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患者男,56岁,住院号16238,病案号04074674。因头晕、视物成双2 d 于2004年7月2日收住眼科。以往有明确的高血压病史3年,血压波动在160/100 mmHg,否认糖尿病、重症肌无力病史。1 d 前在其他医院颅脑 CT 检查无明显异常。眼科情况:双眼视力5.0,外眼(-),角膜透明,KP(-),前房2 mm,虹膜(-),瞳孔3 mm,光反射灵敏,晶状体、玻璃体无浑浊,眼底、眼压正常,眼球运动正常。眼球外转受限而内视。辅助检查:血常规、尿常规、大便常规正常,ECG 正常。诊断:麻痹性斜视。予以丹参、能量合剂、地塞米松治疗3 d,病状无好转,渐出现口角歪斜,左侧面肌运动障碍。急诊颅脑 CT 示:左基底节可见小点状低密度影,边缘不清。请神经内科会诊:BP 220/120 mmHg,急性病容,神清,左眼裂变小,闭眼无力,左侧额纹减少,左侧周围性面瘫,伸舌左偏,左侧分离性眼球震颤,颈软,四肢肌力、肌张力正常,腱反射对称(++),深、浅感觉对称存在,病理征
Male patient, 56 years old, hospital number 16238, case number 04074674. Due to dizziness, depending on the material in pairs 2 d on July 2, 2004 received ophthalmology. In the past there is a clear history of hypertension for 3 years, blood pressure fluctuations in 160/100 mmHg, denied the history of diabetes, myasthenia gravis. 1 d before the other brain CT examination showed no abnormalities. Ophthalmology: binocular vision 5.0, Outer eye (-), corneal transparency, KP (-), anterior chamber 2 mm, iris (-), pupil 3 mm, light reflection sensitive, lens, vitreous no turbidity, fundus, intraocular pressure normal , Eye movement is normal. Eye outside the limited and inward looking. Auxiliary examination: blood, urine, stool routine normal ECG normal. Diagnosis: paralytic strabismus. To Salvia, energy mixture, dexamethasone treatment 3 d, no improvement in symptoms, gradually appear skew angle, left facial muscle dyskinesia. Emergency brain CT showed: left basal ganglia seen little dot-like low density, the edge is not clear. Please neurology consultation: BP 220/120 mmHg, acute disease, Shen Qing, fissile left eye, weak eyes, frontal reduction on the left, peripheral facial paralysis on the left, left tongue extensor, left detached nystagmus, Neck soft, limb muscle strength, normal muscle tone, symmetrical tendon reflexes (++), deep and shallow sense of symmetry, pathological signs