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患者,男,25岁,住院号137333。于入院前40天自觉感冒,随后出现左眼眶周围疼痛,伴视物成双,尤以向左侧视时双影更加明显,一个月后,左眼睑下垂,启闭不能,但视力正常。患病后在外地经头颅 CT 检查、腰穿、X 线头颅平片及脑电图检查均未发现异常,后入我院。4年前曾患“剥脱性皮炎”已愈。个人及家族史无特殊记述。检查:一般检查正常,意识清楚语言流利。双眼视力:右0.9、左0.5,与发病前视力相同。左眼睑下垂,眼球不突出,局部皮肤无红肿及瘀血,眼球各方位活动不能,固定于正中位,瞳孔左>右,光反射左侧迟钝,右侧存在灵敏。双眼底正常,双侧角膜反射存在。其它组颅神经检查正常。辅助检查:双侧视神经孔、眶上裂 X 线平片未发现异常,脑
Patient, male, 25 years old, hospital number 137333. 40 days before admission conscious cold, followed by left orbital pain, with double vision, especially to the left when the double shadow more obvious, a month later, the left eyelid ptosis, opening and closing can not, but normal vision. After the illness in the field by skull CT examination, lumbar puncture, X-ray skull plain film and EEG examination were not found abnormal, later into our hospital. 4 years ago suffering from “exfoliative dermatitis” has been more. No special personal and family history. Check: general inspection is normal, clear sense of language fluency. Binocular vision: right 0.9, left 0.5, the same as before the onset of vision. Left eyelid ptosis, eyeball is not prominent, local skin without swelling and blood stasis, the eye can not move in all directions, fixed in the median, pupil left> right, light reflection left dull, there is sensitive right. Both eyes are normal, bilateral corneal reflex exists. Cranial nerves in other groups were normal. Auxiliary examination: bilateral optic nerve hole, supraorbital fissure X-ray showed no abnormalities, brain