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病历摘要患者男性,86岁。因头痛、记忆力下降4 d,于2002年12月31日入住我院。神经内科查体未发现病理体征,行脑CT检查示双侧脑室后角广泛白质异常,右侧脑室旁可疑小腔隙灶。未发现引起记忆力下降的急性病变,血压172／78 mm Hg。为调整血压收入内科。既往有冠心病、高血压病史。1998年1月22日诊断为前列腺癌,分化好,行双侧睾丸曲细精管剥脱术。2000年7月因甲状腺腺瘤行右侧甲状腺部分切除术。2000年12月诊断为结肠多发性绒毛状腺瘤,部分癌变,行扩大的右半结肠切除术。2001年10月诊断为结肠溃疡型腺癌,高分化,行乙状结肠楔形切除。2002年8月诊断为左肾透明细胞癌,行左肾部分切除术。入院查体:血压189／86 mm Hg,浅表淋巴结未触及,颈静脉无怒张,双肺未闻及湿哕音,心率86次／min,律齐,各瓣膜听诊区未闻及杂音,腹平软,肝脾未及,双下肢轻度可凹陷性水肿。
Summary of patient history Male, 86 years old. Due to a headache, memory loss 4 d, in December 31, 2002 admitted to our hospital. Neurology examination found no pathological signs of brain CT scan showed extensive white matter abnormalities of the bilateral ventricle, right ventricular plexus suspected small lacunar lesions. No acute changes in memory were found, with a blood pressure of 172/78 mm Hg. To adjust the blood pressure income medical. Past history of coronary heart disease, hypertension. January 22, 1998 diagnosis of prostate cancer, well differentiated, line bilateral testicular seminiferous tubule stripping. July 2000 due to thyroid adenoma right thyroidectomy. December 2000 diagnosis of colon multiple villous adenoma, partial cancer, line expansion of the right half of the colon resection. October 2001 diagnosis of colon-type ulceration of adenocarcinoma, well-differentiated, line sigmoid colon wedge resection. August 2002 diagnosis of left renal clear cell carcinoma, left partial nephrectomy. Admission examination: blood pressure 189/86 mm Hg, superficial lymph nodes not touched, no jugular vein engorgement, lungs unheard and wet 哕 sound, heart rate 86 beats / min, law Qi, the valve auscultation area did not smell and noise, Abdomen soft, liver and spleen not yet, both lower extremity pitting edema.