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病历摘要女性,56岁。突发眩晕、头痛、呕吐伴双下肢发软4天。患者于4天前无明显诱因突

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题目:

病历摘要女性,56岁。突发眩晕、头痛、呕吐伴双下肢发软4天。患者于4天前无明显诱因突发眩晕,视物旋转,后枕部胀痛不适,伴呕吐胃内容物数次,非喷射性,无呕吐咖啡样物,双下肢发软,难以站立,卧床休息后呕吐略缓解,但仍眩晕,视物旋转,不敢起床,不敢抬头。病后无意识障碍,无抽搐,无吞咽困难。当时测血压220/130mmHg,急查头颅CT示在小脑蚓部有高密度出血病灶。在急诊室脱水降压治疗后收住院。既往史:有高血压病史20年,服用"代文"治疗,每日1片,血压控制尚好。否认糖尿病病史。无食物、药物过敏史。查体:T36.8℃,P82次/分,R19次/分,BP160/1OOmmHg。心肺腹部检查未见异常。神清,无失语、复视,脑神经12对正常,四肢肌力5级。双侧指鼻试验阳性,快速轮替动作稍笨拙,双侧跟膝胫试验欠稳准。感觉正常。腱反射正常。双侧Babinski征阴性。颈有抵抗,Brudzinski征阴性,双侧kernig征阴性。要求:根据以上病历摘要,请写出初步诊断及诊断依据、鉴别诊断、进一步检查与治疗原则。

答案:

参考答案:

初步诊断及诊断依据

初步诊断:1.小脑蚓部出血2.高血压病3级(极高危)

诊断依据:1.病史:(1)既往有高血压病史。发病时测血压220/130mmHg。(2)典型的临床表现:突发眩晕、视物旋转、呕吐。2.查体:有双侧指鼻试验(+),快速轮替动作稍笨拙,双侧跟膝胫试验欠稳准,颈有抵抗。3.辅助检查:头颅CT示小脑蚓部高密度出血性病灶。

鉴别诊断:1.椎-基底动脉供血不足2.小脑或脑干梗死进一步检查CTA或MRA

治疗原则:1.卧床、镇静、通便、控制血压以避免再出血:脱水降颅内压,对症支持治疗。2.检查有动脉瘤则要行DSA介入栓塞。3.开颅手术结扎动脉瘤。

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