Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
.pdf
CHAPTER 12 Neurological symptoms
292
Dizziness
Dizziness is often nonspecific and no cause is found, but one of the fol-
lowing will be discovered in a proportion of patients. Distinguish be-
tween dizziness and vertigo (which has a sensation of movement), the
latter being more specific for an identifiable lesion.
Some differential diagnoses and typical outline evidence
Panic attacks
and
hyperventilation
Suggested by: associated anxiety and claustrophobia.
Finger and lip paresthesia of hyperventilation. Resting
tachypnea, no hypoxia
Confirmed by: ABGs
: PO
2
normal or i, dCO
2
;
CXR: normal, spirometry normal
Response to anxiolytics and psychotherapy
Postural
hypotension
due to drugs to
lower BP, loss of
circulating vol-
ume, dehydration,
diabetic auto-
nomic neuro-
pathy, old age +
heavy meal,
dopamine
agonists,
Addison’s disease
Suggested by: associated palpitations, loss of
consciousness. Supine and standing BP after 1 minute:
>10 mm drop
Confirmed by: response of BP changes to treatment of
cause
Anemia Suggested by: subconjunctival pallor (± face, nail, and
hand pallor)
Confirmed by: CBC: dHb
Hypoxia Suggested by: blue hands and tongue (central cyanosis),
restlessness, confused, drowsy, or unconscious
Confirmed by: ABG: dPaO
2
<60 mmgH on blood gas
analysis or pulse oximetry of <90% satura
t
ion (mild) or
<80% (severe)
DIZZINESS1
293
Carotid sinus
hypersensitivity
Suggested by: onset on head turning or shaving neck
Confirmed by: reproduction of symptoms while turning
neck or pressure on carotid sinus
Epilepsy Suggested by: aura followed by other positive
neurological symptoms
Confirmed by: EEG findings
Drug effect Suggested by: history of taking sedative or hypotensive
drug, including alcohol
Confirmed by: resolution of symptom after stopping
drug
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 12 Neurological symptoms
294
Vertigo
Vertigo is a sensation of movement of self ± the environment, especially
rotation or oscillation.
Some differential diagnoses and typical outline evidence
Vertibrobasilar
insufficiency
(brain stem
ischemia)
Suggested by: visual disturbances, other signs of
cerebral ischemia, e.g., dysarthria, faint
Confirmed by: carotid Doppler evidence of arterial
disease. MRA of brain and neck vessels
Benign
positional
vertigo
Suggested by: attacks with duration of minutes only
Confirmed by: head tilt test: nystagmus af
t
er 5 seconds,
lasting a minute. Shorter duration when repeated
Ménière’s
disease
Suggested by: attacks with duration of up to 24 hours.
Progressive deafness (especially in older age groups)
Confirmed by: audiometry: hearing loss with loudness
recruitment
Vestibular
neuronitis
Suggested by: sudden, single prostrating attack, usually
with nystagmus, with resolution over weeks
Confirmed by: caloric testing
Middle ear
disease
Suggested by: painful ear, recurrent attacks, or
persistent vertigo and nystagmus
Confirmed by: audiometry: conductive deafness.
Otoscopic appearance of otitis media or
cholesteotoma
Reversible
drug toxicity
Suggested by: vertigo, slurring of speech and
nystagmus with suggestive drug history, e.g., alcohol,
barbiturates, phenytoin
Confirmed by: resolution on withdrawal of drug.
Drug levels if in doubt
Wernicke’s
encephalopathy
(due to thiamine
deficiency,
usually in
alcoholism)
Suggested by: persistence of vertigo, slurring of speech
and nystagmus despite withdrawal of alcohol
Confirmed by: resolution or improvement on thiamine
treatment
VERTIGO1
295
Ototoxic
drugs
Suggested by: recurrent attacks or persistent vertigo
and little nystagmus, history of streptomycin, gentamy-
cin, kanamycin, phenytoin, quinine, or salicylates, etc.
Confirmed by: bilateral loss of response to caloric tests.
