Transcript 980602-專護 - 成大醫院斗六分院

98年專科護理師訓練
神經系統常見問題之評估 (一)
頭痛 Headache
頭暈 Dizziness
成大醫院神經科
黃涵薇醫師
頭痛 Headache
Pain-sensitive cranial structures
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顱外
 Skin, subcutaneous tissues, muscles extracranial arteries, periosteum of
skull
 Eye, ear nasal cavities perinasal sinuses
顱內
 血管
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腦膜
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Intracranial venous sinuses and their large tributaries, esp. pericavernous
structures
Arteries within the dura and pia-subarachnoid, particulary the proximal
parts of the ACA, MCA and the intracranial segment of ICA
The middle meningeal and superficial temporal arteries
Parts of the dura at the base of the brain
顱神經
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The optic, oculomotor, trigeminal, glossopharyngeal, vagus, (and the first
three cervical nerves)
Areas of refer pain from intracranial structures
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From supratentorial structures
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From infratenotrial structures
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Anterior 2/3 of head (V1, V2 dermatones)
Vertex, posterior head and neck
From VII, IX, X cranial nerves
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Naso-orbital region, ear, throat
Pain from extracrainal part of body NOT refer to head, EXCEPT
 Cervical portion of ICA
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Upper cervical spine
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Eyebrow, supraorbital region
occiput
Angina pectoris (rare)
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Jaw, vertex
｢國際頭痛疾病分類｣ ICHD
(International Classification of Headache Disorders)
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第一版在1988年公布，第二版於2004年刊登於
Cephalalgia雜誌。
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不論是中文版或英文版的｢國際頭痛疾病分類｣都長
達一百五十頁以上 !
在英文版第二版中，作者建議－｢這份內容龐大的
分類文件不是用來背的，這是一份須要一次又一次
不斷查看的文件。｣
頭痛 Headache
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原發性 (Primary)
次發性 (Secondary)
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以決定頭痛的原因及訂定適切的治療計畫
原發性頭痛 (primary headache)
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意謂頭痛本身即為痛的成因。
超過百分之九十的頭痛患者屬於此類。
重點就是排除次發性的可能。
無預兆偏頭痛
Migraine without aura
A. 至少有5次能符合基準B-D的發作
B. 頭痛發作持續4-72小時 (未經治療或治療無效)
C. 頭痛至少具下列二項特徵：
1. 單側
2. 搏動性
3. 疼痛程度中或重度
4. 日常活動會使頭痛加劇或避免此類活動（如走路或爬樓
梯）
D. 當頭痛發作時至少有下列一項：
1. 噁心及/或嘔吐
2. 畏光及怕吵
E. 非歸因於其他疾患
典型預兆偏頭痛性頭痛
Typical aura with migraine headache
A. 至少有2次符合基準B-D的發作
B. 預兆至少包括下列一項，但無肢體無力：
1. 完全可逆視覺症狀，包括正向特徵 (如：閃爍的光、點或線) 及/或負向特
徵 (即視力喪失)
2. 完全可逆感覺症狀，包括正向特徵 (即針刺感)及/或負向特徵 (即麻木感)
3. 完全可逆失語性語言障礙
C. 至少具下列2項：
1.單側的視覺症狀及/或單側感覺症狀
2. 至少一種預兆症狀在≧5分鐘逐漸產生，及/或不同預兆症狀，在≧5分鐘相
繼發生
3. 每一種症狀持續≧5及≦60分鐘
D. 符合無預兆偏頭痛 基準B-D的頭痛，在預兆同時或預兆之後的60分鐘內發生
E. 非歸因於其他疾患
緊縮型頭痛
Tension-type headache
A. Frequent: 至少有十次能符合基準B-D之發作，且發作平均每月≧1日但＜
15日，已至少三個月（每年≧12日且＜180日, 頭痛持續30分鐘至7日
Chronic: 頭痛平均發作每月≧15日，已＞3個月（每年≧180日）且符合
基準B-D, 頭痛持續數小時或可能持續不斷
B. 頭痛至少具下列二項特徵：
1. 雙側
2. 壓迫/緊縮性（非搏動性）
3.程度輕或中度
4.不因日常活動如走路或爬樓梯而加劇
C.下列兩項皆符合：
1. 無噁心或嘔吐（可能有食慾不振）
2. 最多只有畏光或怕吵其中一項症狀
D. 非歸因於其他疾患
叢發性頭痛
Cluster headache
A. 至少有5次符合基準B-D之發作
B. 位於單側眼眶、上眼眶及/或顳部重度或極重度疼痛，如不治
療可持續15至180分鐘
C. 頭痛時至少伴隨下列一項：
1. 同側結膜充血及/或流淚
2. 同側鼻腔充血及/或流鼻水
3. 同側眼皮水腫
4. 同側前額及臉部出汗
5. 同側瞳孔縮小及/或眼皮下垂
6. 不安的感覺或躁動
D. 發作頻率為每二日一次至每日八次
E. 非歸因於其他疾患
典型三叉神經痛
Classical trigeminal neuralgia
A. 發作性 (paroxysmal) 疼痛發作，持續由不到一秒到兩分鐘，影
響三叉神經一支或一支以上分支的支配區，且符合基準B及C
B. 疼痛至少具下列一項特徵：
1. 劇烈、尖銳、表淺或刺戳痛
2. 於誘發區引發或由誘因引發
C. 就個別病人而言，疼痛的發作型態是固定 (stereotyped) 的
D. 沒有神經功能缺損的臨床證據
E. 非歸因於其他疾患
次發性頭痛 (Secondary headache)
