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患者女,45岁,病案号:70922,主因左侧肢体运动障碍半个月,在地方医院做CT检查确诊为“脑血栓形成”,静点脉通500ml加ATP40mg,一日一次,治疗一疗程(15天)后,病情好转,为进一步巩固治疗而转来我院,查体:体温36.7℃,脉搏82次/分,呼吸16次/分,血压16/11KPa,神志清,语言流利,双瞳孔正大等园,面部左侧中枢性面瘫体征,颈软无抵抗,胸廓对称,心肺听诊正常,腹平坦,肝脾不大,脊柱四肢无畸形,左侧肢体皮肤感觉正常。左上肢肌力Ⅲ级,下肢肌力Ⅳ级,肌腱反射正常,病理反射未引出。根据以上症状及体征,结合脑CT检查结果,诊断脑血栓形成,给予静点10％葡萄糖500ml加胞二磷胆碱0.5U,一日一次,当第1次静点液体输入约250ml时,患者亦出现轻微头疼,未行任何处理,液体输完后,头疼剧烈,难以忍受,但无恶心呕吐和意识障碍,测血压16/12KPa,查体无新病情变化。即服去痛片1片,颅痛定30mg,症状逐渐缓解。第2次用
Female, 45 years old, medical record number: 70,922, mainly due to left limb movement disorders for half a month, at the local hospital to do CT examination diagnosed as “cerebral thrombosis”, intravenous infusion of 500ml plus ATP40mg, once a day, a course of treatment (15 days), the condition improved, to further consolidate the treatment and transferred to our hospital, physical examination: body temperature 36.7 ℃, pulse 82 beats / min, breathing 16 beats / min, blood pressure 16 / 11KPa, Pupil Zhengda Park, facial left facial paralysis symptoms, soft neck non-resistance, thoracic symmetry, normal auscultation of the heart and lungs, abdominal flat, small spleen, limb deformity, left skin feel normal. Left upper limb muscle strength Ⅲ, Ⅳ lower limb muscle strength, tendon reflex normal, pathological reflex did not lead. According to the above symptoms and signs, combined with brain CT examination results, the diagnosis of cerebral thrombosis, given intravenous 10% glucose 500ml plus citicoline 0.5U, once a day, when the first intravenous fluid input about 250ml, patients There are slight headache, without any treatment, after the fluid is lost, the headache is severe and unbearable, but no nausea and vomiting and disturbance of consciousness, measuring blood pressure 16 / 12KPa, physical examination no new changes in condition. Take a piece of clothes to painkillers, headache set 30mg, symptoms gradually eased. The second use