"The patient has no previous history of hypertension, no history of diabetes, no history of similar episodes. Has a history of chronic bronchitis, with frequent attacks in autumn and winter. No history of smoking and alcohol abuse. ”

"After admission, the physical examination showed that the vital signs were stable, the cardiopulmonary examination showed no abnormalities, and no dry or wet rales were heard in both lungs. Soft abdomen, no tenderness and rebound tenderness. ”

"On a neurological examination, it was found that the patient's articulation was not clear, his voice was slightly hoarse, and he choked when drinking water. Eye movement was normal, no nystagmus was found, soft palate movement was slightly poor, gag reflex was slightly poor, and other cranial nerve examinations found no abnormalities. ”

"The muscle tone of the limbs is normal, the muscle strength of the limbs is weak fourth, the tendon reflexes are symmetrical and normal, and there is no elicited case reflex. On sensory examination, the patient's pain and temperature perception is normal. ”

"After admission, low-molecular-weight dextran is given intravenous infusion and low-flow oxygen. Currently, the patient's condition is stable. That's my debriefing. ”

Ding Feng's professionalism has always been recognized and admired by Lin Lin. Her report was detailed when it should be detailed and simple when it should be simple, but she did not miss any important links.

"Dr. Ding's report just now is very detailed and the treatment is very timely, including the examination and medication are in place. At present, the patient's diagnosis is not yet clear, so please give your opinion. Facing Ding Feng's near-perfect report, Ling Xiaoyun really couldn't find a place for her to play prestige.

"In addition to chronic bronchitis, this patient has no bad habits and no underlying pathologies, such as hypertension and diabetes."

"From the perspective of the patient's pathogenesis, the location of the patient's lesion should be dominated by the blood vessels of the posterior circulation of the brain. Since the CT scan didn't find any lesions, I was more inclined to have a TIA (transient ischemic attack) diagnosis. Li Yun'e was very confident in her judgment and spoke first.

"I also agree with Mr. Li's diagnosis, however, the patient still has some suspicious signs and needs to continue to be observed. If the patient's signs disappear quickly, the diagnosis is established. Ding Feng is also inclined to the diagnosis of TIA.

Faced with such a situation, other doctors chose to remain silent.

"Dr. Lin, what is your opinion?" Ling Xiaoyun knew that Yu Zhitong cared about Lin Lin's opinion.

"Okay, I'll give you my opinion."

"Although I have not done a physical examination for a patient, I believe that the results of Dr. Ding's physical examination are accurate."

"From the patient's mode of onset, the time of onset, the symptoms and signs that appeared after the onset of the disease, and the head CT examination, I also agree that the patient's onset this time is mainly caused by the lesion of the posterior cerebral circulation."

"If you are more specific, I think that the patient's damage is mainly in the medulla oblongata and the lower pons. However, I do not agree with the diagnosis of TIA in this patient, and I believe that the diagnosis of this patient should be incomplete 'dorsolateral bulbar syndrome', which is caused by the blockage of individual branches of the posterior inferior cerebellar artery. ”

"The reason why I made this diagnosis is because the patient is currently supported by physical signs, such as poor movement of the soft palate, poor gag reflex, choking on water, hoarseness of speech, poor arthritization, and decreased muscle strength in the limbs."

"It is said to be incomplete 'dorsolateral bulbar syndrome' because some of the signs are not yet recognized, or are atypical. For example, signs of cerebellar damage, imaging changes of cerebellar damage, muscle loss should be predominantly on one side, etc. ”

"This is the positioning diagnosis of this patient, as for the qualitative diagnosis, there should be no suspense, it must be an ischemic lesion. Because CT has a diagnosis rate of more than 99% for cerebral hemorrhage. ”

"Let me explain again why the CT of the patient's head did not see the lesions. I think there are three possibilities. ”

"First, at the time of the examination, it was only four hours before the onset of the patient's illness. We know that whether it is an infarction in the cerebral hemisphere, cerebellum or brainstem, within 24 hours after the onset of the disease, especially within 12 hours, the lesion is in the 'isodense phase' with normal brain tissue, and at this time, CT is not easy to find the lesion. ”

"Second, it is the location of the lesion, which is just in the posterior fossa of the brain. We know that there are many bony bulges in the posterior fossa of the brain. These protruding bones are prone to artifacts during CT examination, which can cause observation of the brainstem, cerebellum and other parts, and even cover up the lesions. Therefore, in these places, the absence of lesions does not mean that there are no lesions. ”

"Third, at present, the patient's signs are not obvious, and it cannot be ruled out that the patient's lesions are relatively small, as small as less than 1 centimeter. This is because, in a CT scan, each layer is exactly 1 centimeter apart. If the lesion is less than 1 cm, it may not be detected by CT. ”

"Now, I'm going to focus on what we need to pay attention to in diagnosis, treatment, and observation."

"First, the patient is still in the acute phase, and the current signs do not mean that the signs will remain the same for the next few hours or days."

"The peak of edema after cerebral infarction may not arrive until 2 weeks after the onset of illness in individual patients. If this is the case, the patient's condition may continue to deteriorate. ”

"Therefore, we must closely observe the patient's changes in speech and consciousness, muscle strength in the limbs, and changes in swallowing, all of which may be aggravated, and even some new signs will appear, such as signs of cerebellar damage."

"Second, since I judge it to be an incomplete 'dorsolateral bulbar syndrome,' it is necessary to prevent the patient from inhaling food or fluids into the lungs when eating and drinking. Once this happens, it will be very dangerous. ”

"Therefore, I suggest that the diet at this stage should be mainly semi-liquid, such as paste-like food, and try not to feed water directly to the patient."

"It is necessary to closely observe the patient's body temperature, blood picture, and rales in the lungs, and once the possibility of aspiration pneumonia is found, it should be checked and dealt with in time."

"Actually, what I am most worried about now is not the cerebral infarction, but the aspiration pneumonia caused by the cerebral infarction that impairs the swallowing function. Because the process of cerebral infarction is irreversible, it is not fatal for this patient. ”

"And this patient has a history of chronic bronchitis, and once aspiration pneumonia develops, it will be very troublesome and very difficult to treat. Therefore, aspiration pneumonia is what we need to focus on. ”

"Of course, preventing the recurrence or aggravation of the primary disease is also something we must attach great importance to, and Dr. Ding has done a good job in this regard."

"In terms of nursing, it is necessary to turn over frequently, pat the back frequently, and suction. The prevention of complications and the guarantee of nutrition must be carried out simultaneously and are indispensable. ”