Part XXV - NEUROLOGY
第八分冊(cè)——神經(jīng)系統(tǒng)疾病
Section - Evaluation of the Patient
病人評(píng)估
Chapter 438 - APPROACH TO THE PATIENT
第438章——診療途徑
Robert C. Griggs
The symptoms of nervous system diseases are a part of everyday experience for most normal people. Slips of the tongue, headaches, backache and other pains, dizziness, light-headedness, numbness, muscle twitches, jerks, cramps, and tremors all occur in totally healthy persons. Mood swings with feelings of elation and depression, paranoia, and displays of temper are equally a part of the behavior of completely normal people. The rapid increase in information about neurologic diseases coupled with the intense interest of people in all walks of life in medical matters has focused public attention on both common and rare neurologic conditions.
神經(jīng)系統(tǒng)癥狀是大多數(shù)正常人每天都能體驗(yàn)到的一些情況。像口誤(slips of the tongue)、頭痛、背痛和其他疼痛、頭暈、肌肉抽搐或抽動(dòng)、痙攣性震顫等，都是完全健康者也可能發(fā)生的。情感波動(dòng)時(shí)的喜氣洋洋或郁郁寡歡、妄想、發(fā)怒等，也是完全正常者可能出現(xiàn)的。神經(jīng)系統(tǒng)疾病認(rèn)識(shí)的迅速提高，以及醫(yī)療活動(dòng)與各界人士的密切關(guān)系，使得常見和罕見情況都能引起公眾的關(guān)注。
Most older people are concerned that they or their spouse have or are developing Alzheimer's disease or stroke or both. The almost ubiquitous tremor of the elderly prompts concern about Parkinson's disease. Many younger patients are concerned about multiple sclerosis or brain tumor, and few normal people lack one or more symptoms suggesting the diagnosis of a serious neurologic disease. For most of these and other common diagnoses, imaging and other tests are typically normal when symptoms first appear and should not be obtained to reassure the patient or physician. Moreover, the widespread availability of neurodiagnostic imaging and electrophysiologic, biochemical, and genetic testing has detected "abnormalities" in many young and most elderly persons. In evaluating a patient's symptoms, it is imperative that a clinical diagnosis be reached without reference to a neurodiagnostic laboratory finding. Patients with disorders such as headache, anxiety, or depression usually do not have abnormal laboratory studies. Abnormalities that are noted on various neurodiagnostic studies are often incidental findings whose treatment may be justified and necessary but will not improve the patient's symptoms. Abnormalities detected incidentally that do not have signs or symptoms may, as for disorders such as hypertension, require aggressive evaluation and treatment, but in general, the adage that it is difficult to improve the asymptomatic patient should be kept in mind. Thus, in elderly patients, few imaging or electrophysiologic studies are interpreted as "normal" but in the absence of specific complaints consistent with the findings, treatment and even further evaluation should reflect an estimate of the specificity and sensitivity of the test, as well as the likelihood that the patient will require and benefit from treatment. It is a good rule-of-thumb that one should never obtain (or refer to the result of) a neurodiagnostic procedure without a specific diagnosis or at least a differential diagnosis in mind.
很多老人都在關(guān)心自己或其配偶是否已有或正在發(fā)生Alzheimer病(早老性癡呆)和中風(fēng)；面老人幾乎都有的震顫，則會(huì)帶來Parkinson病的憂慮。很多年齡較輕的病人關(guān)心自己是否有多發(fā)性硬化和腦腫熘，而且正常人幾乎都可能有一兩種提示嚴(yán)重神經(jīng)系統(tǒng)疾病的癥狀。像這些和其他常見病變癥狀初見時(shí)，影像檢查和其他試驗(yàn)往往都是正常的．但病人和醫(yī)生卻不能以此自慰，掉以輕心。另一方面，神經(jīng)診斷性影像、生化、電生理和遺傳檢查，又能從很多年輕和大多數(shù)老人中發(fā)現(xiàn)“異常改變”。在對(duì)病人癥狀進(jìn)行評(píng)估時(shí)，重要的是不能依托神經(jīng)診斷性實(shí)驗(yàn)室檢查結(jié)果來建立臨床診斷。像頭痛、聲慮及抑郁之類病變。實(shí)驗(yàn)室檢查一般并無異常。而由各種神經(jīng)診斷性檢查發(fā)現(xiàn)的異常，往往是伴隨性的，對(duì)此進(jìn)行治療可能是正確和必要的。但卻不能使病人癥狀獲得改善。沒有癥狀或體征而偶然檢測(cè)到的異常，像高血壓之類病變時(shí)，可能需要積極追查和冶療，但是很難使無癥狀病人得到改善的一般性規(guī)律，是應(yīng)該記取的。因此對(duì)老年病人來說，沒有什么影像或電生理檢查可以評(píng)估為“正�！�，但是如果沒有與此“異常發(fā)現(xiàn)”相應(yīng)的特異癥狀，則治療甚至進(jìn)一步檢查也只是對(duì)檢查的敏感性和特異性進(jìn)行評(píng)估，以及病人需要和受惠于治療的可能性。在沒有特異診斷至少是鑒別診斷方面的考慮時(shí)，不要輕動(dòng)神經(jīng)診斷檢查(或參照其檢查結(jié)果)，是一條很好的經(jīng)驗(yàn)。
It is important to allow the patient to describe any symptoms in his or her own words. Direct questions are often necessary to fully characterize the patient's problem, but suggested terms or descriptors for symptoms are frequently grasped by the patient unfamiliar with medical terminology and then parroted to subsequent interviewers. The patient's terms should always be used when recording symptoms. Terms such as lameness, weakness, numbness, heaviness, cramps, and tiredness may each mean pain, weakness, or alteration of sensation to some patients.
