眩晕首次病程录(国外英文资料).docVIP

眩晕首次病程录 So many, and 874266 2012-10-10-00-00 for the first time One. Medical history: Patient, old man, 60 years old. He was admitted to hospital for dizziness, rotatory companion vomiting 2 hours. 3. Physical examination: BP: 180/100 MMHG, conscious light moderately severe coma, unclear words are normal, normal mental, bilateral pupils about 3 mm in diameter, sensitive light reflex slow disappeared, left and right sides of the nasolabial groove shallow symmetry, the tongue around the center bias or cooperation, double lung breath sounds clear, both lungs not smell and dry wet then sound, HR: 80 BPM, law of qi, the cardiac dullness boundary is not big, each valve auscultation area did not smell and pathologic murmur. The left and right sides of the limb muscle, the muscle tone is low and normal, the tendon reflex is symmetrical, the bilateral Babinski is negative, the neck is non-resistant, and the kerb is positive. The eye level tremor, fast to right, the nose test is accurate. The head CT of our hospital was not abnormal. Diagnosis and differential diagnosis: Primary diagnosis: the vertebral basement artery is not supplied with blood pressure and hypertension 2. The diagnosis: (1) locating diagnosis: patients with onset of the genuine vertigo, tinnitus and hearing impairment, unconscious barriers and cranial nerve involvement is located in vestibular nerve system, subject to review specific parts of line head CT or MRI of skull (2) the qualitative diagnosis: elderly patients with male and female, a history of high blood pressure and diabetes, has been no formal treatment, the acute onset, genuine vertigo as the main performance, tinnitus and hearing impairment, unconscious barriers and cranial nerve involvement, clinical examination in all aid to check (-), consider for VBI, its necessary head MRI confirmed. Diagnosis: the cerebellum and brain stem lesion: acute onset of disease, with dizziness, walking instability as the main expression, can have a ball paralysi