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意謂頭痛由其他原因所引起
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頭部與頸部外傷
顱部或頸部血管疾患
非血管性顱內疾患
物質或物質戒斷
感染
體內恆定疾患
頭顱,頸,眼,鼻,耳,口,鼻竇,牙或其他面部或顱部結構疾患
精神疾患
｢國際頭痛疾病分類｣ ICHD II
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需治療引起頭痛之原因。
與腦瘤相關的頭痛
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The pain has no specific features
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If unilateral , the pain is nearly always on the same side of
tumor
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tend to be deep-seated, usually non-throbbing
Lasts a few minutes to an hour or more
Occur once or many times during a day
Physical activity and changes in position of the head may provoke
pain, whereas rest diminishes its frequency
Supratentorial/infratentorial tumor 的頭痛以interauricular
circumference為分界
Late stage, IICP leads to
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Unilateral to bioccipital or bifrontal headache, nocturnal awakening,
projectile vomiting
與中風相關的頭痛
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25% stroke with headache
around the onset
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50% headache onset prior to
the neurological deficits
pressing or throbbing
If unilateral, pain is usually
ipsilateral to the side of
stroke
More in
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large stroke
posterior circulation
with a history of primary
headache
老年人的特殊頭痛
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Temporal arteritis (Giant cell arteritis)
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肇因於頭部動脈的發炎, 多是外頸動脈的分支
頭皮動脈腫脹壓痛併ESR或CRP上升
可能伴隨polymyalgia rheumatica及jaw claudication
變異性大, 故凡是60歲以上新發的持續性頭痛均需懷疑此診斷,
進行適當的診察
易併發前側缺血性視神經病變(anterior ischemic optic neuropathy)
導致失明, 由一側失明進展至另一側的時間小於一週
需積極用高劑量類固醇預防治療, 治療三天內顯著緩解頭痛
通常也有腦部缺血及失智的危險
Hypnic headache
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鈍痛, 只在睡眠中發生, 使病人醒來
三項中具其二
 首次發作在50歲以後, 醒來後頭痛持續15分鐘以上, 一個月
發生15次以上
無自主神經系統症狀, 且噁心, 畏光, 怕吵不超過一項
”雷擊般頭痛” Thunderclap headache
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Subarachnoid hemorrhage
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Sentinel leak
Acute hypertensive crisis
Cervical artery dissection
Pituitary hypoplexy
Cerebral spasm
Primary thunderclap headache
Primary cough headache
Primary headache associated with sexual activity
Cerebral venous thrombosis
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需懷疑顱內高壓之頭痛 IICP Headache
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Symptoms
 廣泛性脹痛, 平躺更易頭痛
 Valsalva maneuver會更痛
 半夜痛醒 (nocturnal awakening)
 噴射性嘔吐 (projectile vomiting)
IICP Signs
 視乳頭水腫 (papilloedema)
 盲點擴大
 視野缺損
 第六對腦神經痲痺
 臥姿經腰椎穿刺測量出腦脊髓液壓力增加 (在非肥胖者
＞200mm H2O；在肥胖者＞250mm H2O)
 Cushing response
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Hypertension, bradycardia, slow and irregular breathing
腦脊髓液低壓之頭痛
Intracranial hypotension
A. 整個頭(diffuse)及/或鈍痛，在坐起或站立後15分鐘內惡化，至少
具下列一項，且符合基準D：
1. 頸部僵硬
2. 耳鳴
3. 聽力障礙
4. 畏光
5. 噁心
B. 至少具下列一項：
1. MRI有腦脊髓液低壓的證據（如：硬腦膜對比增強）
2. 傳統脊髓攝影、CT脊髓攝影、或腦池攝影術證實有腦脊髓液滲漏
3. 在坐姿，腦脊髓液起始壓力＜60mm H2O
C. 有/無硬腦膜穿刺或導致腦脊髓液瘻管病因等病史
D. 頭痛在硬腦膜外血液貼片後72小時內緩解
原發性頭痛和次發性頭痛可以並存 !
Approach patients with
headache
Head
Ache …
有關頭痛需要獲得的病史
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Location
Quality
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Tightness, pressure, throbbing, stabbing…
Intensity
Mode of onset, time-intensity curve, and duration
Precipitating, aggravating and relieving factors
Associative symptoms
評估頭痛的嚴重程度
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目測類比量表(Visual analogue scale ,VAS)