讓病人用自己的語言敘述癥狀是很重要的。為充分了解病人談到的情況，常須直接提出—些問題，但是不熟悉醫(yī)學(xué)術(shù)語的病人，往往把這些提示性術(shù)語或描述詞記在心里，下次就診時(shí)照樣搬用。記錄癥狀一定要用病人自己的語言。像走路發(fā)拐、虛弱、麻木、發(fā)沉、痙攣、疲困之類的辭語，對(duì)某些病人來說，可能是用來分別反映疼痛、軟弱或感覺異常。 www.med126.com
Chapter 439 - THE NEUROLOGIC HISTORY
第439章——神經(jīng)病史
Ralph F. Jozefowicz
The neurologic history is the most important component of neurologic diagnosis. A careful history frequently determines the cause and allows one to begin localizing the lesion(s), aiding in the determination whether the disease is diffuse or focal. Symptoms of acute onset suggest a vascular cause or seizure; symptoms that are subacute in onset suggest a mass lesion such as a tumor or abscess; symptoms that have a waxing and waning course with exacerbations and remissions suggest a demyelinating cause; symptoms that are chronic and progressive suggest a degenerative disorder.
神經(jīng)病史是神經(jīng)病診斷中最重要的資料。細(xì)致的病史常能決定病因，確定損害所在部位，還能協(xié)助確定病變是局灶性還是彌漫性的。急性起病的癥狀，提示血管性或?yàn)?a class="channel_keylink" href="/tcm/2009/20090113023702_77828.shtml" target="_blank">癲癇發(fā)作；亞急性癥狀提示質(zhì)塊性損害如腫瘤或膿腫；癥狀起伏波動(dòng)，有加劇也有緩解，提示失髓鞘性病變；慢性和進(jìn)行性癥狀則提示變性類疾病。
The history is often the only way of diagnosing neurologic illnesses that typically have normal or non-focal findings on neurologic examination. These illnesses include many seizure disorders, narcolepsy, migraine and most other headache syndromes, the various causes of dizziness, and most types of dementia. The neurologic history may often provide the first clues that a symptom is psychological in origin. The following are points to consider when obtaining a neurologic history:
神經(jīng)系統(tǒng)檢查正常或無局灶性征象的神經(jīng)系統(tǒng)病變，往往只能通過病史來診斷，包括很多癲癇發(fā)作性病變、偏頭痛和其他大多數(shù)類型的頭痛證候、各種病因性頭暈以及大多數(shù)類型的癡呆等。神經(jīng)病史往往還是提示癥狀系精神性原因所致的最先線索。以下是收集神經(jīng)病史時(shí)要注意的一些要點(diǎn)：醫(yī)學(xué) 全在.線提供www.med126.com
Carefully identify the chief complaint or major problem. Not only is the chief complaint important in providing the first clue to the physician as to the differential diagnosis, it is also the reason why the patient is seeking medical advice and treatment. If the chief complaint is not properly identified and addressed, the proper diagnosis may be missed and an inappropriate diagnostic work-up may be undertaken. Establishing a diagnosis that does not incorporate the chief complaint frequently focuses attention on a coincidental process irrelevant to the patient's concerns.
仔細(xì)確定主訴或主要問題。主訴（chief complaint)不但在鑒別診斷上是為醫(yī)生提供的首先線索，還是病人趨醫(yī)求治的原因。如主訴未被正確確定，正確診斷就可能失之交臂，以致可能在錯(cuò)誤的途徑上追索診斷。沒有納入主訴的診斷，往往不是病人當(dāng)前真正關(guān)注的問題，而是落腳在伴隨的病變上。
Listen carefully to the patient for as long as is necessary. A good rule of thumb is to listen initially for at least 5 minutes without interrupting the patient. The patient often volunteers the most important information at the start of the history. During this time, the examiner can also assess mental status, including speech, language, fund of knowledge, and affect, and observe the patient for facial asymmetry, abnormalities of ocular movements, and an increase or a paucity of spontaneous movements as seen with movement disorders.
