Detailed Treatment Process
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Male, 70 years old. On the evening of October 8, symptoms began. The ambulance medical record noted: Sudden dizziness, weakness in all four limbs, pale complexion, and numbness in all four limbs, with no vomiting or aphasia. No history of cardiovascular or cerebrovascular disease was reported. Blood pressure was 250 mmHg. Muscle strength was grade 2 in the left limbs and grade 4 in the right limbs. The accompanying doctor diagnosed “cerebrovascular accident (TIA or between TIA and stroke)” and administered oxygen and torasemide. Upon arrival at the hospital emergency department, there was a handover between the ambulance crew and the emergency physician.
Emergency Medical Record (handwritten scan; characters may be unclear) Department: Internal Medicine Emergency October 8 Chief complaint: Lower limb weakness for 1 hour. No fall, no syncope, accompanied by dizziness. He usually has dizziness. Bp 200/110 mmHg. Past history of hypertension, no diabetes. PE: Bp 200/110 mmHg. Alert, answers questions appropriately. Coarse breath sounds in both lungs, no rales. Abdomen negative. Dx: 1. Hypertension; hypertensive heart disease. Management: 1. Blood routine, liver and kidney function, electrolytes, D-dimer, cardiac injury markers including BNP. 2. Blood glucose, electrocardiogram, oxygen inhalation, cardiac monitoring. 3. Neurology consultation recommended. 0.9% sodium chloride 100 ml + nicardipine 10 mg intravenous infusion at 10 mL/h. Note: Related to changes in condition. Sudden dizziness and weakness. Ambulance blood pressure 250/110 mmHg. No loss of consciousness, history of hypertension.
Hospital Emergency Phase: Head CT Radiology Report Name: *** Department: Neurology Requested by: Head CT plain scan Examination: Head CT plain scan Radiological findings: Small punctate hypodense foci in the bilateral basal ganglia and centrum semiovale. Ventricles, cisterns, sulci, and fissures are widened. Midline structures show no significant shift. Radiological diagnosis: Deep lacunar ischemic lesions in the brain; age-related brain changes. Please correlate with clinical findings; MRI may be warranted if necessary. Report written: October 8 Report reviewed: Examination time: October 8
Laboratory Report Specimen: Blood Department: Emergency Internal Medicine Emergency blood glucose: 7.1 H (3.9-6.1 mmol/L) Serum potassium: 3.83 (3.5-5.1 mmol/L) Serum sodium: 138 (135-147 mmol/L) Serum chloride: 97 (95-105 mmol/L) Total carbon dioxide: 31.5 H (20-30 mmol/L) Blood urea: 6.4 (2.5-6.4 mmol/L) Blood uric acid: 277 (208-428 umol/L) Serum creatinine: 105 (62-115 umol/L) NT-proBNP: 1776 (age <75: <125 pg/ml; age >75: <450 pg/ml) Cardiac troponin I (chemiluminescence): 0.03 (0-0.04 ng/ml) Myoglobin (chemiluminescence): 35.4 (17.4-105.7 ng/ml) D-dimer (automated): 0.17 (0.01-0.55 mg/L) Specimen received: October 8 Report date: October 8
The neurology physician’s original handwritten notes were illegible. At the family’s request, following intervention by the hospital medical affairs office, the neurologist rewrote the emergency record on a separate sheet in clearer handwriting (handwritten scan; characters may be difficult to decipher): Outpatient Record Sudden dizziness and weakness. Ambulance blood pressure 250/110 mmHg. No loss of consciousness. History of hypertension. (Physical examination) PE: Alert, fluent speech, clear articulation, answers questions appropriately. Symmetric nasolabial folds. Right pupil 0.3 cm, reactive to light. Left eye blind. Tongue midline. All four limbs show voluntary movement. Bilateral finger-nose test performed. Diagnosis: Hypertension? Management: Head CT plain scan performed; no obvious abnormal density seen intracranially in emergency setting. Blood pressure control. Follow-up.
The patient was subsequently admitted to the cardiology ward. The following imaging reports were generated: Head CT Radiology Report Department: Cardiology Requested: Head CT plain scan Examination: Head CT plain scan Findings: Small punctate hypodense foci in the bilateral basal ganglia and centrum semiovale. Ventricles, cisterns, sulci, and fissures are widened. Midline structures show no significant shift. Diagnosis: Deep lacunar ischemic lesions in the brain; age-related brain changes. MRI recommended. Report written: October 10 Report reviewed: Examination time: October 10 Head MR Radiology Report Department: Cardiology Requested: Head MR plain scan Examination: Head MR plain scan Radiological findings: Patient uncooperative; significant motion artifact affecting interpretation. Multiple punctate and patchy abnormal signal intensities seen in the bilateral basal ganglia, centrum semiovale white matter, bilateral frontal, temporal, and parietal lobes. These appear hypointense on T1W, hyperintense on T2W, and mixed high/low signal on T2FLAIR. The lesion in the left basal ganglia shows high signal on DWI. Cisterns, fissures, and sulci are variably widened. Midline structures are midline. Radiological diagnosis: Multiple ischemic and infarct lesions in the brain (acute infarction in the left basal ganglia); age-related brain changes. Follow-up recommended. Report written: October 12 Report reviewed: October 12 Examination time: October 11