发布时间:2019-08-10 19:21:23





Case Presentation

Name of patient: Yxxxxi  Gender: Female  Age: 8

Admission date: May 31, 2014

Discharge date: June 24, 2014

Patient’s condition when admitted to hospital: The patient’s name is Ye Muzi at her age of 8, her disease course was 3 days; she was admitted to the hospital with main complaint of “unsteady step accompanied by speaking with a lisp for 3 days”; the patient had unsteady step, staggering gait and easy to fall under no obvious predisposing causes, she was deflective to right severely when walking, with head often deflective to right, and her family members found that the patient wrote more illegibly than ever before and spoke with a lisp, her symptoms above have no obvious changes in recent 3 days, therefore, her family members took her to our hospital for further treatment, and the outpatient arranged the patient in our department with “movement disturbance in legs with unknown origin”; the patient has normal status since she had illness, with steady body temperature, normal food intake, sleep and defecating function, without obvious prodromic infection and bucking caused by drinking water, the patient reported that she has trouble peeing but without pain urination today; past medical history: family members reported that the patient’s concentration is poorer and her scores dropped in recent 1 month;

Physical examination after admission: T 36.2℃,P 84 times/minute,R 24 times/minute,Bp 99/60 mmHg; her expression and status are normal, with smooth breath, no cyanosis, skin rash or haemorrhage on her body and no superficial lymph node enlargement, the patient was isocoria with normal circle and the pupil diameter of 2.0mm, sensitive reflex of light, bulbar conjunctiva was found without edema, flexible eyeball motion, no nystagmus, besides, the pharynx isn’t red, the tonsils isn’t swollen, the neck is soft, the whole lung sounds rough, without obvious dry and wet rale and wheezing; heart sounds are strong, with regular pulse, and the heart rate is 84 times/minute, no noise, the abdomen is soft, swellings of liver and spleen are impalpable, no tenderness and rebound tenderness; limb peripheral nerve is warm, limb muscle strength and muscular tension are normal, somatic sense and position of low limbs are normal; finger nose test, heel-knee-tibia test, alternate test positive, reflex of double biceps and triceps is normal, reflex of double knee jerks and Achilles tendon decreases; Brudzinski sign (-), Kernig sign (-), right Babinski sign (-), double palmomental reflex (-) .

Treatment and diagnosis: the patient was fully examined after the admission, including electromyography, head MRI, electroencephalogram, brainstem auditory evoked potential, serology and other relevant examinations; the patient was given medicines, such as Cefamandole Nafate for Injection against inflammation, Adegold, Mouse Nerve Growth Factor for Injection as neuro nutrition drugs, Mannitol, Torasemide for Injection, Bu Ruide (transcription) to reduce intracranial pressure, when test results return, the treatment of patient will be adjusted;

Laboratory report return: Parainfluenza virus-IgA antibody positive (+); herpes simplex virus (I+II)-IgG antibody positive (+) (19.4); EB virus NA-IgG antibody positive (+) (158); EB virus VCA-IgG antibody positive (+) (72.7). Add arabinoside-cytidine monophosphate against virus.

(June 3, 2014) Head MR reminds brainstem has abnormal signal, left cerebellar hemisphere was involved, caused by inflammation or tumor? Add gamma globulin to the patient, with hormone therapy for 7 days.

(June 6, 2014) Brainstem and left cerebellar hemisphere have abnormal signal, caused by inflection? Please combine with clinic.

(June 13, 2014) Combine with old film of Head Enhanced Scan on June 6, 2014 in this hospital: brainstem swelling and thickening, signal of flaky T1 and T2 in brainstem and left cerebellar hemisphere is same with the old film, FLAIR is high signal; diffusion weight is slightly high signal; fourth ventricle narrows down under pressure, which is same with the old film.

Compared with magnetic resonances on June 3, June 6 and June 12, images on June 3 and June 12 are found similar, the brainstem has diffuse brain swelling, but on June 6, the swelling of brainstem decreased, the disease was improved, by combining with the medical history and therapeutic process, it indicates that hormone and other therapies have effects, in case the brainstem lesion of patient was tumor, she cannot take operation because the extent of disease is large, it is suggested to reexamine the head with magnetic resonance. The patient will have r-globulin as hormone therapy for 5 days on June 18.

(June 5, 2014) Results return of skull base CT: brainstem has abnormal signal, inner ear CT scan finds no obvious abnormality, the brainstem is abnormal, three dimensional ear CT have no abnormality, brainstem and left cerebellar hemisphere change, please combine with clinical recommendations to make further inspection. Caused by atlanto-axial subluxation?

Current diagnosis:

1. Ataxia to be tested; brainstem and left cerebellar hemisphere are involved

2. Parainfluenza virus inflection

3. Herpes simplex virus inflection

4. EB virus inflection

Now the patient has low-grade fever, and has fever 1-2 times a day, dizziness, no vomiting and diarrhea, the patient has more sleep today, but still unsteady, without hyperspasmia, after physical examination, the patient has symptoms, such as right sense, normal status, smooth breath, sensitive reflex of light, flexible eyeball motion, no nystagmus, heart, lung, and abdomen are normal after physical examination, limb peripheral nerve is warm, limb muscle strength and muscular tension are normal, somatic sense and position of low limbs are normal; finger nose test, heel-knee-tibia test, alternate test positive, reflex of double biceps and triceps is normal, reflex of double knee jerks and Achilles tendon decreases; Brudzinski sign (-), Kernig sign (-), right Babinski sign (-), double palmomental reflex (-) ; physician needs to continue to observe the change of illness of the patient.
































  • 问:翻译合作的流程一般是什么?
  • 问:翻译本地化主要是做什么的?
    答:1.软件本地化 2. 网站本地化, 3. 媒体文档本地化
  • 问:擅长翻译哪些专业领域?
  • 问:什么是 “耳语传译”(whispering)?