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病历摘要女患,14岁。因四肢进行性乏力、运动障碍5天,于1986年10月29日入院。患者5天前自觉乏力、四肢运动不灵活,走路易摔倒,呈进行性加重,渐至不能走路,不能握物,上床及翻身困难,语言低弱等。6年前曾有相似表现,经中国医大附属医院诊为格林-巴利综合征,因病情较重,出现呼吸肌麻痹及球麻痹,行气管切开,用人工呼吸治疗48天,除遗有右足下垂外,无其他异常而出院。既往史无特殊记载。入院时查体生命指征正常,发育营养中等。心肺肝脾无异常所见。神经系统检查:神志清,构音障碍,咽反射(±),双上肢肌力Ⅳ级,抬举困难,双手握力差,手指不能夹纸及握笔,双上肢肱二头肌反射(±)。双下肢肌力Ⅰ～Ⅱ级,右足下垂,浅反射存在。双下肢膝反射(-)。四肢皮肤痛觉存在。血尿便常规化验正常。诊
Female patient history, 14 years old. Due to limb weakness, dyskinesia 5 days, on October 29, 1986 admission. 5 days before the patient conscious fatigue, limb movement is not flexible, easy to fall and walk, was progressive increase, gradually unable to walk, can not hold things, go to bed and turning difficulties, language weakness. 6 years ago had similar performance, the Chinese Medical University Affiliated Hospital diagnosed with Guillain-Barre syndrome, due to severe illness, respiratory muscle paralysis and ball paralysis, tracheotomy, artificial respiration for 48 days, except for the legacy Right foot drooping, no other abnormalities and discharged. No previous history of special records. Physical examination during admission indications normal, moderate nutrition and development. No abnormal heart and lung liver and spleen seen. Nervous system examination: Consciousness, dysarthria, pharyngeal reflex (±), upper extremity muscle strength grade Ⅳ, lifting difficulties, poor grip, fingers can not hold paper and pen, upper biceps reflexes (±). Lower extremity muscle strength Ⅰ ~ Ⅱ level, right foot drooping, shallow reflection exists. Lower extremity knee reflex (-). Extremity skin pain exists. Hematuria routine test normal. Clinic