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邱××,女,54岁,住院号79939,1964年5月5日入院。家属代诉:昏迷、失语20小时。患者于入院前一日晚饭后约5分钟突然头昏、脑晕,随即倒地,呼之不应。呕吐三次,非喷射性,吐出物为当晚所吃之食物。战栗、出汗、小便潴留、无抽搐。经单位抢救无效,次日转来我院。平素有头昏,余无特殊。体检:T38℃、P54次/分、R23次/分、BP120/80 mmHg。呈嗜睡状态,面部潮红,咽喉部有痰鸣声,两肺有干湿性罗音,心率缓慢且节律不齐。瞳孔等大约2毫米,对光反应存在,眼底正常。左侧面神经、外展神经麻痹,悬雍垂活动差,发音、伸舌困难、四肢肌张力增强,腱反射亢进,左侧有陈挛及踝陈挛,感觉无障碍,双侧划跖试验(+)。
Qiu × ×, female, 54 years old, hospital number 79939, May 5, 1964 admission. Family members on behalf of: coma, aphasia 20 hours. Patients in the day before admission about 5 minutes after dinner suddenly dizzy, brain halo, then fell to the ground, call should not. Vomit three times, non-jetting, and the discharge is the food eaten on that night. Trembling, sweating, urinary retention, no convulsions. Rescued by the unit is invalid, the next day transferred to our hospital. Usually have dizziness, I no special. Physical examination: T38 ℃, P54 times / min, R23 beats / min, BP120 / 80 mmHg. Was drowsy, facial flushing, throat sputum ringing both dry and wet rales of lungs, slow heart rate and irregular rhythm. About 2 mm pupil, the presence of light response, normal eyes. Left facial nerve, abducens palsy, uvula activity is poor, pronunciation, difficult to extend the tongue, limb muscle tone enhancement, tendon hyperreflexia, the left side of the clonus and ankle Chenyou, sensory barrier, bilateral planted plantar test +).