Initial admission(January to July, 2018)
A 63-year-old female patient surnamed _____ lives in _______, China, in January 2018, there was no obvious inducement to the right limb fatigue, accompanied by Vague language. On the same day, the family immediately sent to Ningbo fourth Hospital diagnosed as "cerebral infarction ".Then the patient was transferred to Ningbo first Hospital, Ningbo first Hospital with "right basal ganglia infarction, rheumatic heart disease valve replacement, hypertension" admitted to hospital, anticoagulant treatment, improve circulation, nutritional nerve, improve urination and other symptomatic treatment, control blood pressure, blood lipids, blood sugar and other stroke risk factors for 10 days, the patient was discharged after stable condition. Due to left right limb motor dysfunction, dysphagia and other symptoms, then came to Xiangshan County Rehabilitation Hospital rehabilitation, outpatient with "cerebral infarction recovery period" admitted to the hospital.Patients have more than 10 years of rheumatic heart disease, valve replacement and other past history, long-term oral "warfarin sodium tablets" anticoagulant treatment, no chest tightness and other discomfort.On her first day in hospital, doctors, nurses, therapists examined and evaluated her and signed informed consent and rehabilitation notification. Admission coagulation function examination showed that the international ratio(INR) of prothrombin was 1.17↑(reference range 0.82-1.15), and the rest was in normal range.Specialist examination:mind clear, mental state,the wheelchair pushed into the ward. Drinking water cough, tongue extension right, bilateral limb shallow feeling normal.Assessment of unarmed muscle strength (MMT): right upper limb proximal muscle strength 2, distal muscle strength 0; Right lower extremity muscle strength grade 2, muscle tension is normal, passive joint motion range is normal.Brunnstrom stage: right upper limb I, hand I, lower limb II. Sitting balance grade 1, standing balance grade 0, Watian drinking water test level 4, right Babinsky sign (+). Hoffman's (+) on the right.Can complete self-turn over, slightly assisted sitting, can not stand and walk.Barthel index 25 points, daily life ability: heavy dependence.The patients were mainly treated with physical factor therapy, acupuncture therapy, exercise training, occupational therapy and speech training.The patients were discharged after 6 months of systematic rehabilitation. At this time, the patient can independently turn over, stand and walk under assistance, sit balance grade 3, stand balance grade 1, Watian drinking water test level 2, right lower limb muscle strength grade 3. Ask patients to continue family rehabilitation training after discharge, regular review.
Recovery after discharge (July, 2018, to August , 2020)
After discharge from hospital, the patient stayed at home for 2 months and went to other hospitals for rehabilitation. But in the patient description, the treatment of stroke rehabilitation in other hospitals is more acupuncture treatment. At this time, the patient has many small subcutaneous hematoma symptoms, but eventually recovered within 2 weeks.
Multiple soft tissue damage and second admission (August to September, 2020)
2 years after discharge, the patient developed pain in the right hip after receiving acupuncture treatment in other hospitals,at that time can walk, no skin damage, no redness and fever, no subcutaneous ecchymosis, no dizziness and headache, no nausea and vomiting, no numbness and discomfort of both lower limbs, the patient did not pay attention at that time. After 2 days, the pain in the right hip gradually aggravated, with a large area subcutaneous hematoma. The family members massaged and pulled the subcutaneous hematoma and the lateral thigh of the right thigh, and then appeared many cord-like plaques(figure 1).After 15 days, the patient was re-sent to Xiangshan County Rehabilitation Hospital, diagnosed to“ Multiple soft tissue injury in right hip and thigh”.Vital sign:pulse 63/ min, body temperature 36.6℃, respiration 18/ min, blood pressure 127/64 mmHg.Admission blood tests showed a decrease in mild red blood cells (2.81) and a decrease in mean hemoglobin content (25.8),admission blood tests showed a decrease in mild red blood cells (2.81) and a decrease in mean hemoglobin content (25.8), slightly elevated erythrocyte distribution width CV(16.5) and hypersensitive C reactive protein (9.20). Because of the massive subcutaneous hematoma in the right hip, D- blood dimer was 4.8↑(reference range <0.9, unit ug/ml), prothrombin time 29↑(reference range 11-15, unit s), activated partial thromboplastin time 42.9↑(reference range 25.4-38.4, unit s), international standardized ratio(INR) 2.48↑(reference range 0.76-1.15), PT activity 19↓(reference range 80-150, unit %).Admission physical examination: clear mind, mental state, on crutches into the ward, large area of right hip (20×20 cm) subcutaneous hematoma,obvious bruising, the swelling is strong. Right lower extremity joint movement is limited. The deep and shallow sensation of the right lower extremity was normal, the muscle strength of the right biceps femoris was grade 2+, the muscle strength of the quadriceps femoris was grade 4+, the muscle strength of the iliopsoas muscle was grade 2+, the muscle strength of the distal right lower extremity induced contraction, and the range of passive joint motion was normal.Sitting balance level 3, standing balance level 2, right Babinsky sign (+), right Hoffman sign (+), can complete independent turn over, a small amount of auxiliary sit up, can not stand and walk. Barthel index 71 points, eating 8 points, bathing 3 points, personal hygiene 3 points, dressing 5 points, Stool control 10 points, urine control 10 points, toilet 8 points, transfer 12 points , walking 12 points, up and down stairs 0 points. Daily life ability: mild dependence.