脊髓小脑萎缩症案

发布时间：2018-03-31 21:11

本文选题：脊髓小脑　切入点：少寐多梦　出处：《中国针灸》2017年05期

【摘要】：正患者,日本男性,44岁,于2016年6月14日就诊。主诉:走路不稳,伴言语不利4年。现病史:于2012年出现走路不稳、平衡能力差等症状,于日本当地医院诊治,行颅脑磁共振成像检查后诊断为脊髓小脑萎缩症,给予口服胞磷胆碱钠胶囊治疗,效果欠佳。2016年6月自觉症状加重,有时难以坐稳,遂经人介绍来我国进行中医治疗。刻下症见:精神尚可,面色萎黄,走路不稳,言语不利,心烦焦虑,少寐多梦,食欲欠佳,大便秘结,舌质暗淡,脉沉细。患
[Abstract]:The patient, who is 44 years old from Japan, was admitted to the hospital on June 14, 2016. The chief complaint is: walking instability and unfavorable speech for 4 years. Present history: symptoms such as unstable walking, poor balance, etc., developed in 2012, were treated at a local hospital in Japan. The diagnosis of spinal cerebellar atrophy after craniocerebral magnetic resonance imaging (MRI), which was treated with oral citicoline sodium capsule, was not effective. After being introduced to our country for traditional Chinese medicine treatment. Engraved symptoms: spirit, yellow, walking instability, speech adverse, upset anxiety, sleep more dreams, appetite poor, big constipation knot, the quality of the tongue is dim, the pulse is thin.
【作者单位】：黑龙江中医药大学;黑龙江中医药大学附属第一医院;
【分类号】：R246.6;R249

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