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區分頭痛為十級，即1至10分。
「0」代表沒有頭痛、「10」代表這一輩子最嚴
重的疼痛。
概括而言1到3分表示「輕度」，4到6分表「中
度」，7到9分表「重度」，而10分表示「極重
度」。
SNOOP
Maria-Carman B. Wilson, MD.
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Symptoms（症狀）如發燒，倦怠，體重減輕
Neurological（神經學）症狀或徵象
Onset（發生）突然，快速惡化
Older（年紀大的病患）出現新發生或逐漸惡
化之頭痛
Previous（原先）頭痛的頻率、強度、時程、
特色改變
焦點病史
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病人這種頭痛有多久了？
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長時間持續多年且未曾改變的頭痛常為原發性頭痛，
如偏頭痛。
新頭痛的發生，特別是超過50歲，則是個警訊。
若病人已有多年頭痛，它改變了嗎？
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了解原本頭痛的改變，包括頻率、強度、時程等不
同的特徵。
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何時頭痛發生？
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夜間頭痛可能是次發性，導因於某些引起顱內壓上
昇的情形。有些時候，剛睡醒時也會有次發性頭痛。
因為這些相似性，頭痛發生的時間需進一步探討來
決定原發或次發。
睡眠時發生的頭痛可以是原發的。叢發性頭痛及偏
頭痛都可在睡眠時發生或將人痛醒。
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頭痛是突發或慢慢發生？
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對於數秒或數分鐘即痛到最痛者，可能會評估是否
有潛在疾患如腦出血、栓塞、顱內壓上昇等情形。
原發性頭痛，包括不明原因（idiopathic）、刺戳性
(stabbing)頭痛、咳嗽或用力(exertion)引起的、和性
交有關的、叢發性及叢發類(variant)，都可以快速發
生。
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是否曾注意到下列神經學症狀：意識混亂、意
識不清、麻木、無力、言語視力或平衡因難、
或其他神經學不正常的症狀及徵象？
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若在偏頭痛發生前產生這些症狀，病人可能符合預
兆偏頭痛。然而，必須區分不符合典型預兆偏頭痛
的症狀及徵象，因此會仔細的詢問相關病史看看是
否這些症狀指向其他問題。
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若病人曾經歷過預兆，它是如何發生又持續多
久？
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偏頭痛預兆通常在數分鐘內逐漸產生，約在15至20
分鐘達到頂峰後，約25分鐘消失。
依定義，偏頭痛預兆小於一小時。若預兆超過一小
時，需小心是否為migraineous infarct。
是否曾經歷發燒、倦怠、體重減輕或全身不適？
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這些症狀可能和潛在的感染、發炎或惡性腫瘤有關，
可能有進一步檢查的必要
焦點身體檢查
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Physical examination
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T/P/R and BP
Head and neck
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Local heat/swelling/erythema
Local tenderness / knocking pain
Eyes injection/ bruit
Neck bruit
Neck stiffness
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Neurological examination
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Consciousness level / content
Cranial nerves
Pupil size, light reflex, (eye fundus)
 EOM limitation
 Facial palsy, gag reflex, tongue deviation
Motor system
 Muscle power
 DTR
Sensory system
 Pinprick, light touch
Coordination system
 F-N-F / H-K-S test
Gait
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III, IV, VI 眼動神經
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眼皮下垂 ptosis
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partial / complete
眼動是否對稱, 有無雙影
0正常~ -4不動
0
0
X
0
0
0
X
0 0
0
0
0
0
0
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肌力 Muscle Power
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5分: 正常
4分: 抗阻力
3分: 抗重力
2分: 平移
1分: 肌肉收縮
0分: 不動
5
5 5
5 5
5
5
5
5 5
5
5
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肌腱反射 DTR (deep tendon reflex)
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Hypo
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Normal
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0~1
Low motor neuron lesion
2
++
++
++
Hyper
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3~clonus
Upper motor neuron lesion
++
++
↓
↑
實驗室與診斷檢查
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血液檢查
影像學檢查
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CT or MRI ?
CTA/MRA or conventional angiography ?
腦脊髓液檢查
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Open / close pressure
CSF appearance
WBC, RBC, total protein, lactic acid, glucose
