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患者迟某某,女性;46岁,于1996年6月10日,以“双眼视神经乳头炎”入眼科诊疗。1 一般资料患者一月前自觉双眼视力下降,伴头痛,恶心经门诊诊为“双眼视神经乳头炎”诊疗一周,视力恢复不明显,曾去哈市进一步检查,“CT”排除颅内占位病变,因而仍诊为“双眼视神经乳头炎”,回本院眼科继续治疗。检查:一般状态尚可,血压12.0/9.2kpa,脉博80次/分,体温36.2℃。心肺听诊无异常,肝脾未能及,颈强阴性,病理反射阴性。
Patient XX, female; 46 years old, on June 10, 1996, with “binocular optic neuritis” into ophthalmology. 1 General Information Patients with binocular vision decreased a month ago, with headache, nausea, out-patient diagnosis of “binocular optic neuritis” a week of treatment, visual acuity was not obvious, went to Harbin for further examination, “CT” exclusion intracranial space lesions, It is still diagnosed as “binocular optic neuritis”, back to hospital ophthalmology continue treatment. Check: The general state is acceptable, blood pressure 12.0 / 9.2kpa, Pulse Bo 80 times / min, body temperature 36.2 ℃. Cardiopulmonary auscultation was normal, liver and spleen failed, neck strong, negative pathological reflex.