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病历摘要单××,男,44岁,干部,病历号179725,于1981年1月16日入院。主诉:头晕、发呆3个月,左半身活动不灵1个多月。患者于1980年10月中旬有一天上火车站接人,走到途中突然感头晕、步态不稳、视物成双,当时蹲下休息片刻好转,由其儿子扶回家,睡觉后症状缓解,10月22日家人发现患者呆滞、贪吃、多睡。12月16日凌晨3时许起床小便,发现左上下肢活动不灵,当时血压130/90毫米汞柱。既往无高血压病史。检查:缄默状态,血压150/100毫米汞柱,心界不大,心律齐,心率96次/分,心音不低钝,未闻杂音,双肺未闻干湿性罗音。眼底视乳头边缘清,色如常,视网膜动脉细,光反射增强,动静脉交叉处有压迫现象。左面纹浅,伸舌稍偏左,左上下肢肌力0度,腱反射击>右,左侧病理反射阳性,左腹壁及提睾反射消失,无脑膜刺激征。心电图:念性前侧壁、正后壁心肌梗塞演变期,下壁陈旧性心肌梗塞。血肌酸磷酸激酶36单位,GOT 135单
Medical record summary single × ×, male, 44 years old, cadre, medical record number 179725, was January 16, 1981 admission. Chief complaint: dizziness, daze for 3 months, left half of the activity is not working more than 1 month. Patients in the middle of October 1980 one day access to the train station, suddenly felt dizzy on his way to go, gait instability, depending on the material in pairs, then a moment to sit down and take a rest, his son back home, relieve symptoms after going to bed, October 22 family members found that patients sluggish, gluttonous, more sleep. At about 3 a.m. on December 16, he got up urinating and found that his upper left and lower extremity activities were not working properly. At that time, blood pressure was 130/90 mm Hg. No previous history of hypertension. Check: silent state, blood pressure 150/100 mm Hg, the heart is not big, heart rate Qi, heart rate 96 beats / min, heart sound is not low blunt, unheard noise, the lungs did not smell wet and dry rales. Optic papillae margin clear, color as usual, fine retinal artery, light reflex enhancement, arteriovenous cross there oppression. The left pattern is shallower, the tongue is slightly deviated to the left, the left upper extremity muscle strength is 0 degree, the tendon reflex strikes> the right and left pathological reflex positive, the left abdominal wall and the cremaster reflex disappear, and the meningeal irritation sign. ECG: meditative anterior wall, posterior wall myocardial infarction evolution, inferior wall of the old myocardial infarction. Blood creatine phosphokinase 36 units, GOT 135 single