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患者,男性,73岁,从86年春起出现双手不自主细微震颤,头晕,失眠,二个月后,步伐蹒跚,不能走直线,站立欠稳,无力感。以后病情进展较缓慢,既往患高血压十余年,无饮酒史。查体:Bp20.0/13.1KPa、神清、构音正常、眼底动脉细、反光强、AV 交征(+),视盘边缘清楚,无眼震,余脑神经未见示位征。两侧上下肢肌力正常,Romberg 氏征,睁闭眼不稳,走直线不稳,站立时须两脚分开。跟膝试验欠稳准,两手意向性震颤。指指指鼻试验正常。未引出病理反射。化验室检查,血三脂,血尿常规均正常范围。头部 CT 扫描示小脑萎缩。临
Patients, male, 73 years old, from the spring of 86 appear involuntary hands tremor, dizziness, insomnia, two months later, the pace faltering, can not go straight, standing firm, powerless feeling. After the progression of the disease is more slow, past history of hypertension more than ten years, no drinking history. Physical examination: Bp20.0 / 13.1KPa, Shen Qing, normal acupuncture, fundus arterial thin, reflective, AV sign (+), optic disc edge clear, no nystagmus, I showed no signs of brain. On both sides of the upper and lower limb muscle strength normal, Romberg’s sign, eyes open and unstable eyes, go straight and unstable, stand to separate the two feet. Knees trial with less accurate, hands intention tremor. Pointing finger test is normal. Did not lead to pathological reflex. Laboratory tests, blood triglyceride, hematuria routine normal range. Head CT scan shows cerebellar atrophy. Pro