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郑××,男,21岁,住院号14095,1974年12月11日上午9时急症住院。患者住院前一天上午8时半开始四肢麻木无力,进行性加剧,午餐时行走困难,当晚四肢瘫痪,不能翻身。入院翌日晨排尿困难,即送我院。既往无类似发作,近期无“感冒”发烧。查体:体温36.5℃,脉搏84次/分,呼吸24次/分,血压120/80毫米汞柱。神清,被动体位,心率84次/分,律齐,无杂音。除下腹可摸及胀大的膀胱外,查体未见其它异常。神经系检查:颅神经除咽反射减弱,轻度吞咽障碍外余正常,脑膜刺激征、深浅感觉均无异常,四肢对称性弛缓性瘫痪,肌力近端1°,远端0°,浅反射减弱,深反射消失,无病理反射。植物神经检查:胸以下无汗,膀胱尿贮留。
Zheng × ×, male, 21 years old, hospital number 14095, at 9 am on December 11, 1974 acute hospitalization. The patient had numbness and progressive exacerbations at 8:30 a.m. on the day before hospitalization, difficulty walking during lunch, paralyzed limbs that night and could not stand up. On the morning of admission dysuria, that is to send our hospital. No previous episodes, no recent “cold” fever. Physical examination: body temperature 36.5 ℃, pulse 84 beats / min, breathing 24 beats / min, blood pressure 120/80 mm Hg. Shen Qing, passive position, heart rate 84 beats / min, law Qi, no noise. In addition to the lower abdomen can touch and swollen bladder, the examination showed no other abnormalities. Nervous system examination: the cranial nerve in addition to pharyngeal reflex, mild dysphagia normal, meningeal irritation, no abnormal sense of depth, limbs symmetry flaccid paralysis, muscle proximal 1 °, distal 0 °, shallow reflex Weakened, deep reflections disappeared, no pathological reflex. Autonomic nerve examination: no sweat below the chest, bladder urinary retention.