Culture / antigen identification / PCR
Headache Hygiene Tips (1)
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Get Regular Sleep
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Eat Regular Meals
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Go to bed and wake up at regular times each day
Do not sleep excessively on the weekends and too little on the
weekdays
Most adults need approximately 6-8 hours of sleep per night
Low blood sugar can trigger a headache
Eat regular meals three times each day including protein, fruits,
vegetables and carbohydrates
Too much sugar may lead to a rapid increase in blood sugar followed
by a rapid decline in blood sugar, which can trigger a headache
Get Moderate Amounts of Routine Exercise
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Moderate exercise three to five times each week will help reduce stress
and keep you physically fit
Too much exercise or inconsistent patterns of exercise may trigger
headache
Headache Hygiene Tips (2)
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Drink Plenty of Water
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Limit Caffeine, Alcohol and other Drugs
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A normal adult should drink plenty of water throughout the day
Dehydration may cause headaches
Caffeine is a stimulant and caffeine withdrawal may cause headaches
when blood levels of caffeine taper
Alcohol may be a trigger for headaches and alcohol in moderation may
reduce the number of headaches
Reduce Stress
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Stress may lead to an increase in headache
Relaxation and stress management may help reduce headaches
Headache - Cases discussion
CASE 1
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28歲女性
主訴: 頭痛三個月
現在病史：
 似乎三個月前就開始會頭痛，然後發現次數愈來愈頻繁，也愈痛，
尤其最近這兩週較嚴重，甚至胃口不好，吃不下飯。
 頭痛的部位是整個頭，緊緊脹脹的痛、好像是整圈緊紮的痛，早
上睡醒或者好好去睡一覺後，會覺得好一點，經常是越到下午越
容易頭痛。但是不曾有半夜痛醒來的經驗。
 頭痛起來時，並沒有眼前出現閃光，眼睛周圍沒有痛，不會怕光，
沒有伴隨嘔吐或噁心，最近視力正常，記憶力也還好。
 最近沒有感冒、發燒、鼻塞、濃鼻涕，也沒有過敏性鼻炎、鼻竇
炎。耳朵也不會痛。手腳活動正常，不會常跌倒
 最近半年換新工作，因工作還未完全熟悉，且業務量大，常常加
班，自覺很辛苦 。
身體檢查：
 血壓 136/88 mmHg 心跳 96/min
 意識清醒、記憶正常，神經學檢查一切正常
CASE 2
25 year-old female, no underlying disease
 Subacute progressive headache for 2 months
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Diffuse, swelling sensation
Cough and defecation worse the headache
Midnight headache, awaking her from sleep
nausea/vomiting while headache
Blurred vision (+)
Body weight loss (+)
Fever (-)
Summary of N.E. & lab
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Conscious clear
Neck supple
NE all normal, except papilloedema (OU)
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CSF open pressure 310 mmH2O, no cell
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Lupus leukoencephalopathy with IICP
頭暈 Dizziness
病人主訴Dizziness”頭暈”的意思是…. ?
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Vertigo 眩暈
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Nonspecific “dizziness”
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an illusion of motion
“spinning sensation”, ”whirling” , ”tilting”
likely to indicate an abnormality of the semicircular
canals or the central nervous system structures that
process signals from the semicircular canals
“giddy” or “lightheaded”
Disequilibrium
Presyncope
當病人主訴”頭暈”….
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40% have peripheral vestibular dysfunction
25% have other problems, such as presyncope and
disequilibrium
15% have a psychiatric disorder
10% have a central brainstem vestibular lesion
10 % remains uncertain in approximately
區分vertigo和dizziness (1)

