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陈某某,男性,42岁。于1974年6月27日因失语,烦燥不安,呕吐伴右半身活动受限入院。检查:意识不清,压眶无反应,两侧瞳孔等大,光反应存在;双眼视乳头边清,无出血。动:静=2:3。右侧肢体软瘫,肌力零级。腱反射左右对称,右足Babinski′s征(+)。体温正常,脉搏62次/分,BP200/140mmHg无项强,两肺清、心音纯、律齐,腹平软,余正常。诊断:脑出血。治疗:给氧、冰帽、系统降颅压,抗感染等治疗。6月29日双乳头边欠清晰,次日因有呼吸道梗阻表现行气管切开术,术后呼吸功能改善。7月1日双眼乳头边不清,高出2d,A:V=1:2,无出血、渗出。一周后再查双眼底:双视乳头边不清,乳头
Chen Moumou, male, 42 years old. On June 27, 1974 due to aphasia, irritability, vomiting with right half-body restricted access to hospital. Check: Consciousness, pressure orbital non-response, both sides of the pupil and other light responses exist; binocular as the nipple clear, no bleeding. Move: static = 2: 3. Right limb paralysis, muscle zero. Symmetry of tendon reflexes, right foot Babinski’s sign (+). Normal body temperature, pulse 62 beats / min, BP200 / 140mmHg no items strong, lungs clear, heart sound pure, law Qi, abdominal soft, more than normal. Diagnosis: cerebral hemorrhage. Treatment: oxygen, ice cap, the system down intracranial pressure, anti-infection treatment. June 29 double papillae side less clear, the performance of the next day due to airway tracheostomy tracheostomy, postoperative respiratory function improved. July 1 nipple edge unclear, higher than 2d, A: V = 1: 2, no bleeding, exudation. A week later check his eyes: bilateral unclear side of the nipple, nipple