98年专科护理师训练神经系统常见问题之评估(一)课件

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98年專科護理師訓練神經系統常見問題之評估(一)頭痛H1頭痛Headache頭痛Headache2Pain-sensitivecranialstructuresl顱外lSkin,subcutaneoustissues,musclesextracranialarteries,periosteumofskulllEye,earnasalcavitiesperinasalsinusesl顱內l血管lIntracranialvenoussinusesandtheirlargetributaries,esp.pericavernousstructureslArterieswithintheduraandpia-subarachnoid,particularytheproximalpartsoftheACA,MCAandtheintracranialsegmentofICAlThemiddlemeningealandsuperficialtemporalarteriesl腦膜lPartsoftheduraatthebaseofthebrainl顱神經lTheoptic,oculomotor,trigeminal,glossopharyngeal,vagus,(andthefirstthreecervicalnerves)Pain-sensitivecranialstructu3lFromsupratentorialstructureslAnterior2/3ofhead(V1,V2dermatones)lFrominfratenotrialstructureslVertex,posteriorheadandnecklFromVII,IX,XcranialnerveslNaso-orbitalregion,ear,throatPain from extracrainal part of body NOT refer to head,EXCEPTlCervicalportionofICAlEyebrow,supraorbitalregionlUppercervicalspinelocciputlAnginapectoris(rare)lJaw,vertexAreasofreferpainfromintracranialstructuresFromsupratentorialstructures4國際頭痛疾病分類ICHD(InternationalClassificationofHeadacheDisorders)l第一版在1988年公布，第二版於2004年刊登於Cephalalgia雜誌。l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!l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。國際頭痛疾病分類ICHD(Internationa5l原發性(Primary)l次發性(Secondary)l以決定頭痛的原因及訂定適切的治療計畫頭痛Headache原發性(Primary)頭痛Headache6原發性頭痛(primaryheadache)l意謂頭痛本身即為痛的成因。l超過百分之九十的頭痛患者屬於此類。l重點就是排除次發性的可能。原發性頭痛(primaryheadache)意謂頭痛本身7無預兆偏頭痛MigrainewithoutauraA.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.非歸因於其他疾患無預兆偏頭痛Migrainewithoutaura8典型預兆偏頭痛性頭痛TypicalaurawithmigraineheadacheA.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.非歸因於其他疾患典型預兆偏頭痛性頭痛Typicalaurawith9緊縮型頭痛Tension-typeheadacheA.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.非歸因於其他疾患緊縮型頭痛Tension-typeheadacheA10叢發性頭痛ClusterheadacheA.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.非歸因於其他疾患叢發性頭痛ClusterheadacheA.至少有11典型三叉神經痛ClassicaltrigeminalneuralgiaA.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CB.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.非歸因於其他疾患典型三叉神經痛Classicaltrigeminal12次發性頭痛(Secondaryheadache)l意謂頭痛由其他原因所引起l頭部與頸部外傷l顱部或頸部血管疾患l非血管性顱內疾患l物質或物質戒斷l感染l體內恆定疾患l頭顱,頸,眼,鼻,耳,口,鼻竇,牙或其他面部或顱部結構疾患l精神疾患國際頭痛疾病分類ICHDIIl需治療引起頭痛之原因。次發性頭痛(Secondaryheadache)意謂頭痛13與腦瘤相關的頭痛lThepainhasnospecificfeaturesltendtobedeep-seated,usuallynon-throbbinglLastsafewminutestoanhourormorelOccuronceormanytimesduringadaylPhysicalactivityandchangesinpositionoftheheadmayprovokepain,whereasrestdiminishesitsfrequencylIfunilateral,thepainisnearlyalwaysonthesamesideoftumorlSupratentorial/infratentorialtumor的頭痛以interauricularcircumference為分界lLatestage,IICPleadstolUnilateraltobioccipitalorbifrontalheadache,nocturnalawakening,projectilevomiting與腦瘤相關的頭痛Thepainhasnospecif14與中風相關的頭痛l25%strokewithheadachearoundtheonsetl50%headacheonsetpriortotheneurologicaldeficitslpressingorthrobbinglIfunilateral,painisusuallyipsilateraltothesideofstrokelMoreinllargestrokelposteriorcirculationlwithahistoryofprimaryheadache與中風相關的頭痛25%strokewithheadac15老年人的特殊頭痛lTemporalarteritis(Giantcellarteritis)l肇因於頭部動脈的發炎,多是外頸動脈的分支l頭皮動脈腫脹壓痛併ESR或CRP上升l可能伴隨polymyalgiarheumatica及jawclaudicationl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