24.3 🩺 內科專科考前版

R2-R3 / Fellow 等玚。

24.3.0.1 📌 䞀頁重點敎理

  • 22E 匷調HINTS 是 ED bedside skill > 早期 MRI for cerebellar stroke
  • Vestibular migraine ICHD-3 criteria established
  • Persistent Postural-Perceptual Dizziness (PPPD) 被認可
  • TaiwanMéniÚre 健保條件、vestibular rehab 埩健科

24.3.0.2 📜 22E vs 21E 差異

項目 21E 22E
HINTS exam 提 匷化 + > MRI within 24h
Vestibular migraine 略 詳述 ICHD-3
PPPD — 新增
Cerebellar stroke management 提 匷化 swelling monitoring

24.3.0.3 🧠 深床機蜉

24.3.0.3.1 Vestibular System
  • 3 semicircular canals + 2 otolith organs (utricle, saccule)
  • CN VIII vestibular branch
  • äž­æšž vestibular nuclei → 小腊、cortex、ocular motor
  • VOR (vestibulo-ocular reflex) maintains gaze
24.3.0.3.2 BPPV 機蜉
  • Otoconia (calcium carbonate crystals) 埞 utricle 鬆動
  • 跑進 semicircular canal (90% 埌管)
  • 重力圱響 + endolymph flow → cupula deflection → vertigo
24.3.0.3.3 Cerebellar Stroke
  • PICA / AICA / SCA 血管領域
  • AICA 也垞合䜵內耳 ischemia → 停呚邊 pattern
  • Swelling peak 48-72h → 死亡率高
24.3.0.3.4 Vestibular Migraine
  • ICHD-3 criteria
  • Recurrent vertigo + migraine Hx + temporal association
  • Treatment 同 migraine
24.3.0.3.5 PPPD (Persistent Postural-Perceptual Dizziness)
  • Chronic > 3 個月
  • Subjective unsteadiness
  • 倚 anxiety / acute vestibular event 埌
  • Treatment: vestibular rehab + SSRI

24.3.0.4 💊 進階治療

24.3.0.4.1 BPPV
  • Epley (posterior canal)
  • Semont
  • Brandt-Daroff (home)
  • Lateral canal: BBQ roll / Gufoni
24.3.0.4.2 Vestibular Neuritis
  • Methylprednisolone early (1 mg/kg)
  • Vestibular rehab > BZD long-term
24.3.0.4.3 MéniÚre
  • 1st: low salt + diuretic
  • 2nd: betahistine (efficacy uncertain)
  • 3rd: intratympanic steroid (dexamethasone)
  • 4th: intratympanic gentamicin (vestibular ablation, hearing loss risk)
  • Surgical: endolymphatic sac decompression, vestibular nerve section, labyrinthectomy
24.3.0.4.4 Vestibular Migraine
  • Trigger avoidance
  • Acute: triptans, NSAID
  • Prevention: BB, TCA, topiramate, CGRP mAb
24.3.0.4.5 Cerebellar Stroke
  • ICU + serial neuro
  • Decompressive surgery if swelling
  • Antiplatelet / statin / risk factor control

24.3.0.5 🌟 Clinical Pearls (10 條)

  1. 「Ask: 䜠芺埗怎暣的暈?」 必先分類
  2. HINTS 圚 acute vestibular syndrome 比 MRI 敏感
  3. Peripheral nystagmus suppress with fixation vs central does not
  4. AICA stroke 可停 peripheral合䜵 inner ear
  5. PPPD 越䟆越被認識 as chronic dizziness
  6. Vestibular rehab evidence-based
  7. BZD 短期 only
  8. Cerebellar swelling at 48-72h = ICU monitor
  9. 䞍胜因 DWI - rule out stroke within 24h
  10. Vestibular migraine 是 chronic dizziness 重芁原因

24.3.0.6 🔍 特殊情境

24.3.0.6.1 1. 老人 dizziness
  • Multi-sensory
  • Polypharmacy
  • BPPV + presyncope + neurologic 同時可胜
  • 跌倒颚險高
24.3.0.6.2 2. ICU dizziness
  • 倚 multi-factorial
  • Drug, electrolyte, 重芁 r/o stroke
24.3.0.6.3 3. 劊嚠 dizziness
  • 倚 vasovagal / hypoglycemia
  • Avoid medications
24.3.0.6.4 4. 兒童 dizziness
  • Migraine equivalent
  • Vestibular paroxysmia
  • 兒科神經會蚺

24.3.0.7 📍 台灣 Context

24.3.0.7.1 健保
  • 急性 vertigo: ED workup
  • MéniÚre 治療健保
  • Audiogram: 健保
  • MRI vertigo: 條件絊付
24.3.0.7.2 台灣
  • Vestibular rehab 埩健科
  • 耳錻喉、神經科、埩健科協同

24.3.0.8 ⚠ 老闆地雷區

  1. 老人 vertigo 党當 BPPV
  2. Acute vestibular syndrome 䞍做 HINTS
  3. BPPV 䞍做 Epley
  4. BZD 長期
  5. äž­æšž vertigo 䞍 MRI
  6. AICA stroke 停 peripheral 挏
  7. MéniÚre 絊 BZD 䞻治
  8. Vestibular migraine 挏蚺

24.3.0.9 🎓 內專考重點預枬

  1. 4 類頭暈
  2. HINTS exam
  3. BPPV + Epley
  4. MéniÚre + 治療
  5. Cerebellar stroke
  6. Vestibular migraine
  7. PPPD22E
24.3.0.9.1 跚章節敎合
  • Ch 23 Syncope
  • Ch 28 Gait
  • Ch 36 Hearing
  • Ch 439 Stroke
  • Ch 441 Migraine

24.3.0.10 📖 延䌞閱讀

  • AAO-HNSF BPPV Clinical Practice Guideline
  • Bárány Society Vestibular Migraine Diagnostic Criteria (ICHD)
  • AAN Vestibular Neuritis
  • AHA Stroke Guidelines

24.3.0.11 📚 䞉階段教材玢匕

⚠ AI 草皿。