No signs of disease in brain stem, ears, or cerebellum
Brain stem
ischemia
Suggested by: sudden onset, and associated with
peripheral vascular disease
Confirmed by: associated cranial nerve abnormalities,
long tract signs
Posterior fossa
tumor
Suggested by: mild vertigo of onset over months and
slight nystagmus. Bilateral papilledema. Ipsilateral
absent corneal reflex. Cranial nerve lesions V, VI, VII,
X, and XI. Ipsilateral cerebellar and contralateral
pyramidal signs
Confirmed by: MRI scan showing tumor
Multiple
sclerosis (MS)
Suggested by: sudden onset and central-type nystagmus
(occurs equally in both directions and sometimes
vertically) in young person, other neurological
disturbances, scanning speech, optic atrophy
Confirmed by: other similar neurological episodes
disseminated in time and space and multiple,
enhancing lesions in various parts of nervous system
on MRI scan
Migraine Suggested by: associated headache (vertigo instead of
visual aura)
Confirmed by: resolution and recurrence consistent
with natural history of migraine
Temporal lobe
epilepsy
Suggested by: associated temporal lobe symptoms,
e.g., odd taste, smells, visual hallucinations
Confirmed by: EEG findings
Ramsay Hunt
syndrome
Suggested by: associated ear pain, lower motor
neuron (LMN) facial palsy
Confirmed by: zoster vesicles at the external auditory
meatus or pharynx
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 12 Neurological symptoms
296
Seizure
There is often a history of aura, loss of consciousness, and tonic and
clonic movements.
Some differential diagnoses and typical outline evidence
Febrile
convulsion
Suggested by: young age, especially in childhood and
associated with a febrile illness
Confirmed by: normal EEG and CT scan and no
subsequent recurrence without febrile illness on
follow-up
Idiopathic
epilepsy—new
presentation
Suggested by: young age, especially in teens
Confirmed by: abnormal or normal EEG and normal
CT scan but subsequent recurrence
Known idiopathic
epilepsy
Suggested by: history of previous seizures
Confirmed by: PMH of past investigations and on
treatment
Brain tumor Suggested by: older age (but any age), headaches,
papilledema.
Confirmed by: CT or MRI scan showing cerebral
mass
Epilepsy due to
meningitis
Suggested by: fever, neck stiffness
Confirmed by: CT scan and lumbar puncture
Epilepsy due to
old brain scar
tissue
Suggested by: past history of serious head injury,
or stroke
Confirmed by: abnormal EEG, CT or MRI brain scan
Alcohol
withdrawal
Suggested by: recent heavy alcohol intake (usually
superimposed on habitually high intake)
Confirmed by: subsequent episodes in similar
circumstances
Hypoglycemia
from too much
insulin in a diabetic,
or insulinoma
Suggested by: sweating, hunger ± known diabetic on
insulin or medication
Confirmed by: blood glucose d (<40 mg/dL) during
episode
Sudden severe
hypotension
(especially
cardiac arrest)
Suggested by: peripheral and central cyanosis, no
pulse or BP
Confirmed by: ECG shows asystole or ineffectual fast
or slow rhythm (or electromechanical dissociation)
SEIZURE1
297
Severe
electrolyte
disturbance
due to very high
or low sodium,
calcium,
magnesium, etc.
Suggested by: abnormality on serum biochemistry
Confirmed by: no recurrence of seizures after
metabolic abnormality treated
“Functional”
seizure (pseudo-
seizure)
Suggested by: always occurring in front of audience,
eyes closed during episode
Confirmed by: normal EEG when episode
documented on video recording. Normal CT scan
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 12 Neurological symptoms
298
Transient neurological deficit
There is sudden dysphasia, with facial or limb weakness resolving within
24 hours.
Some differential diagnoses and typical outline evidence
Transient
cerebral
ischemic attack
TIA from
thromboembolus
or due to carotid
artery stenosis or
vasculitic
process
Suggested by: onset over minutes and then immediate
improvement with prospect of complete resolution
within 24 hours ± carotid bruit
Confirmed by: resolution within 24 hours, absence of
previous seizure, no throbbing migrainous headache,
no chest pain, normal ECG and troponin after
12 hours, normal plasma sodium, normal blood sugar,
no witnessed seizures and normal CT or MRI scan.
Doppler ultrasound of carotids (to seek operable
stenosis). ESR or CRP i (if there is a vasculitic
process, e.g., cranial arteritis)
Atrial fibrillation
with cerebral
embolus
Suggested by: Irregularly irregular pulse
Confirmed by: irregularly irregular QRS complexes, no
P wave on ECG
Intracerebral
space–occupying
lesion: tumor,
aneurysm
hematoma,
arteriovenous
malformation
Suggested by: associated headache
Confirmed by: CT or MRI scan appearance
Transient
hypotension
due to
arrhythmia or
myocardial
infarction
Suggested by: history of chest pain or PMH of IHD
Confirmed by: ECG: ST
changes. iTroponin. 24-hour
ECG: recurrence of arrhythmia
Todd’s paralysis
(following
seizure)
Suggested by: witness’s history of seizure
Confirmed by: EEG changes
TRANSIENT NEUROLOGICAL DEFICIT1
299
Migraine Suggested by: associated headache (neurological deficit
instead of visual aura)
Confirmed by: resolution consistent with other features
of migraine
Hypoglycemic
episode
Suggested by: a known diabetic and associated sudden
hunger, sweating, confusion
Confirmed by: blood glucose <40 mg/dL
Hyponatremia Suggested by: dd sodium concentration
(e.g. <120 mmol/L) and d serum osmolality.
