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宋某,女,43岁。1984年12月31日就诊。两下肢瘫痪,双目失明4天。1周前自觉腰背酸痛,两下肢麻木胀痛,痿软乏力。继而出现两下肢不能自主活动,双目失明,伴小便潴留,大使不通。经某县医院检查诊为视神经脊髓炎。住院3天,用抗生素、激素等药物治疗无效,而转来我院。10年前曾患“急性黄疽型肝炎”,经住院治疗而愈。平素月经量多。共生育6胎。检查:体温36.3℃,脉搏80次/分,呼吸20次/分,血压120/80毫米汞柱。神清,面目虚浮,舌体活动灵活。心肺听诊无异常。腹软,肝脾未触及,膀胱区膨隆,叩诊浊音,肠鸣音减弱。舌苔薄白,脉细弱。神经系统检查:吞咽反射存在,颈项无强直,胸_5以下
Song, female, 43 years old. Visited on December 31, 1984. Two limbs paralyzed, blinded for 4 days. One week ago, she felt pain in the back, numbness in the lower limbs, and weak weakness. Then there were two limbs that were unable to operate autonomously. They lost both eyesight and had urinary retention. The ambassadors were unreasonable. After a county hospital examination diagnosed as optic nerve myelitis. In hospitalization for 3 days, treatment with antibiotics, hormones, and other drugs was ineffective and transferred to our hospital. Ten years ago, he had suffered from acute jaundice hepatitis and was hospitalized. There are more menstrual periods. A total of 6 births. Check: body temperature 36.3°C, pulse 80 beats/minute, breath 20 breaths/minute, blood pressure 120/80 mm Hg. God is clear, face is vacant, tongue activity is flexible. Cardiopulmonary auscultation was normal. The abdomen is soft, the liver and spleen are not touched, the bladder area is bulging, the voice is dulled, and the bowel sounds are weakened. Thin white tongue coating, weak pulse. Neurological examination: presence of swallowing reflexes, no stiff neck, chest _5 or less