5.10 × 10¹²/L, hemoglobin 161 g/L, hematocrit 45.90, MCV 90.0 fL, MCH 31.6 pg ↑, MCHC 351 g/L, platelets 130 × 10⁹/L, lymphocytes 32.30%, monocytes 6.80%, neutrophils 59.30%. February 23 coagulation: PT 9.50 s, INR 0.91, fibrinogen 3.08 g/L, APTT 28.10 s, TT 15.70 s. February 23 biochemistry: Total bilirubin 16.30 μmol/L, direct bilirubin 4.20 μmol/L, total protein 70.00 g/L, albumin 42.40 g/L, globulin 27.60 g/L, A/G 1.54, ALT 29.00 IU/L, AST 18.50 IU/L, glucose 8.8 mmol/L ↑, potassium 3.86 mmol/L, sodium 142.70 mmol/L, chloride 104.4 mmol/L, AST/ALT 0.64. February 23 immunology: RPR negative, TPAb 0.030 S/CO, HIV Ag/Ab 0.06 S/CO, HBsAg 0.000 IU/mL, Anti-HBs 3.15 mIU/mL, etc. (all other markers negative or within normal limits). March 1 blood routine: WBC 11.05 × 10⁹/L ↑, RBC 4.53 × 10¹²/L, hemoglobin 144 g/L, hematocrit 39.50 ↓, MCV 87.2 fL, MCH 31.8 pg ↑, MCHC 365 g/L, platelets 168 × 10⁹/L, lymphocytes 24.80%, monocytes 4.90%, neutrophils 69.90%, CRP <1.28 mg/L. March 1 coagulation: PT 11.50 s, INR 1.09, fibrinogen 1.98 g/L ↓, APTT 22.70 s ↓, TT 16.00 s, D-dimer 0.13 mg/L. March 1 biochemistry: Total bilirubin 8.50 μmol/L, ALT 21.20 IU/L, AST 15.20 IU/L, urea 7.38 mmol/L, creatinine 46.0 μmol/L, potassium 2.87 mmol/L ↓, sodium 138.00 mmol/L, chloride 101.2 mmol/L. March 1 urine routine: Normal. March 2 blood routine: WBC 14.20 × 10⁹/L ↑, neutrophils 88.40% ↑, CRP 80.60 mg/L ↑. March 2 biochemistry: Urea 10.21 mmol/L ↑, sodium 134.00 mmol/L ↓, triglycerides 13.00 mmol/L ↑, HDL-C 0.64 mmol/L ↓. March 8 blood routine: WBC 10.49 × 10⁹/L ↑, neutrophils 90.30% ↑, CRP 14.38 mg/L ↑. March 8 coagulation: D-dimer 0.58 μg/mL ↑. March 8 biochemistry: Glucose 13.6 mmol/L ↑, potassium 3.40 mmol/L ↓, sodium 132.00 mmol/L ↓. March 13 biochemistry: HbA1c 7.0% ↑, glucose 6.2 mmol/L ↑, vitamin B12 >1476 pmol/L ↑. March 13 blood routine: Neutrophils 71.30% ↑. March 14 postprandial glucose 10.57 mmol/L ↑. March 24 blood routine: RBC 3.86 × 10¹²/L ↓, hemoglobin 120 g/L ↓, hematocrit 34.70 ↓, neutrophils 82.90% ↑. March 24 biochemistry: Total bilirubin 25.60 μmol/L ↑, direct bilirubin 9.40 μmol/L ↑, AST 40.60 IU/L ↑, hs-CRP 7.70 mg/L ↑. March 27 urine: WBC 2+, microscopy 8-10 WBC/HPF ↑. March 29 blood routine: RBC 3.65 × 10¹²/L ↓, hemoglobin 113 g/L ↓, hematocrit 32.70 ↓. March 29 biochemistry: Potassium 2.88 mmol/L ↓. Key imaging and consultations February 22 chest X-ray: Increased markings in both lower lungs. February 22 carotid ultrasound: Plaques at bilateral carotid bifurcations and right internal carotid artery. February 23 sleep study: Severe OSAHS with severe hypoxemia. March 8 head CT: Large infarcts in right temporal lobe and bilateral occipital lobes with age-related changes. March 9 head MRI: Large infarcts in right temporo-occipital and left occipital regions (some relatively fresh, possible local microhemorrhage), multiple fresh lacunar infarcts in right basal ganglia, multiple lacunar and ischemic lesions, age-related brain changes. March 10 carotid MRA: Poor visualization of main trunks of bilateral middle cerebral arteries with multiple stenoses. Absent bilateral posterior communicating arteries. Narrow left vertebral artery with multiple stenoses. Dominant right vertebral artery. Multiple distal stenoses. March 14 cranial MR perfusion: Subacute infarcts with microhemorrhage and extensive hypoperfusion in both hemispheres. March 21 cerebral DSA: Multiple severe stenoses of bilateral middle and anterior cerebral arteries with moyamoya-like changes. Left vertebral artery occlusion. Limited collateral flow. March 29 repeat cranial MR perfusion: Reduced areas of severe hypoperfusion compared with prior scan. Hospital course and treatment The patient was admitted to otolaryngology on February 22 for preoperative evaluation. On February 24 he underwent vocal cord polyp resection under general anesthesia. On March 1 he underwent uvulopalatopharyngoplasty plus bilateral tonsillectomy (laser) under general anesthesia. On March 6 he reported blurred vision in both eyes. Ophthalmology consultation suggested ischemic optic neuropathy. Head MRI confirmed large infarcts. He was transferred to neurology on March 10 for specialist care. Treatment included clopidogrel for antiplatelet therapy, atorvastatin for lipid control and plaque stabilization, butylphthalide to improve circulation, dextran-amino acid for volume expansion, and mecobalamin for neuroprotection. Further evaluation of intracranial vessels and stroke risk factors was performed. DSA showed moyamoya-like vascular changes. External neurology consultation agreed with current management and recommended elective neurosurgical evaluation for moyamoya disease. He developed urinary symptoms suggestive of urinary tract infection, which improved with levofloxacin. After comprehensive treatment, his blurred vision persisted but was mildly improved. Repeat MR perfusion showed reduced hypoperfusion areas. He was discharged in stable condition with medications. Comorbidities: None Discharge status Mild intermittent throat pain and persistent blurred vision. Blood pressure 135/70 mmHg. Alert but mildly slow reactions. Able to count fingers at 50 cm with either eye. Otherwise normal neurological examination. Heart rate 80 beats/min, regular. Clear lung sounds. No edema. Discharge medications and advice 1. Health education: Quit smoking, limit alcohol, light diet, balanced nutrition, regular exercise, regular sleep and bowel habits, maintain positive mood. 2. Precautions: Take medications on schedule, monitor blood pressure and glucose. Long-term antiplatelet and statin therapy for secondary prevention (if no contraindications). Regular follow-up blood tests. Continue visual rehabilitation exercises. Seek immediate care for new neurological symptoms. Elective neurosurgical consultation for moyamoya-like vasculopathy. 3. Discharge medications: Clopidogrel 75 mg daily, atorvastatin 20 mg nightly, telmisartan 40 mg daily, oxiracetam 800 mg twice daily, mecobalamin 0.5 mg three times daily. 4. Follow-up: Neurology outpatient clinic Monday or Tuesday afternoons. Blood routine in 3 days. Treatment outcome: Improved March 30, 11:00