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1病历摘要女,60岁。主因头痛呕吐,右侧肢体无力,5 h入院。头颅CT示左侧丘脑出血后侵入脑室。查体:BP 160/90 mm Hg,神清,双瞳孔左∶右=2∶2 mm Hg,对光反射灵敏,右侧肢体肌力DV级,左侧肢体肌力V级,肌张力正常,双征阴性,入院后吸氧,脱水降颅压,冰帽等治疗,并行左侧脑室穿刺引流
1 medical record summary female, 60 years old. Mainly due to headache and vomiting, right limb weakness, 5 h admission. Head CT showed the left thalamic haemorrhage into the ventricle. Examination: BP 160/90 mm Hg, Shen Qing, double pupil left: right = 2: 2 mm Hg, sensitive to light reflex, the right limb muscle strength DV level, left limb muscle strength V level, muscle tone normal, Double negative, admission oxygen, dehydration reduce intracranial pressure, ice caps and other treatment, parallel left ventricular puncture drainage