l易併發前側缺血性視神經病變(anteriorischemicopticneuropathy)導致失明,由一側失明進展至另一側的時間小於一週l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l通常也有腦部缺血及失智的危險lHypnicheadachel鈍痛,只在睡眠中發生,使病人醒來l三項中具其二l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l無自主神經系統症狀,且噁心,畏光,怕吵不超過一項老年人的特殊頭痛Temporalarteritis(Gi16”雷擊般頭痛”ThunderclapheadachelSubarachnoidhemorrhagelSentinelleaklAcutehypertensivecrisislCervicalarterydissectionlPituitaryhypoplexylCerebralspasmlPrimarythunderclapheadachelPrimarycoughheadachelPrimaryheadacheassociatedwithsexualactivitylCerebralvenousthrombosis”雷擊般頭痛”ThunderclapheadacheSu17需懷疑顱內高壓之頭痛IICPHeadachelSymptomsl廣泛性脹痛,平躺更易頭痛lValsalvamaneuver會更痛l半夜痛醒(nocturnalawakening)l噴射性嘔吐(projectilevomiting)lIICPSignsl視乳頭水腫(papilloedema)l盲點擴大l視野缺損l第六對腦神經痲痺l臥姿經腰椎穿刺測量出腦脊髓液壓力增加(在非肥胖者200mmH2O；在肥胖者250mmH2O)lCushingresponselHypertension,bradycardia,slowandirregularbreathing需懷疑顱內高壓之頭痛IICPHeadacheSympt18腦脊髓液低壓之頭痛IntracranialhypotensionA.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60mmH2OC.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小時內緩解腦脊髓液低壓之頭痛Intracranialhypote19原發性頭痛和次發性頭痛可以並存!原發性頭痛和次發性頭痛可以並存!20Approach patients with headacheApproachpatientswithheadach21lLocationlQualitylTightness,pressure,throbbing,stabbinglIntensitylModeofonset,time-intensitycurve,anddurationlPrecipitating,aggravatingandrelievingfactorslAssociativesymptomsHead Ache有關頭痛需要獲得的病史LocationHeadAche有關頭22評估頭痛的嚴重程度l目測類比量表(Visualanaloguescale,VAS)l區分頭痛為十級，即1至10分。l0代表沒有頭痛、10代表這一輩子最嚴重的疼痛。l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。評估頭痛的嚴重程度目測類比量表(Visualanalogu23SNOOPMaria-Carman B.Wilson,MD.lSymptoms（症狀）如發燒，倦怠，體重減輕lNeurological（神經學）症狀或徵象lOnset（發生）突然，快速惡化lOlder（年紀大的病患）出現新發生或逐漸惡化之頭痛lPrevious（原先）頭痛的頻率、強度、時程、特色改變SNOOP24焦點病史l病人這種頭痛有多久了？l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。l新頭痛的發生，特別是超過50歲，則是個警訊。l若病人已有多年頭痛，它改變了嗎？l了解原本頭痛的改變，包括頻率、強度、時程等不同的特徵。焦點病史病人這種頭痛有多久了？25l何時頭痛發生？l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。l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。何時頭痛發生？26l頭痛是突發或慢慢發生？l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。l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。頭痛是突發或慢慢發生？27l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？l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。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、28l若病人曾經歷過預兆，它是如何發生又持續多久？l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。l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migraineousinfarct。l是否曾經歷發燒、倦怠、體重減輕或全身不適？l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若病人曾經歷過預兆，它是如何發生又持續多久？29焦點身體檢查lPhysicalexaminationlT/P/RandBPlHeadandnecklLocalheat/swelling/erythemalLocaltenderness/knockingpainlEyesinjection/bruitlNeckbruitlNeckstiffness焦點身體檢查Physicalexamination30lNeurologicalexaminationlConsciousnesslevel/contentlCranialnerveslPupilsize,lightreflex,(eyefundus)lEOMlimitationlFacialpalsy,gagreflex,tonguedeviationlMotorsystemlMusclepowerlDTRlSensorysystemlPinprick,lighttouchlCoordinationsystemlF-N-F/H-K-StestlGaitNeurologicalexamination31lIII,IV,VI眼動神經l眼皮下垂ptosislpartial/completel眼動是否對稱,有無雙影X000000X0000000正常-4不動III,IV,VI眼動神經X000000X00000032l肌力MusclePowerl5分:正常l4分:抗阻力l3分:抗重力l2分:平移l1分:肌肉收縮l0分:不動555555555555肌力MusclePower55555555555533l肌腱反射DTR(deeptendonreflex)lHypol01lLowmotorneuronlesionlNormall2lHyperl3clonuslUppermotorneuronlesion+肌腱反射DTR(deeptendonreflex)+34實驗室與診斷檢查l血液檢查l影像學檢查lCTorMRI?lCTA/MRAorconventionalangiography?l腦脊髓液檢查lOpen/closepressurelCSFappearancelWBC,RBC,totalprotein,lacticacid,glucoselCulture/antigenidentification/PCR實驗室與診斷檢查血液檢查3598年专科护理师训练神经系统常见问题之评估(一)课件36HeadacheHygieneTips(1)lGetRegularSleeplGotobedandwakeupatregulartimeseachdaylDonotsleepexcessivelyontheweekendsandtoolittleontheweekdayslMostadultsneedapproximately6-8hoursofsleeppernightlEatRegularMealslLowbloodsugarcantriggeraheadachelEatregularmealsthreetimeseachdayincludingprotein,fruits,vegetablesandcarbohydrateslToomuchsugarmayleadtoarapidincreaseinbloodsugarfollowedbyarapiddeclineinbloodsugar,whichcantriggeraheadachelGetModerateAmountsofRoutineExerciselModerateexercisethreetofivetimeseachweekwillhelpreducestressandkeepyouphysicallyfitlToomuchexerciseorinconsistentpatternsofexercisemaytriggerheadacheHeadacheHygieneTips(1)GetR37HeadacheHygieneTips(2)lDrinkPlentyofWaterlAnormaladultshoulddrinkplentyofwaterthroughoutthedaylDehydrationmaycauseheadacheslLimitCaffeine,AlcoholandotherDrugslCaffeineisastimulantandcaffeinewithdrawalmaycauseheadacheswhenbloodlevelsofcaffeinetaperlAlcoholmaybeatriggerforheadachesandalcoholinmoderationmayreducethenumberofheadacheslReduceStresslStressmayleadtoanincreaseinheadachelRelaxationandstressmanagementmayhelpreduceheadachesHeadacheHygieneTips(2)Drink38Headache-Cases discussionHeadache-Casesdiscussion39CASE1l28歲女性l主訴:頭痛三個月l現在病史：l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。l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。l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。l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l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。l身體檢查：l血壓136/88mmHg心跳96/minl意識清醒、記憶正常，神經學檢查一切正常CASE128歲女性40CASE225year-oldfemale,nounderlyingdiseaselSubacuteprogressiveheadachefor2monthslDiffuse,swellingsensationlCoughanddefecationworsetheheadachelMidnightheadache,awakingherfromsleeplnausea/vomitingwhileheadachelBlurredvision(+)lBodyweightloss(+)lFever(-)CASE225year-oldfemale,nou41SummaryofN.E.&lablConsciousclearlNecksupplelNEallnormal,exceptpapilloedema(OU)lCSFopenpressure310mmH2O,nocellSummaryofN.E.&labConscious42LupusleukoencephalopathywithIICPLupusleukoencephalopathywith43頭暈Dizziness頭暈Dizziness44病人主訴Dizziness”頭暈”的意思是.?lVertigo眩暈lanillusionofmotionl“spinningsensation”,”whirling”,”tilting”llikelytoindicateanabnormalityofthesemicircularcanalsorthecentralnervoussystemstructuresthatprocesssignalsfromthesemicircularcanalslNonspecific“dizziness”l“giddy”or“lightheaded”lDisequilibriumlPresyncope病人主訴Dizziness”頭暈”的意思是.?Vert45l40%haveperipheralvestibulardysfunctionl25%haveotherproblems,suchaspresyncopeanddisequilibriuml15%haveapsychiatricdisorderl10%haveacentralbrainstemvestibularlesionl10%remainsuncertaininapproximately當病人主訴”頭暈”.40%haveperipheralvestibular46區分vertigo和dizziness(1)lTimecourselVertigoisnevercontinuouslEvenwhenthevestibularlesionispermanent,thecentralnervoussystemadaptstothedefectsothatvertigosubsidesoverseveralweekslProvokingfactorslSomeareprecipitatedbymaneuversthatchangeheadpositionormiddleearpressurelmaneuversthatchangeheadpositionwithoutloweringbloodpressureordecreasingcerebralbloodflowisdiagnosticlAggravatingfactorslAllvertigoismadeworsebymovingthehead.lIfheadmotiondoesnotworsenthefeeling,itisprobablyanothertypeofdizziness.