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患者,女,33岁,全身皮肤变硬、发紧12年,雷诺氏现象10年,双手足指(趾)溃烂3年,头痛并进行性下肢无力2月而入院。查体:神清,面具脸,全身皮肤僵硬,少皱纹,鼻呈鹰嘴状,唇薄,张口受限,皮肤有色素沉着,浅表淋巴结未触及。心(-),两肺呼吸音弱,未闻及罗音。神经系统:双侧瞳孔等大等圆,光反射存在,颈有抗力,右侧上下肢肌力零级,左侧正常。右侧巴彬斯基氏症及戈登氏症均阳性,深感觉减弱,
The patient, female, was 33 years old. Her body skin became firm and tightened for 12 years. Raynaud’s phenomenon was 10 years. His hands and toes festered for 3 years. He had a headache and progressive lower limb weakness was admitted to hospital in February. Examination: Shen Qing, mask face, body skin stiffness, less wrinkles, the nose was olecranon-shaped, thin lips, limited mouth opening, skin pigmentation, superficial lymph nodes not touched. Heart (-), the breath sounds are weak in both lungs, and no rales are heard. Nervous system: Bilateral pupils and other large circles, light reflexes, neck resistance, the right upper and lower limb muscle strength zero, left normal. On the right side, Babinski’s disease and Gordon’s disease are positive, and deep feeling is weakened.