| III. Physical Examination | III. 體格檢查 |
A. A. General: mental status, temperature, hydration status,
pallor, or cyanosis.
B. Vital signs: tachycardia, bradycardia, irregularity, or
orthostatic hypotension.
C. Cardiovascular: heart sounds, murmurs, bruits, edema,
rales, and pulses.
D. Neurologic: cranial nerves, reflexes, strength and
sensation, tremor, Romberg's sign, gait, and cerebellar
signs | A. 一般檢查：心理狀態(tài)、體溫、水合狀況、蒼白和發(fā)紺。
B. 生命體征：心動(dòng)過(guò)速、心博徐緩、不規(guī)則及直立性低血壓。
C. 心血管：心音、雜音、嘈聲、水腫、羅音、脈博。
D. 神經(jīng)性：顱內(nèi)神經(jīng)、反射、力度和感覺(jué)、震顫、Romberg’s體征、步態(tài)和腦部體征?！?/td> |
| IV. Testing | IV. 實(shí)驗(yàn)室檢查 |
| A. Electrocardiogram （ECG） | A. 心電圖（ECG） |
| The most important single initial test to evaluate syncope is the ECG; it is easy and inexpensive and can quickly identify life-threatening arrhythmias or ischemia. Although the diagnostic yield is only 5%, if the ECG is normal, ischemia, arrhythmias, and organic heart disease are very unlikely. If the ECG is abnormal but does not clearly demonstrate a likely cause for syncope （complete heart block or runs of ventricular tachycardia, for example）, other tests are needed to clarify the underlying problem that may be related to the syncope. The result of the ECG, therefore, helps to direct the course of further workup. | 開(kāi)始檢查暈厥時(shí)最重要的單項(xiàng)初始實(shí)驗(yàn)室檢查是ECG。這種方法簡(jiǎn)便價(jià)廉、可迅速識(shí)別對(duì)生命有威脅的心律不齊或局部缺血。雖然陽(yáng)性診斷率僅5%，只要ECG正常，也基本能排除心肌局部缺血、心率不齊和器質(zhì)性心臟病。如果ECG檢查異常，但無(wú)法清楚地驗(yàn)證暈厥的潛在原因（如完全性傳導(dǎo)阻滯或室性心動(dòng)過(guò)速），就需要進(jìn)行其他檢查，以澄清與暈厥相關(guān)的潛在疾病。因此，ECG結(jié)果有助于指導(dǎo)進(jìn)一步的檢查?！?/td> |
| B. Cardiac monitors | B. 心臟監(jiān)測(cè) |
1. Holter monitor or telemetry performed for 24 hours. For patient with organic heart disease, this gives a diagnostic yield of from 2% for arrhythmias correlated to symptoms to 21% with unrelated arrhythmias. Extending this monitoring to 72 hours is not useful.
2. A loop event monitor is a portable, prolonged ambulatory event recorder indicating if there is recurrent syncope and no organic heart disease （yield = 24% to 47%）. | 1. 進(jìn)行24小時(shí)動(dòng)態(tài)心電監(jiān)測(cè)或遠(yuǎn)程監(jiān)測(cè)。對(duì)器質(zhì)性心臟病患者，這種檢查能診斷2%的有癥狀心律失常和21%的無(wú)癥狀心律失常。將監(jiān)測(cè)時(shí)間延長(zhǎng)至72小時(shí)并無(wú)意義。
2. 記憶環(huán)心血管事件監(jiān)測(cè)器是一種便攜式、可長(zhǎng)時(shí)間記錄病人活動(dòng)時(shí)心血管事件的裝置，可以表明是否有復(fù)發(fā)性暈厥與器質(zhì)性心臟?。ㄔ\斷率為24%至47%）?！?/td> |
| C. Electrophysiologic studies. | C. 電生理檢查 |
| This invasive cardiac monitoring and arrhythmia induction procedure gives a 50% diagnostic yield for those with organic heart disease or abnormal ECG （compared with 10% if no organic heart disease）. This is considered the gold standard for arrhythmia diagnosis but it is expensive and invasive. Powerful predictors of a positive test are an ejection fraction less than 40%, bundle branch block, or atrial fibrillation. | 電生理檢查是一種有創(chuàng)心臟監(jiān)測(cè)與心律失常誘發(fā)手段，對(duì)器質(zhì)性心臟病或ECG異?；颊哌M(jìn)行檢查時(shí)，其診斷率為50%（無(wú)器質(zhì)性心臟病患者的診斷率為10%）。它是心律失常診斷的金標(biāo)準(zhǔn)。只是價(jià)格貴，且是有創(chuàng)性的。對(duì)射血分?jǐn)?shù)小于40%及束支傳導(dǎo)阻滯或房性纖顫的陽(yáng)性檢查效果最好?！?/td> |
