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1.病例介绍 女,14岁,因头晕、复视、行走不稳1天,于1997年1月7日住院,患者1月6日晨起出现头晕,行走不稳,向左侧倾倒,复视,但无头痛,视物旋转感,无发热,无喷射性呕吐。于当地卫生所输液治疗(药名不详),症状无明显改善,仍坚持上学,但行走不稳,在系鞋带时身体向左侧摔倒两次,注视前方及左侧时视物成双,无耳鸣,声音嘶哑及饮水呛咳等症状。查体意识清楚,语言流利,问答切题,右利手,双侧瞳孔等大等圆,对光反射正常,眼球可见水平震颤,向前注视时有复视,眼底正常。口角无偏斜,伸舌居中,四肢肌力Ⅴ级,肌张力正常。生理反射存在,病理反射未引出,行走时步态不稳,并向左侧倾倒,无膀胱直肠功能障碍,血常规;入院时白细胞5.7G/L,血小板261G/L。
1. Case description Female, 14 years old, due to dizziness, diplopia, unstable walking 1 day, was hospitalized on January 7, 1997, patients dizzy from January 6 morning, unstable walking, dumping to the left, complex However, no headache, depending on the sense of rotation, no fever, no ejection vomiting. In the local health clinic infusion treatment (unknown drug name), no significant improvement in symptoms, still insist on going to school, but walking unsteadily, when the system laces the body fell to the left twice, watching the front and left when the material into double , No tinnitus, hoarseness and choking cough and other symptoms. A clear physical examination, fluent language, question and answer, right hand, bilateral pupils and other large circle, the normal light reflex, the eye can see the level of tremor, looking forward when diplopia, fundus normal. Mouth angle without skew, tongue middle, limb muscle strength Ⅴ level, normal muscle tone. Physiological reflex exists, the pathological reflex did not lead to walking gait instability, and to the left dumping, no bladder and bowel dysfunction, blood; admission white blood cells 5.7G / L, platelet 261G / L.