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病历摘要马××,女,31岁,职员,住院号A:26365,1980年10月22日入院。病史:八年前自觉右下肢发凉,右小腿逐渐变细,并累及右侧大腿。近两年来右下肢肌肉萎缩,无力,跛行。右侧上胸部针刺样疼痛。并沿肋间向对侧放散。咳嗽,翻身时加重。曾被诊为脊髓空洞症,肌萎缩侧索硬化症,多发性硬化症,脊髓蛛网膜炎等。治疗不见好转。三个月来,右足底发麻,逐渐向上蔓及至中胸部。二便正常。 1977年曾患流脑治愈。父亲患胃癌病故。检查:体温36.8℃、脉搏88次/分、血压110/80毫米汞柱。查体合作,心肺无异常,腹平软,肝脾未及。双足背动脉搏动正常,全身无畸形。颈神经(-),眼底(-)。右下肢肌肉萎缩:膝上15厘米处周径比对侧少7厘米,膝下15厘米处周径比对侧少3厘米。肌力Ⅳ级弱。双下肢肌张力稍高。右侧胸3至腰1痛觉消失,触觉减退,腰以下痛觉减退,深部感觉正常。右侧腹壁反射消失,膝和跟腱反射亢
Medical records summary Ma × ×, female, 31 years old, staff, hospital number A: 26365, admitted to hospital on October 22, 1980. History: Eight years ago conscious right lower extremity cold, right lower leg tapering, and involving the right thigh. Right lower extremity muscle atrophy, weakness, limp over the past two years. On the right chest acupuncture-like pain. And along the intercostal space to the opposite side. Cough, increase when turning over. Have been diagnosed as syringomyelia, amyotrophic lateral sclerosis, multiple sclerosis, spinal arachnoiditis. Treatment did not improve. Three months, the right foot numbness, and gradually spread to the middle of the chest. Two will be normal. 1977 was suffering from meningitis. Father suffering from stomach cancer. Check: body temperature 36.8 ℃, pulse 88 beats / min, blood pressure 110/80 mm Hg. Physical examination, no abnormal heart and lungs, abdominal soft, liver and spleen not yet. Bipedal artery pulse normal, no deformity. Cervical nerve (-), fundus (-). Right lower extremity muscular atrophy: 15 cm on the knee at 7 cm less than the contralateral side, 15 cm below the knee at 3 cm less than the contralateral side. Muscle strength grade Ⅳ is weak. Lower extremity muscle tone slightly higher. The right chest 3 to the waist 1 pain disappeared, tactile hypothyroidism, pain relief below the waist, deep feeling normal. Reflex disappears on the right abdominal wall, knee and Achilles tendon reflex