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MS？
主诉 病史
Chief complain: numbness and lacking strength for 2 weeks. Current medical history: the patient had numbness of right toe without specific reasons, and progress to right lower limb, involving the right arm and right face one day later, accompany with lacking strength of right body, holding objects and walking unsteady, blurred vision of both eyes, no tinnitus, dizziness, dysphagia, urine difficulty or other discomfort. The MRI result of Tongji Hospital shows: multiple abnormal signal of white matter of bilateral cerebral hemisphere and medulla oblongata, considering demyelinating lesions, MS has high possibilities. The patient didn’t get specific treatment, the disease didn’t get better. The patient came to our hospital for clear diagnosis and treatment, the out-patient admitted as “multiple sclerosis”. Since the patient got the disease, the spirit and sleep are ok, appetite is not good. Strength and weight decreased
查体 辅查
Special examination: conscious, cranial nerves (-), soft neck, left body’s muscle strength and tension are normal, pathological sign (-), right body’s muscle strength is level 4, paresis test is positive, muscle tension is normal, Babinski sign (+). Right face and body’s superficial feeling decreased, Finger to nose test and With the knee-shin test of the right side are less stable and accurate. Kernig sign (-).
诊断 处理
Numbness and lacking strength of right body unknown: MS?
随访 讨论
which good advises for next teatment？
发布于 15-07-13 21:29
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