Part XXV - NEUROLOGY
第八分册——神经系统疾病
Section - Evaluation of the Patient
病人评估
Chapter 438 - APPROACH TO THE PATIENT
第438章——诊疗途径
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.
神经系统症状是大多数正常人每天都能体验到的一些情况。像口误(slips of the tongue)、头痛、背痛和其他疼痛、头晕、肌肉抽搐或抽动、痉挛性震颤等，都是完全健康者也可能发生的。情感波动时的喜气洋洋或郁郁寡欢、妄想、发怒等，也是完全正常者可能出现的。神经系统疾病认识的迅速提高，以及医疗活动与各界人士的密切关系，使得常见和罕见情况都能引起公众的关注。
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.
很多老人都在关心自己或其配偶是否已有或正在发生Alzheimer病(早老性痴呆)和中风；面老人几乎都有的震颤，则会带来Parkinson病的忧虑。很多年龄较轻的病人关心自己是否有多发性硬化和脑肿熘，而且正常人几乎都可能有一两种提示严重神经系统疾病的症状。像这些和其他常见病变症状初见时，影像检查和其他试验往往都是正常的．但病人和医生却不能以此自慰，掉以轻心。另一方面，神经诊断性影像、生化、电生理和遗传检查，又能从很多年轻和大多数老人中发现“异常改变”。在对病人症状进行评估时，重要的是不能依托神经诊断性实验室检查结果来建立临床诊断。像头痛、声虑及抑郁之类病变。实验室检查一般并无异常。而由各种神经诊断性检查发现的异常，往往是伴随性的，对此进行治疗可能是正确和必要的。但却不能使病人症状获得改善。没有症状或体征而偶然检测到的异常，像高血压之类病变时，可能需要积极追查和冶疗，但是很难使无症状病人得到改善的一般性规律，是应该记取的。因此对老年病人来说，没有什么影像或电生理检查可以评估为“正常”，但是如果没有与此“异常发现”相应的特异症状，则治疗甚至进一步检查也只是对检查的敏感性和特异性进行评估，以及病人需要和受惠于治疗的可能性。在没有特异诊断至少是鉴别诊断方面的考虑时，不要轻动神经诊断检查(或参照其检查结果)，是一条很好的经验。
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.
让病人用自己的语言叙述症状是很重要的。为充分了解病人谈到的情况，常须直接提出—些问题，但是不熟悉医学术语的病人，往往把这些提示性术语或描述词记在心里，下次就诊时照样搬用。记录症状一定要用病人自己的语言。像走路发拐、虚弱、麻木、发沉、痉挛、疲困之类的辞语，对某些病人来说，可能是用来分别反映疼痛、软弱或感觉异常。 www.med126.com
Chapter 439 - THE NEUROLOGIC HISTORY
第439章——神经病史
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.
神经病史是神经病诊断中最重要的资料。细致的病史常能决定病因，确定损害所在部位，还能协助确定病变是局灶性还是弥漫性的。急性起病的症状，提示血管性或为癫痫发作；亚急性症状提示质块性损害如肿瘤或脓肿；症状起伏波动，有加剧也有缓解，提示失髓鞘性病变；慢性和进行性症状则提示变性类疾病。
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:
神经系统检查正常或无局灶性征象的神经系统病变，往往只能通过病史来诊断，包括很多癫痫发作性病变、偏头痛和其他大多数类型的头痛证候、各种病因性头晕以及大多数类型的痴呆等。神经病史往往还是提示症状系精神性原因所致的最先线索。以下是收集神经病史时要注意的一些要点：医学 全在.线提供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.
仔细确定主诉或主要问题。主诉（chief complaint)不但在鉴别诊断上是为医生提供的首先线索，还是病人趋医求治的原因。如主诉未被正确确定，正确诊断就可能失之交臂，以致可能在错误的途径上追索诊断。没有纳入主诉的诊断，往往不是病人当前真正关注的问题，而是落脚在伴随的病变上。
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.
以充分的时间倾听病人的陈诉。接诊开始，至少应有5分钟时间让病人不被打断地尽情诉述，是一条很好的工作方法。病人长会在病史陈述的开始，自动把最重要的信息吐露出来。医生则可在这个时间，观察病人的精神状态，包括语言、知识水平和情绪，注意面部是否对称、眼睛运动有无异常、自发性运动增加还是减少（如运动性病变)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.
正确引导病人，不去讨论过去诊断性检查结果和保健医生的意见。须知实验室检查结果异常，对病人的主要问题可能只是偶合关系，也可能是正常变异。
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、服药史、精神病史、家族史以及社会和职业史。很多神经病是内科疾病的合并症，或者是药物的不良反应。如帕金森神经功能障碍（parkinsonism)往往是应用甲氧氯普胺（metoclopramide)的合并症，神经安定药大多已有此反应。很多神经性病变都有遗传性，很多病例都可能有阳性家族史而确立诊断。职业亦可在一些神经病史中起到主要作用，如弯管综合征（carpal tunnel syndrome)（电脑键盘操作员)和末梢神经病（接触铅及其他毒素)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.
会见病史代述者。痴呆和意识状态失常的病人，一般不能提供翔实、完成的病史，须由知情家属提供要点，以利正确诊断。特别是痴呆和某些右半球损害而又不同程度认识障碍（agnosias)（不能察觉疾病)的患者，不能提供确切病史，更须有人代诉。发作性意识部分缺失者（如晕厥和癫痫发作)也须有人代诉遗漏的病史。
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.
为病人总结病史。总结病史是一项很有效的方法，肯定确已获得作出印象诊断所需的各项重要资料。总结归纳，还能是医生补充最初采取病史时可能很明确的病史缺陷。病人或代诉者还可在此时纠正病史中的一些错误信息。
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.
请病人说出自觉何系病变，结束病历问询。此举可使医生对病人关心和认识到的问题有所了解。有些病人是心怀某一特定诊断而来就诊求索的，如病人往往怀疑自己的神经症症状，是由于多发性硬化、Alzheimer病和脑肿瘤之类病变所致。
