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患者,女,58岁,2014年7月2日入院,主诉头昏、头闷1月,门诊查头颅CT提示双侧基底节腔隙性梗死,以脑梗死收入住院。患者有高血压、糖耐量异常及脑梗死病史5年,一直予以阿司匹林肠溶片、厄贝沙坦、阿托伐他汀钙等药物治疗。体检:BP 130/70mmH g,P 75次/min,发育营养正常(158cm,55kg)。心肺听诊正常,腹部平软,无压痛及反跳痛,肝脾肋下未及。神志清楚,言语正常,无面舌瘫,两侧肢体肌力5级,巴彬斯基征阴性。
Patient, female, 58 years old, admitted to hospital on July 2, 2014, complained of dizziness, head boring in January, out-patient examination of cranial CT tips bilateral basal ganglia lacunar infarction, admission to hospital with cerebral infarction. Patients with hypertension, impaired glucose tolerance and history of cerebral infarction for 5 years, been given aspirin enteric-coated tablets, irbesartan, atorvastatin, calcium and other drug treatment. Physical examination: BP 130/70 mmHg, P 75 times / min, normal developmental nutrition (158cm, 55kg). Cardiopulmonary auscultation normal, flat and soft abdomen, no tenderness and rebound tenderness, liver and spleen ribs did not. Consciousness, normal speech, faceless tongue paralysis, limb muscle strength on both sides of 5, Babinski sign negative.