以充分的時(shí)間傾聽病人的陳訴。接診開始，至少應(yīng)有5分鐘時(shí)間讓病人不被打斷地盡情訴述，是一條很好的工作方法。病人長會(huì)在病史陳述的開始，自動(dòng)把最重要的信息吐露出來。醫(yī)生則可在這個(gè)時(shí)間，觀察病人的精神狀態(tài)，包括語言、知識(shí)水平和情緒，注意面部是否對(duì)稱、眼睛運(yùn)動(dòng)有無異常、自發(fā)性運(yùn)動(dòng)增加還是減少（如運(yùn)動(dòng)性病變)等。
Steer the patient away from discussions of previous diagnostic test results and of the opinions of previous caregivers. Abnormal results of laboratory studies may be incidental to the patient's primary problem or may simply represent a normal variant.
正確引導(dǎo)病人，不去討論過去診斷性檢查結(jié)果和保健醫(yī)生的意見。須知實(shí)驗(yàn)室檢查結(jié)果異常，對(duì)病人的主要問題可能只是偶合關(guān)系，也可能是正常變異。
Take a careful medical history, medication history, psychiatric history, family history, and social and occupational history. Many neurologic illnesses are complications of underlying medical disorders or are due to adverse effects of drugs. For example, parkinsonism is a frequent complication of use of metoclopramide and most neuroleptic agents. A large number of neurologic disorders are hereditary, and a positive family history may establish the diagnosis in many instances. Occupation plays a major role in various neurologic disorders such as carpal tunnel syndrome (in computer keyboard operators), and peripheral neuropathy (caused by exposure to lead or other toxins).
深入了解病史、服藥史、精神病史、家族史以及社會(huì)和職業(yè)史。很多神經(jīng)病是內(nèi)科疾病的合并癥，或者是藥物的不良反應(yīng)。如帕金森神經(jīng)功能障礙（parkinsonism)往往是應(yīng)用甲氧氯普胺（metoclopramide)的合并癥，神經(jīng)安定藥大多已有此反應(yīng)。很多神經(jīng)性病變都有遺傳性，很多病例都可能有陽性家族史而確立診斷。職業(yè)亦可在一些神經(jīng)病史中起到主要作用，如彎管綜合征（carpal tunnel syndrome)（電腦鍵盤操作員)和末梢神經(jīng)�。ń佑|鉛及其他毒素)等。
Interview surrogate historians. Patients with dementia or altered mental status are usually unable to provide exact details of the history, and a family member may provide key details needed to make an accurate diagnosis. This is especially true for patients with dementia and certain right hemispheric lesions with various agnosias (lack of awareness of disease) that may interfere with their ability to provide a cogent history. Surrogate historians also provide missing historical details for patients with episodic loss of consciousness, such as syncope and epilepsy.
會(huì)見病史代述者。癡呆和意識(shí)狀態(tài)失常的病人，一般不能提供翔實(shí)、完成的病史，須由知情家屬提供要點(diǎn)，以利正確診斷。特別是癡呆和某些右半球損害而又不同程度認(rèn)識(shí)障礙（agnosias)（不能察覺疾病)的患者，不能提供確切病史，更須有人代訴。發(fā)作性意識(shí)部分缺失者（如暈厥和癲癇發(fā)作)也須有人代訴遺漏的病史。
Summarize the history for the patient. Summarizing the history is an effective way to ensure that all details were covered sufficiently to make a tentative diagnosis. Summarizing will also allow the physician to fill in historical gaps that may not have been apparent when the history was initially taken. In addition, the patient or surrogate may correct any historical misinformation at this time.
為病人總結(jié)病史。總結(jié)病史是一項(xiàng)很有效的方法，肯定確已獲得作出印象診斷所需的各項(xiàng)重要資料。總結(jié)歸納，還能是醫(yī)生補(bǔ)充最初采取病史時(shí)可能很明確的病史缺陷。病人或代訴者還可在此時(shí)糾正病史中的一些錯(cuò)誤信息。
End by asking the patient what he or she thinks is wrong. This allows the physician to evaluate the patient's concerns about and insight into the condition. Some patients have a specific diagnosis in mind that spurs them to seek medical attention. Multiple sclerosis, amyotrophic lateral sclerosis, Alzheimer's disease, and brain tumors are diseases that patients often suspect may be the cause of their neurologic symptoms.
請(qǐng)病人說出自覺何系病變，結(jié)束病歷問詢。此舉可使醫(yī)生對(duì)病人關(guān)心和認(rèn)識(shí)到的問題有所了解。有些病人是心懷某一特定診斷而來就診求索的，如病人往往懷疑自己的神經(jīng)癥癥狀，是由于多發(fā)性硬化、Alzheimer病和腦腫瘤之類病變所致。