Associated confusion
Confirmed by: resolution of deficit as sodium
concentration and osmolality abnormality corrected
Multiple
sclerosis (MS)
Suggested by: sudden-onset and central-
t
ype nystagmus
(occurs equally in both directions and sometimes
vertically) in young person, other neurological
disturbances, scarring speech, optic atrophy
Confirmed by: other similar neurological episodes
disseminated in time and space and multiple,
enhancing lesions in various parts of nervous system
on MRI scan
Psychological
(no neurological
deficit)
Suggested by: past history of similar episodes from
young (<30 years) age
Confirmed by: absence of any objective evidence of
physical cause of deficit on follow-up
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 12 Neurological symptoms
300
Fatigue, “tired all the time”
This is generally a poor lead, but consider the following.
Some differential diagnoses and typical outline evidence
Depression Suggested by: early-morning wakening, fatigue worse in
the morning that never goes away during the day,
anhedonia, poor appetite
Confirmed by: response to psychotherapy or
antidepressants
Sleep apnea
syndrome
Suggested by: frequent awakening at night, snoring and
breathing pauses during sleep (history from a sleeping
partner), and sleepiness during the day
Confirmed by: multiple dips in PO
2
or O
2
saturation
while asleep during home or sleep lab monitoring
Drug-induced Suggested by: taking sedating drug, including antiepilep-
tic treatment
Confirmed by: improvement by stopping or changing
drug
Postviral
fatigue
Suggested by: history of recent viral illness, especially
glandular fever
Confirmed by: resolution after weeks or months
Diabetes
mellitus
Suggested by: thirst, polyuria, polydipsia, family history
(but all may be absent)
Confirmed by: fasting blood glucose
≥140 mg/dL on
two occasions OR fasting, random, or GTT glucose
≥200 mg/dL in combination with symptoms
Chronic
fatigue
syndrome (CFS)
Suggested by: (1) impaired memory and concentration
unrelated to drugs or alcohol use, (2) unexplained
muscle pain, (3) polyarthralgia, (4) unrefreshing sleep,
(5) postexertional malaise lasting over 24 hours,
(6) persisting sore throat not caused by glandular fever,
(7) unexplained tender cervical or axillary nodes
Confirmed by: 4/7 or more of the above present for
>6 months
Poor sleep habit Suggested by: long work hours, little sleep, insomnia
Confirmed by: sleep diary and improvement with better
sleep habits
Parasomnias Suggested by: restless legs, cataplexy, narcolepsy, and
day-time somnolescence
Confirmed by: response of symptoms to stimulant
medication
Chapter 13
301
Neurological signs
Examining the nervous system 302
Disturbed consciousness 303
Best motor response 304
Best verbal response 305
Eye opening 305
Speech disturbance 306
Dysarthria 307
Anosmia (absent sense of smell) 308
Abnormal ophthalmoscopy 310
Ophthalmoscopic findings in the diabetic patient 312
Ophthalmoscopic findings in the hypertensive patient 314
Loss of central vision and acuity only 316
Peripheral visual-field defect 318
Ptosis (drooping of one or both upper eyelids) 320
Large (mydriatic) pupil with no ptosis 322
Small (miotic) pupil with no ptosis 323
Squint and diplopia: ocular palsy 324
Loss of facial sensation 325
Jaw muscle weakness 326
Facial muscle weakness 328
Loss of hearing 330
Abnormal tongue, uvula, and pharyngeal movement 331
Multiple cranial nerve lesions 332
Odd posture of arms and hands at rest 333
Fine tremor of hands 334
Coarse tremor of hands 335
Wasting of some small muscles of hand 336
Wasting of arm and shoulder 338
Abnormalities of arm tone 339
Weakness around the shoulder and arm without pain 340
Incoordination on rapid wrist rotation or hand
tapping (dysdiadochokinesis) 341
Muscle wasting 342
Weakness around one lower limb joint 343
Bilateral weakness of all foot movements 344
Spast
i
c paraparesis 345
Hemiparesis (affecting arm and leg) 346
Disturbed sensation in upper limb 347
Diminished sensation in arm dermatome 348
Diminished sensation in the hand 349
Disturbed sensation in lower limb 350
Brisk reflexes 352
Diminished reflexes 353
Gait abnormality 354
Difficulty in rising from chair or squatting position 356
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Соседние файлы в папке Библиотека им академика М.И. Перельмана