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患者,女性,60岁,农民。头晕、呕吐、左肢体麻木1天入院。病后无头痛、眩晕及神志障碍。既往高血压病史4年。体温36.8℃,脉搏70次/分,呼吸19次/分,血压21/13kPa。心肺(-)。神志清,双上睑无下垂,两瞳孔等大等圆,对光反射灵敏,右眼球中间位,不能内收及外展,左眼球外展位不能内收,并有复视,左眼球水平震颤。眼底动脉硬化Ⅱ级。四肢肌力正常,病理反射(-)。临床诊断:高血压病,脑梗塞(右侧脑干),一个半综合征。按脑梗塞处理,住院20日痊愈出院。
Patient, female, 60 years old, farmer. Dizziness, vomiting, left numbness 1 day admission. No headache, dizziness and delirium after illness. Previous history of hypertension 4 years. Body temperature 36.8 ℃, pulse 70 beats / min, breathing 19 beats / min, blood pressure 21 / 13kPa. Cardiopulmonary (-). Consciousness, double upper eyelid without sagging, two pupils and other large circle, sensitive to light reflection, right eye medial, can not adduction and abduction, left eye ball abduction can not be adducted, and diplopia, left eye level tremor . Fundus arteriosclerosis Ⅱ level. Normal limb muscle strength, pathological reflex (-). Clinical diagnosis: hypertension, cerebral infarction (right brainstem), a half syndrome. Treatment by cerebral infarction, hospitalized 20 days were discharged.