论文部分内容阅读
病历摘要患者男性,55岁。因行走不稳,进行性加重4年于2006年8月7日入院。4年前无明显诱因出现行走不稳,易摔倒,逐渐出现双手活动笨拙,记忆力减退;症状呈缓慢进展,渐至行走困难。慢性乙型肝炎病史30余年,肝硬化4年,糖尿病1年余,心房颤动1年,近几年偶有黑便。入院后体格检查:呈慢性病容,面色晦暗,神志清楚,近记忆力明显减退,音节欠清。无眼球震颤,伸舌居中,软腭抬举尚可。双侧咽反射消失,四肢肌张力偏高,以右侧明显,右下肢近端肌力5-级,其余肢体肌力5级;四肢腱反射对称且活跃,右侧Chaddock征阳性,深浅感觉正常,双侧指鼻试验、轮替试验及跟-膝-胫试验动作不准确;Romberg征阳性,独自行走不能。简易精神状态量表(MMSE)评分为23分。
Patient summary Male, 55 years old. Due to unstable walking, progressive increase in 4 years on August 7, 2006 admitted. 4 years ago there was no obvious incentive to walk unsteady, easy to fall, gradually appear clumsiness in his hands, memory loss; symptoms showed a slow progress, gradually moving difficult. Chronic hepatitis B history of more than 30 years, 4 years of cirrhosis, more than 1 year of diabetes, atrial fibrillation for 1 year, occasional melena in recent years. Physical examination after admission: a chronic disease, looking dull, conscious, near memory significantly decreased, syllable less clear. No nystagmus, tongue middle, soft palate lift still acceptable. Bilateral pharyngeal reflex disappeared, limb muscle tension was high to the right obvious lower extremity proximal muscle 5-level, the other limb muscle strength 5; limb tendon reflex symmetry and active, right Chaddock sign positive, the sense of depth of normal , Bilateral finger nasal test, rotation test and heel-knee-tibia test inaccurate; Romberg sign positive, can not walk alone. The Mini Mental Status Scale (MMSE) score was 23 points.