Time course

Vertigo is never continuous
 Even when the vestibular lesion is permanent, the central
nervous system adapts to the defect so that vertigo subsides
over several weeks

Provoking factors


Some are precipitated by maneuvers that change head position or
middle ear pressure
 maneuvers that change head position without lowering blood
pressure or decreasing cerebral blood flow is diagnostic
Aggravating factors

All vertigo is made worse by moving the head.

If head motion does not worsen the feeling, it is probably
another type of dizziness.
區分vertigo和dizziness (2)

Associated signs and symptoms

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Nystagmus
 is not always readily visible, although it often can be elicited by
provocative maneuvers or with electronystagmography.
Postural instability
 it is common for patients with vertigo to have difficulty maintaining
steady upright posture when walking, standing, and even sitting
unsupported, particularly when the symptoms are acute.
Hearing loss
 very suggestive of a peripheral cause of vertigo, although their
absence does not exclude the diagnosis
Brainstem signs
 The presence of additional neurologic signs strongly suggests the
presence of a central vestibular lesion.
Peripheral vertigo
Benign paroxysmal positional vertigo


The most common form of positional vertigo, accounting
for nearly 1/2 of patients with peripheral vestibular
dysfunction
Most commonly attributed to calcium debris within the
posterior semicircular canal, known as canalithiasis


posterior canal BPPV more often than the anterior (superior) and
horizontal semicircular canals
Symptoms

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recurrent episodes of vertigo lasting one minute or less
provoked by specific types of head movements
typically recur periodically for weeks to months without therapy
may be associated with nausea and vomiting
have no other neurologic complaints
Dix-Hallpike maneuver

With the patient sitting, the neck is
extended and turned to one side. The p’t is
then placed supine rapidly, so that the
head hangs over the edge of the bed. The
patient is kept in this position and
observed for nystagmus for 30 seconds.
Nystagmus usually appears with a latency
of a few seconds and lasts less than 30
seconds. It has a typical trajectory, beating
upward and torsionally, with the upper
poles of the eyes beating toward the
ground. After it stops and the patient sits
up, the nystagmus will recur but in the
opposite direction. Therefore, the patient
is returned to upright and again observed
for nystagmus for 30 seconds. If
nystagmus is not provoked, the maneuver
is repeated with the head turned to the
other side. If nystagmus is provoked, the
patient should have the maneuver repeated
to the same (provoked) side; with each
repetition, the intensity and duration of
nystagmus will diminish.
Vestibular neuritis


Viral or postviral inflammatory disorder affecting the
vestibular portion of the eighth cranial nerve
Symptoms
 Sapid onset of severe vertigo
 nausea, vomiting
 gait instability.
preserved ability to ambulate. toward the affected side
have no other neurologic complaints

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Signs
 Spontaneous vestibular nystagmus

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unilateral, horizontal, or horizontal-torsional
suppressed with visual fixation
does not change direction with gaze
fast phase of nystagmus beats away from the affected side.
Meniere's disease

Arise from abnormal fluid and ion homeostasis in the inner ear


endolymphatic hydrops with distortion and distention of the
membranous, endolymph-containing portions of the labyrinthine
system
Syndrome

episodic vertigo


Sensorineural hearing loss




associated with nausea and vomiting, and persists from 20 minutes to 24
hours duration
often initially affects the lower frequencies.
progresses over time, and often results in permanent hearing loss at all
frequencies in the affected ear over an 8 to 10 year period
typically associated with intense aural fullness or pressure in the ear or the
side of the head
Tinnitus


characteristically low pitch
may be associated with auditory distortion
Central vertigo
Lateral medullary infarction