區分vertigo和dizziness(1)Timeco47lAssociatedsignsandsymptomslNystagmuslisnotalwaysreadilyvisible,althoughitoftencanbeelicitedbyprovocativemaneuversorwithelectronystagmography.lPosturalinstabilitylitiscommonforpatientswithvertigotohavedifficultymaintainingsteadyuprightposturewhenwalking,standing,andevensittingunsupported,particularlywhenthesymptomsareacute.lHearinglosslverysuggestiveofaperipheralcauseofvertigo,althoughtheirabsencedoesnotexcludethediagnosislBrainstemsignslThepresenceofadditionalneurologicsignsstronglysuggeststhepresenceofacentralvestibularlesion.區分vertigo和dizziness(2)Associatedsignsandsymptoms4898年专科护理师训练神经系统常见问题之评估(一)课件49PeripheralvertigoPeripheralvertigo50BenignparoxysmalpositionalvertigolThemostcommonformofpositionalvertigo,accountingfornearly1/2ofpatientswithperipheralvestibulardysfunctionlMostcommonlyattributedtocalciumdebriswithintheposteriorsemicircularcanal,knownascanalithiasislposteriorcanalBPPVmoreoftenthantheanterior(superior)andhorizontalsemicircularcanalslSymptomslrecurrentepisodesofvertigolastingoneminuteorlesslprovokedbyspecifictypesofheadmovementsltypicallyrecurperiodicallyforweekstomonthswithouttherapylmaybeassociatedwithnauseaandvomitinglhavenootherneurologiccomplaintsBenignparoxysmalpositionalv51Dix-HallpikemaneuverlWiththepatientsitting,theneckisextendedandturnedtooneside.Theptisthenplacedsupinerapidly,sothattheheadhangsovertheedgeofthebed.Thepatientiskeptinthispositionandobservedfornystagmusfor30seconds.Nystagmususuallyappearswithalatencyofafewsecondsandlastslessthan30seconds.Ithasatypicaltrajectory,beatingupwardandtorsionally,withtheupperpolesoftheeyesbeatingtowardtheground.Afteritstopsandthepatientsitsup,thenystagmuswillrecurbutintheoppositedirection.Therefore,thepatientisreturnedtouprightandagainobservedfornystagmusfor30seconds.Ifnystagmusisnotprovoked,themaneuverisrepeatedwiththeheadturnedtotheotherside.Ifnystagmusisprovoked,thepatientshouldhavethemaneuverrepeatedtothesame(provoked)side;witheachrepetition,theintensityanddurationofnystagmuswilldiminish.Dix-HallpikemaneuverWiththe52VestibularneuritislViralorpostviralinflammatorydisorderaffectingthevestibularportionoftheeighthcranialnervelSymptomslSapidonsetofseverevertigolnausea,vomitinglgaitinstability.lpreservedabilitytoambulate.towardtheaffectedsidelhavenootherneurologiccomplaintslSignslSpontaneousvestibularnystagmuslunilateral,horizontal,orhorizontal-torsionallsuppressedwithvisualfixationldoesnotchangedirectionwithgazelfastphaseofnystagmusbeatsawayfromtheaffectedside.VestibularneuritisViralorp53MenieresdiseaselArisefromabnormalfluidandionhomeostasisintheinnerearlendolymphatichydropswithdistortionanddistentionofthemembranous,endolymph-containingportionsofthelabyrinthinesystemlSyndromelepisodicvertigolassociatedwithnauseaandvomiting,andpersistsfrom20minutesto24hoursdurationlSensorineuralhearinglosslofteninitiallyaffectsthelowerfrequencies.lprogressesovertime,andoftenresultsinpermanenthearinglossatallfrequenciesintheaffectedearoveran8to10yearperiodltypicallyassociatedwithintenseauralfullnessorpressureintheearorthesideoftheheadlTinnituslcharacteristicallylowpitchlmaybeassociatedwithauditorydistortionMenieresdiseaseArisefroma54CentralvertigoCentralvertigo55LateralmedullaryinfarctionlWallenbergsyndromelIpsilateralHornerssyndromelDissociatedsensoryloss(lossofpainandtemperaturesensationontheipsilateralfaceandcontralaterallimbsandtrunk)lAbnormaleyemovementslIpsilaterallossofcornealreflexlHoarsenessanddysphagialIpsilaterallimbataxiaLateralmedullaryinfarction56CerebellarstrokelVertigo,maywithnausea/vomitinglLimbdysmetria,dysarthria,orheadachelUsuallyunabletostandorwalkunsupportedlThedirectionoffallingisnotnecessarilyoppositetothedirectionofthenystagmuslNystagmuslotherthanhorizontalorhorizontal-torsional,lmaychangedirectionwithgazelnotsuppressedwithvisualfixationlPatientswithavasculareventaretypicallyolderand/orhaveatherosclerosisriskfactors(hypertension,diabetes,smoking).CerebellarstrokeVertigo,may57Vestibularschwannoma(acousticneuroma)lSymptomscanbeduetocranialnerveinvolvement,cerebellarcompression,ortumorprogression.lCochlearnerve(95%)lThetwomajorsymptomswerehearinglossusuallychroniclTinnituswaspresentin63percent.lVestibularnerve(61%)lUnsteadinesswhilewalking,whichwastypicallymildtomoderateinnatureandfrequentlyfluctuatedinseveritylTruespinningvertigowasuncommon.lThemostnondescriptvertiginoussensationslTrigeminalnerve(17%)lfacialnumbness(paresthesia),hypesthesia,andpain.lFacialnerve(6%)lfacialparesisand,lessoften,tastedisturbances.lTumorprogressionlpressonthecerebellumorbrainstemandresultinataxia.llowercranialnerves(nervesIX,X,andXI,leadingtodysarthria,dysphagia,aspiration,andhoarsenesslBrainstemcompression,cerebellartonsilherniation,hydrocephalusanddeathcanoccurinuntreatedcases.Vestibularschwannoma(acousti58Peripheralvs.CentralvertigolNystagmuslLatency2-20secondslUsually1minlNofatiguabilitylSometimesreversesdirectionwhenpatientlooksinthedirectionofslowphaselCanbeanydirectionlvisualfixationNOTSuppressedlSevereinstability,patientoftenfallswhenwalkinglOtherneurologicsignsoftenpresentlUsuallylessseverevertigoPeripheralvs.Ce59Other“dizziness”Other“dizziness”60PresyncopelTheprodromalsymptomoffaintingoranearfaint.lSymptomslLastsforsecondstominutesandisoftenrecognizedbythepatientasnearlyblackingout,nearlyfainting.,lightheadedness,afeelingofwarmth,diaphoresis,nausea,andvisualblurringoccasionallyproceedingtoblindnesslusuallyoccurswhenthepatientisstandingorseateduprightandnotwhensupinelSignslAnobservationofpallorbyonlookerslAhistoryofcardiacdisease,includingcardiacdysrhythmias(tachycardiasorbradyarrhythmias),coronaryheartdisease,congestiveheartfailure,isrelevantlTheetiologylOrthostatichypotension,cardiacarrhythmias,andvasovagalattacks.PresyncopeTheprodromalsympto61DisequilibriumlAsenseofimbalancethatoccursprimarilywhenwalkinglEtiologylperipheralneuropathylamusculoskeletaldisorderinterferingwithgaitlvestibulardisorderlcervicalspondylosislParkinsonismlvisualimpairment.DisequilibriumAsenseofimbal62Nonspecificdizzinessl精神科疾病lOftenbuildsupgradually,waxesandwanesoveraperiodof20minutesorlonger,andgraduallyresolvesl1/4majordepressionl1/4generalizedanxietyorpanicdisorderl1/2somatizationdisorder,alcoholdependence,and/orpersonalitydisorderinoneserieslCommonlyrelatedtohyperventilation;maybenosensationofairhungersincethesepatientsarehyperventilatingonlytoaslightdegreel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）l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.)Nonspecificdizziness精神科疾病63Approach