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病历摘要患儿女,12岁。1990年4月19日入院。3年前不明原因双下肢渐瘫痪,双侧感觉消失,以后双上肢亦渐不能活动,且有脊柱弯曲。大小便均不能自理和自控,常需导尿和灌肠。曾多次到外地查治,未明确诊断。发病初2～3月曾在某医院诊断为“脊髓灰质炎”。治疗近1 个月无效。病后无发热,不疼痛。病程呈进行性加重。半年前双上肢还能完成吃饭、打扑克等动作,但无力,现均不能完成。家族中无类似病例。两年前两次脊柱摄片未见畸形。“OT”试验阴性。查体:神志清,精神佳,营养发育差,查体合作。智力相当于同龄正常儿。颈软,胸廓狭小,心率90次/分,心律齐,无杂音。两侧胸廓呼吸运动均匀,肺
Medical records with children, 12 years old. April 19, 1990 admission. 3 years ago, unexplained double lower limb paralysis, both sides disappeared, after both upper extremities gradually unable to move, and the curvature of the spine. Can not take care of themselves and urine, often need to catheterization and enema. Has repeatedly to the field investigation, not a clear diagnosis. Early onset of 2 to 3 months in a hospital diagnosed as “poliomyelitis.” Treatment of nearly 1 month is invalid. No fever after the illness, no pain. The course of progression was aggravating. Six months ago, the upper extremities can complete the meal, playing poker and other actions, but powerless, are unable to complete. No similar cases in the family. Two years ago, no spinal deformity. “OT” test negative. Examination: Consciousness, good spirit, poor nutrition, physical examination. Intelligence equivalent to normal children of the same age. Neck soft, narrow thorax, heart rate 90 beats / min, heart rhythm Qi, no noise. Breathing evenly on both sides of the thorax, lungs