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病历摘要男患,60岁,农民。因右肢活动受限8小时后说话不清,右肢不能活动,门诊以脑血栓收入院。既住无高血压病史。查血压140/90mmHg,心肺肝脾无异常所见。神经系统检查见眼底有轻度动脉反光增强,伸舌向右偏,右侧鼻唇沟变浅,痛觉减退,肌力Ⅰ级,张力增高,腱反射亢进,霍夫曼、巴斯征均(+),腰穿脑脊液无色透明,脑压220mmH20,次日意识不清。头颅 CT 见左侧壳核有肾形高密度影,为脑出血改变,出血量27.8ml,同侧内囊及侧脑室前角受压,未破入脑室。用降颅压药、抗生素、细胞活化剂、补充电解质治疗49天,肌力恢复出院。
Medical history male suffering, 60 years old, farmer. Due to limited right limb activity 8 hours after talking, right limb can not move, outpatient cerebral thrombosis income hospital. Both living without hypertension history. Check blood pressure 140 / 90mmHg, no abnormal heart, liver and spleen seen. Nerve system examination, see the bottom of the fundus with mild arterial reflex enhancement, extending to the right side of the tongue, right nasolabial fissure, pain relief, muscle strength Ⅰ, increased tension, tendon hyperreflexia, Huffman, Bath sign ( +), Lumbar puncture cerebrospinal fluid was colorless and transparent, brain pressure 220mmH20, the next day unconsciousness. Head CT See the left side of the nucleus with kidney-shaped high density, cerebral hemorrhage changes, bleeding 27.8ml, ipsilateral internal capsule and lateral anterior chamber pressure, did not break into the ventricle. With reducing intracranial pressure medicine, antibiotics, cell activators, electrolyte supplementation for 49 days, muscle strength and recovery.