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徐×,男,51岁,住院号2241。该患于1985年4月20日夜,性交时突然剧烈头痛、呕吐,继而昏迷,四小时后来诊,以“脑出血”收入院。既往有无高血压史不详。查体:32/18.7kpa,神志不清,谵妄状态,压眶反射存在,瞳孔右侧3mm,左侧4mm,光反射迟钝,右侧鼻唇沟稍变浅,口角略下陷。颈强(+),右侧肢体轻瘫,克氏征(±),巴氏征(±).入院诊断:脑出血,高血压病治疗期。治疗经过:保持安静,适当给予镇静剂加止血剂,降颅压,抗脑水肿,调节血压,适当补液,加强护理,防止并发症。四天后病情明显好转,意识呈朦胧状态,时有谵语,能进少许全流食。七天后神志清醒,右侧肢体瘫已不明显,可自行翻身,但仍有头痛,颈强(+)。自诉双眼视物不清。眼部检查双眼
Xu ×, male, 51 years old, hospital number 2241. The suffering from the night of April 20, 1985, sudden severe headache during sexual intercourse, vomiting, and then coma, four hours later, with “cerebral hemorrhage” income hospital. No previous history of hypertension is unknown. Physical examination: 32 / 18.7kpa, delirium, delirium, pressure orbital reflex exist, the right pupil 3mm, left 4mm, light reflex slow, the right nasolabial fold slightly shallow mouth a little sag. Neck strong (+), right limb paralysis, Kirschner Sign (±), Pakistan’s sign (±) Admission diagnosis: cerebral hemorrhage, hypertension treatment period. After treatment: to keep quiet, appropriate to give sedatives and hemostatic agents, reducing intracranial pressure, anti-brain edema, blood pressure, appropriate rehydration, and strengthen care to prevent complications. After four days, the condition improved obviously, the consciousness was in a hazy state, sometimes there was a shy language, and could make a little full flow of food. After seven days of consciousness, the right limb paralysis is not obvious, can stand up, but still have headache, neck strong (+). Prosecution eyes blurred vision. Eye examination eyes