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患者男性,27岁。乏力、纳差、尿黄15天伴发热、四肢麻木入院。体温38℃,当地予“感冒通”、“板兰根冲剂”等治疗,体温降至正常,乏力、纳差更明显,尿黄加深,并出现四肢麻木,四肢无力,持物易脱落,行走困难,下蹲后不能起立,渐至上肢抬起困难,不能行走,无吞咽困难,无大小便失禁,于1993年10月20日入院。体检:体温37℃,巩膜中度黄染,浅表淋巴结不大,心肺听诊正常,腹平软,无压痛,肝肋下约1.5cm,质软,触痛(+),脾肋下未扪及。神经系统检查:意识清楚,颅神经正常,眼底正常,四肢末端浅感觉减退,深感觉正常。四肢肌力Ⅱ级,肌张力低,四肢腱反射对称减弱,未引出病理反射。
Patient male, 27 years old. Fatigue, anorexia, urinary 15 days with fever, limb numbness admitted. Body temperature 38 ℃, the local “cold through”, “Ban Langen granules” and other treatment, body temperature dropped to normal, weakness, anorexia more obvious, deepened urine yellow, and limb numbness, limb weakness, the object easy to fall off, walking difficult Can not stand up after squatting, gradually lifting the upper limb difficult, can not walk, no swallowing difficulties, no incontinence, admitted on October 20, 1993. Physical examination: body temperature 37 ℃, scleral moderate yellow dye, superficial lymph nodes, cardiopulmonary auscultation, abdominal soft, no tenderness, liver ribs about 1.5cm, soft, tenderness and. Nervous system examination: Consciousness, normal cranial nerves, normal fundus, shallow extremities feel diminished, deep feeling normal. Limb muscle strength grade Ⅱ, low muscle tone, limb tendon reflex symmetry weakened, did not lead to pathological reflex.