Имя: Maria Da Silva
Возраст: 64 года
Диагноз: 1) Энцефалопатия; 2) Гипертония; 3) Апноэ
Начало курса лечения: 2 Мая 2016
Длительность лечения: 14 дней
Maria Da Silva is a middle-aged woman. The onset was trivial. She had the symptom of memory loss and tremor of head for 3 years. Medical History: she had history of hypertension, took Olmesartan as oral medicine. Her blood pressure was under control. She snored when she was sleeping. No history of diabetes. No history of drug allergy.
Bp: 128/80mmHg; Hr: 86/min. She had a good spirit. Her heart rhythm was normal and strong, without obvious murmur in the valves. The abdomen was soft with no pressing pain or rebound tenderness. The doctor did not touch any abnormal masses in the abdomen. There was no edema in both lower limbs.
Maria Da Silva was alert. She had a poor memory and calculation ability. Her orientation, perception and judgement abilities were normal. The forehead wrinkle pattern was symmetrical. The tongue was centred in the oral cavity. Both eyeballs could move freely and the pupils reacted normally to light stimulus. Both palates could be lifted. Neck was soft with non-resistance. Her left side shrugged strongly. Muscle tone of four limbs was normal. Tendon reflex could be normally elicited. Bilateral Palm jaw reflection was positive. Bilateral pathology sign was negative. Finger-to-nose test, finger-to-finger text and rapid rotation test were normal but slowly done. The meningeal irritation sign was negative. MRI (2015-4-22): Encephalatrophy, ischemic change.
We gave her a complete examination and she was diagnosed with”Encephalatrophy and hypertension.” She received treatment to nourish neurons, improve circulation and adjust blood pressure. Non-invasive ventilator is used to treat her snoring.
After the treatment the patient condition was stable. The trembling of head has been alleviated. Her blood pressure was stable and her sleep apnea syndrome was better.