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病历摘要高某某,女,56岁,头昏流涕、咳嗽一周,手麻、头痛、眩晕、呕吐两天,于1986年3月入院。患者于今年3月19日受凉后头昏流涕,但不发热,第五天出现指趾尖发麻,次晨睁眼无力,头痛,颈痛,视物旋转,呕吐、呛咳,说话含混,走路无力,步态尚可,门诊以脑干脑炎入院。检查:血压130/86mmHg,内科正常。神经系统检查,神志清楚,语言含混,眼底正常,双上眼睑下垂,眼球居中,呈完全性运动不能,双侧瞳孔散大6mm,对光反应消失,鼻唇沟对称,咽反射迟钝,四肢肌力正常,浅深感觉正常,跟腱反射消失外,其它腱反射均减弱。病理反射(-),颈有轻度
High medical records, female, 56 years old, dizziness, runny nose, cough for a week, hand numbness, headache, dizziness, vomiting for two days, in March 1986 admitted. Patients were dizzy and runny on cold on March 19 this year. However, they did not have fever. On the fifth day, their toes pointed numb. Their eyes were weak after the next morning. Headache, neck pain, rotation of their eyes, vomiting, coughing and vociferation , Walking weak, gait is acceptable, outpatient brainstem encephalitis admitted. Check: blood pressure 130 / 86mmHg, internal medicine normal. Nervous system examination, conscious, verbal mixed, fundus normal, double upper eyelid ptosis, eye center, was completely unable to exercise, bilateral mydriasis 6mm, disappeared reaction to light, nasolabial fold symmetry, pharyngeal reflex, limb muscle Normal force, shallow depth of feeling normal, Achilles tendon reflex disappeared, other tendon reflexes are weakened. Pathological reflex (-), neck mild