Wallenberg syndrome

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Ipsilateral Horner's
syndrome
Dissociated sensory loss
(loss of pain and
temperature sensation on the
ipsilateral face and
contralateral limbs and trunk)
Abnormal eye movements
Ipsilateral loss of corneal
reflex
Hoarseness and dysphagia
Ipsilateral limb ataxia
Cerebellar stroke
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Vertigo, may with nausea/vomiting
Limb dysmetria, dysarthria, or headache
Usually unable to stand or walk unsupported
 The direction of falling is not necessarily opposite to the
direction of the nystagmus
Nystagmus
 other than horizontal or horizontal-torsional,
 may change direction with gaze
 not suppressed with visual fixation
Patients with a vascular event are typically older and/or have
atherosclerosis risk factors (hypertension, diabetes, smoking).
Vestibular schwannoma (acoustic neuroma)

Symptoms can be due to cranial nerve involvement, cerebellar
compression, or tumor progression.
 Cochlear nerve (95%)

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Vestibular nerve (61%)
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facial numbness (paresthesia), hypesthesia, and pain.
Facial nerve (6%)


Unsteadiness while walking, which was typically mild to moderate in nature and
frequently fluctuated in severity
True spinning vertigo was uncommon.
The most nondescript vertiginous sensations
Trigeminal nerve (17%)


The two major symptoms were hearing loss usually chronic
Tinnitus was present in 63 percent.
facial paresis and, less often, taste disturbances.
Tumor progression



press on the cerebellum or brainstem and result in ataxia.
lower cranial nerves (nerves IX, X, and XI, leading to dysarthria, dysphagia,
aspiration, and hoarseness
Brainstem compression, cerebellar tonsil herniation, hydrocephalus and death
can occur in untreated cases.
Peripheral
Nystagmus

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vs.
Latency 2-20 seconds
Usually < 1min
Fatiguability (+)
Unidirectional, fast phase
toward the normal ear; never
reverses direction
Horizontal with a torsional
component, never purely
torsional or vertical
visual fixation Suppressed
Unidirectional instability,
walking preserved
Deafness or tinnitus may be
present
Central vertigo

Nystagmus

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No latency
Usually > 1min
No fatiguability
Sometimes reverses direction
when patient looks in the
direction of slow phase
Can be any direction
visual fixation NOT
Suppressed
Severe instability, patient often
falls when walking
Other neurologic signs often
present
Usually less severe vertigo
Other “dizziness”
Presyncope


The prodromal symptom of fainting or a near faint.
Symptoms



Signs



Lasts for seconds to minutes and is often recognized by the patient as
"nearly blacking out" , "nearly fainting." , lightheadedness, a feeling of
warmth, diaphoresis, nausea, and visual blurring occasionally proceeding
to blindness
usually occurs when the patient is standing or seated upright and not when
supine
An observation of pallor by onlookers
A history of cardiac disease, including cardiac dysrhythmias
(tachycardias or bradyarrhythmias), coronary heart disease, congestive
heart failure, is relevant
The etiology

Orthostatic hypotension, cardiac arrhythmias, and vasovagal attacks ..
Disequilibrium


A sense of imbalance that occurs primarily when
walking
Etiology

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peripheral neuropathy
a musculoskeletal disorder interfering with gait
vestibular disorder
cervical spondylosis
Parkinsonism
visual impairment.
Nonspecific dizziness



精神科疾病
 Often builds up gradually, waxes and wanes over a period of 20 minutes
or longer, and gradually resolves
 1/4 major depression
 1/4 generalized anxiety or panic disorder
 1/2 somatization disorder, alcohol dependence, and/or personality
disorder in one series
 Commonly related to hyperventilation; may be no sensation of "air
hunger" since these patients are hyperventilating only to a slight degree
頭部外傷、貧血、慢性阻塞性肺病、 睡眠不足、營養不良、血糖過低
過高、電解質不平衡、長期在密閉的空間工作，疲倦加上工作場所的
不良氣體（二氧化碳、油漆、塗料、麥克筆、修正液、印表機的碳粉
油墨…）
藥物 (例 降血壓藥、鎮定劑、酒精、帕金森氏症藥物、精神用藥、抗
生素.. )
Approach patients with
dizziness
焦點病史

