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1病例介绍艾某,男,62岁。大量饮酒后走楼梯时,不慎摔倒,枕部着地,当即昏迷,头部有伤口出血,到医院急诊,急查头颅CT提示:双侧额叶脑挫裂伤,蛛网膜下腔出血,颅内积气,右侧枕骨骨折,右侧蝶骨大翼及体部交界处骨折,蝶窦积血,右侧上颌窦积液。经治疗,患者神志转清,能对答,言语基本流利,但偶有胡言乱语等精神症状。入院时查体:神志清楚,自发睁眼,言语流利,四肢可自主活动,GCS昏迷评分15分。眼睑无肿胀瘀血,双侧瞳孔等大等
A case introduction Ai Mou, male, 62 years old. After a lot of drinking to go down the stairs, accidentally fell, occipital land, immediately coma, head wound bleeding, to the hospital emergency, emergency head CT tips: bilateral frontal lobe contusion, subarachnoid hemorrhage, Intracranial gas, the right occipital fracture, the right sphenoid big wing and body junction fracture, splenic hemorrhage, right maxillary sinus fluid. After treatment, the patient consciousness clear, can answer, the basic language fluently, but occasionally nonsense and other mental symptoms. Admission examination: conscious, spontaneous eyes open, fluent speech, limbs can be independent activities, GCS coma score 15 points. Eyelid without swelling bleeding, bilateral pupils and so on