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女,58岁。住院号3073。因上腹部疼痛伴胸、腹部、下肢感觉减退,走路不稳半个月,于1979年4月28日入院。查体:体温39℃,呼吸18次/分,脉率84次/分,Bp13.3/9.31Kpa(100/70mmHg)。神志清楚,自动体位,皮肤及巩膜无黄染,无脱水征,浅淋巴结未肿大。五官端正,气管居中,甲状腺无肿大。心肺无异常。腹部软,无腹水征,肝脾未触及。未引出病理反射,胸部乳头以下皮肤浅感觉减退,痛觉存在,肌力及肌张力正常。闭眼站立时身体摇晃(Rom-berg氏征阳性)。眼底检查正常。实验室检查:白细
Female, 58 years old. Hospital number 3073. Due to upper abdominal pain with chest, abdomen, lower extremity sensory decline, walking unsteady for half a month, on April 28, 1979 admission. Physical examination: body temperature 39 ℃, breathing 18 beats / min, pulse rate 84 beats / min, Bp13.3 / 9.31Kpa (100 / 70mmHg). Conscious, automatic position, skin and sclera no yellow dye, no signs of dehydration, superficial lymph nodes are not swollen. Good facial features, tracheal center, no swelling of the thyroid. No abnormal heart and lung. Abdomen soft, no signs of ascites, liver and spleen not touched. Did not lead to pathological reflex, chest skin below the skin nipple sense of diminished pain exist, muscle strength and muscle tone normal. Body shaking with eyes closed (Rom-berg’s sign positive). Fundus examination is normal. Laboratory tests: white