patients with dizzinessApproachpatientswithdizzine64焦點病史lDizziness?Vertigo?Onset(posture),duration,course,aggravatingfactor,relievingfactorlAssociatedSymptomsVomiting?Headache?Visualloss(black-orwhite-out)?Hearingloss?Palpitations?Chestdiscomfort?Dyspnea?Staggeringorataxicgait?Doublevision?Slurredspeech?Numbness/weaknessofthefaceorbody?Clumsiness,orincoordination?lMedications/Substance焦點病史Dizziness?Vertigo?65焦點身體檢查lPhysicalexaminationlPulserateandBPlHeadandnecklEyes:conjunctivapaleornot,visualacuitylEar:tenderness/dischargelNeck:pain/ROMlimitationlExtremitieslJointspain/deformity焦點身體檢查Physicalexamination66lNeurologicalexaminationlConsciousnesslevel/contentlCranialnerveslEOMlimitationlFacialsensation,cornealreflexlNystagmus,hearinglFacialpalsy,gagreflex,tonguedeviationlMotorsystemlMusclepowerlDTRlSensorysystemlPinprick,lighttouchlCoordinationsystemlF-N-F/H-K-StestlGaitNeurologicalexamination67lVIII聽平衡神經l聽力lRinnetest:ACBClWebertest:中央或偏向l眼振00000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區分中耳問題或聽神經問題VIII聽平衡神經00000線條越粗代表幅度越大小6898年专科护理师训练神经系统常见问题之评估(一)课件69l血液檢查lCalorictestlTheheadofthepatientshouldbetiltedat30lWhenwarmwaterat44Cisinfusedintoanear,thenormalresponseisnystagmuswiththefastcomponenttowardtheinfusedear.lWhencoldwaterat30Cisinfused;thenormalresponseisnystagmuswiththefastcomponentawayfromthecoldwater-infusedear.lAudiometry聽力檢查lBrainstemauditoryevokedpotentials腦幹聽覺誘發電位lElectronystagmography眼振圖檢查l影像學檢查l對於後顱窩的病灶MRI優於CT實驗室與診斷檢查血液檢查實驗室與診斷檢查70Short-latency components of BAEPShort-latencycomponentsofBA71Dizziness-Cases discussionDizziness-Casesdiscussion72CASE165y/omale,DMandH/TpoorcontrollAcutevertigoandunsteadinesssinceyesterdaymorning(notedwhilegettingup)lTendtodeviatetorightsidewhilewalkinglCantusechopstickeswellwhileeatinglRightoccipitaldullheadache(+),nausea(+)lNovomiting,notinnituslNolimbsweaknessornumbness,nosphincterproblemlNoottohrea,earpain,drugusageorsignificantinfectionepisodeLMDMxineffective,thusvisitourERCASE165y/omale,DMandH/T73SummaryofN.E.lHearingnormallGaze-evokednystagmus,fastphasetoleftsidelNormalmusclepowerandsensationlRightlimbsdysmetriaanddysdiadochokinesialTendsdeviatetorightsidewhilestandingandwalkingSummaryofN.E.Hearingnormal74RightcerebellarhemisphereinfarctRightcerebellarhemispherei75CASE220y/ofemale,nosignificantpasthistorylProgressiveRthearingimpairmentsinceabout4yearsagolIntermittentvertigo,Rttinnitusassociatedwithunsteadinesswhilechangingpositioninrecent1year,withincreasingfrequencylMouthangledeviatetoLt,mildslurredspeechandoccasionalchokinginrecent1monthlDeniedfacialnumbnessanddoublevisionlNolimbsweaknessornumbness,nosphincterproblemlNoottohrea,earpain,drugusageorsignificantinfectionepisodeCASE220y/ofemale,nosignif76SummaryofN.E.lCranialnervesinvolvementRtFacial(VII)nervepalsyRtVestibulocochlear(VIII)nervelSuspiciousCrNIX,Xinvolvement(accordingtohistory)lNoobviouspyramidalsysteminvolvement0000SummaryofN.E.Cranialnerves77HugerightacousticneuromawithbrainstemandcerebellarcompressionHugerightacousticneuroma78Thanks For Your Attention ThanksForYourAttention79需要立刻求醫的頭痛警訊l任何突發性嚴重的頭痛。l頭痛伴隨抽筋的現象。l頭痛伴隨有發燒的現象。l頭痛伴隨神智不清。l頭痛伴隨昏迷。l頭部外傷以後的疼痛。l以前