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例1 张振刚,男,39岁。主因头晕,双下肢行走不稳1年,加重半月入院。患者1年前就医时发现血压高,按“高血压病”服降压药物治疗头晕症状有所缓解。病后出现复视,常有头晕,失眠,进食量减少,二便控制能力差。查体:血压 20/14.5 kPa,意识清,精神异常,时有所问非所答,多动,查体欠合作。两眼球各方向运动自如。心肺腹(-),四肢肌力V级,肌张力正常。指鼻试验差,轮替试验差,Romberg氏征睁眼,闭眼均不稳。腹壁反射减弱,腱反射活跃。初步诊断:1.
Example 1 Zhang Zhen Gang, male, 39 years old. Mainly because of dizziness, lower extremity walking unstable 1 year, increased half a month admitted to hospital. Patients found high blood pressure 1 year ago to seek medical treatment, according to “Hypertension” service antihypertensive drug treatment of dizziness symptoms have eased. Dipyxemia after the disease, often dizziness, insomnia, reduced food intake, the second will be poor control. Physical examination: blood pressure 20 / 14.5 kPa, consciousness, mental abnormalities, when asked non-answer, hyperactivity, physical examination owed cooperation. Both eyes move freely in all directions. Cardiac lung abdomen (-), limb muscle strength V-class, normal muscle tone. Finger nose test is poor, rotation test is poor, Romberg’s sign eyes open, closed eyes are not stable. Abdominal wall reflex, tendon reflexes active. Preliminary diagnosis: 1.