Dizziness? Vertigo?
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Associated Symptoms

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Onset (posture), duration, course, aggravating factor,
relieving factor
Vomiting? Headache?
Visual loss (black- or white-out)? Hearing loss?
Palpitations? Chest discomfort? Dyspnea?
Staggering or ataxic gait? Double vision? Slurred
speech? Numbness / weakness of the face or body?
Clumsiness, or incoordination?
Medications / Substance
焦點身體檢查

Physical examination


Pulse rate and BP
Head and neck

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Eyes: conjunctiva pale or not, visual acuity
Ear: tenderness / discharge
Neck: pain / ROM limitation
Extremities

Joints pain / deformity

Neurological examination


Consciousness level / content
Cranial nerves
EOM limitation
 Facial sensation, corneal reflex
 Nystagmus, hearing
 Facial palsy, gag reflex, tongue deviation
Motor system
 Muscle power
 DTR
Sensory system
 Pinprick, light touch
Coordination system
 F-N-F / H-K-S test
Gait
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VIII 聽平衡神經

聽力



Rinne test: AC>BC
Weber test: 中央或偏向
眼振
0
0
0
0
←
0
←
←
區分中耳問題
或聽神經問題
線條越粗代表
幅度越大
箭頭越多代表
速度越快
小腦,腦幹或平衡神經問題皆有可能出現眼振
實驗室與診斷檢查


血液檢查
Caloric test
The head of the patient should be tilted at 30º
 When warm water at 44ºC is infused into an ear, the normal
response is nystagmus with the fast component toward the infused
ear.
 When cold water at 30ºC is infused; the normal response is
nystagmus with the fast component away from the cold waterinfused ear.
 Audiometry 聽力檢查
 Brainstem auditory evoked potentials 腦幹聽覺誘發電位
 Electronystagmography 眼振圖檢查


影像學檢查

對於後顱窩的病灶MRI優於CT
Short-latency components of
BAEP
Dizziness- Cases discussion
CASE 1
65 y/o male, DM and H/T poor control

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Acute vertigo and unsteadiness since yesterday morning
(noted while getting up)
Tend to deviate to right side while walking
Can’t use chopstickes well while eating
Right occipital dull headache (+), nausea(+)



No vomiting, no tinnitus
No limbs weakness or numbness, no sphincter problem
No ottohrea, ear pain, drug usage or significant infection episode
LMD Mx ineffective, thus visit our ER
Summary of N.E.

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
Hearing normal
Gaze-evoked nystagmus, fast phase to left side
Normal muscle power and sensation
Right limbs dysmetria and dysdiadochokinesia
Tends deviate to right side while standing and walking
Right cerebellar hemisphere infarct
CASE 2
20 y/o female, no significant past history



Progressive R’t hearing impairment since about 4 years
ago
Intermittent vertigo, R’t tinnitus associated with
unsteadiness while changing position in recent 1 year,
with increasing frequency
Mouth angle deviate to L’t, mild slurred speech and
occasional choking in recent 1 month



Denied facial numbness and double vision
No limbs weakness or numbness, no sphincter problem
No ottohrea, ear pain, drug usage or significant infection episode
Summary of N.E.

Cranial nerves involvement
R’t Facial (VII) nerve palsy
R’t Vestibulocochlear (VIII) nerve
0
0

Suspicious CrN IX, X involvement (according to
history)

No obvious pyramidal system involvement
Huge right acoustic neuroma
with brainstem and cerebellar compression
Thanks For Your Attention ~
需要立刻求醫的頭痛警訊
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任何突發性嚴重的頭痛。
頭痛伴隨抽筋的現象。
頭痛伴隨有發燒的現象。
頭痛伴隨神智不清。
頭痛伴隨昏迷。
頭部外傷以後的疼痛。
以前不頭痛，現在突然發生的頭痛。
以前有頭痛，但現在的型態改變。
咳嗽、用力或彎腰的時候，其頭痛增加。
頭痛導致半夜醒來。
頭痛伴隨著眼睛或耳朵的疼痛。
頭痛伴隨著頸部僵硬。