| D. Tilt table testing | D. 傾斜試驗(yàn) |
| Tilt table testing is indicated for unexplained, recurrent syncope when arrhythmia or organic heart disease is excluded and neurocardiogenic syncope is suspected. In this setting, the sensitivity is 67% to 83% and specificity is 90%. | 在排除心律失?；蚱髻|(zhì)性心臟病并懷疑有神經(jīng)心源性暈厥時(shí)，就需要進(jìn)行傾斜試驗(yàn)，以對(duì)不明因復(fù)發(fā)性暈厥作出診斷。此項(xiàng)檢查的敏感性為67%～83%，特異性是90%?！?/td> |
| E. Echocardiogram and stress | E. 心臟超聲和運(yùn)動(dòng)負(fù)荷試驗(yàn) |
| Echocardiogram and stress tests are used only to evaluate exertional symptoms （echo first in this case） or suspected organic heart disease. | 心臟超聲和運(yùn)動(dòng)負(fù)荷試驗(yàn)僅用于檢查勞力性癥狀（首選超聲）或可疑性器質(zhì)性心臟病。 |
| F. Computed tomography | F. CT掃描。 |
| Computed tomography scan is used to evaluate focal neurologic signs. | CT掃描用于檢查局灶性神經(jīng)病學(xué)體征?！?/td> |
| G. Electroencephalogram | G. 腦電圖（EEG） |
| Electroencephalogram is indicated for seizure activity only. | 腦電圖僅用于癲癇發(fā)作情況檢查?！?/td> |
| H. Carotid massage | H. 頸動(dòng)脈按摩。 |
| Consider this if the patient is aged more than 60 years with unexplained syncope. Perform in the clinic if no bruits, ventricular tachycardia, recent stroke, or myocardial infarction. | 如病人年齡超過(guò)60歲并伴有不明因暈厥時(shí)可考慮此手法。如無(wú)心臟雜音、室性心動(dòng)過(guò)速、新近中風(fēng)或心梗，可在門(mén)診進(jìn)行。 |
| I. Blood tests | I. 血液檢查。 |
| Blood tests, including hematocrit, serum chemistries, and pregnancy test, are not for screening; order only if a specific medical condition is suspected. | 血液檢查包括血細(xì)胞比容、血清化學(xué)和妊娠檢查。血液檢查不用于篩檢。僅在懷疑有特定疾病時(shí)使用?！?/td> |
| J. Psychiatric evaluation | J. 精神病檢查。 |
| Psychiatric evaluation is useful in the setting of a high recurrence rate in a young patient without resultant injuries and no evidence of organic heart disease. | 若年輕患者暈厥復(fù)發(fā)率高且未導(dǎo)致?lián)p傷、無(wú)器質(zhì)性心臟疾病時(shí)，作精神病學(xué)檢查很有效?！?/td> |
| V. Diagnostic assessment | V. 診斷評(píng)估。 |
| The keys to the diagnosis of syncope are the history, physical examination, and ECG, yielding a diagnosis 45% of the time. The history and physical should focus on cardiac, neurologic, and medication-related issues. Directed testing can add 8% to diagnosis. Further classification by age and presence of organic heart disease can help focus evaluation and treatment. If organic heart disease is present or the ECG is abnormal, inpatient telemetry monitoring and electrophysiologic studies are recommended. If organic heart disease is not evident, ambulatory loop ECG and psychiatric evaluations are indicated, as well as possible tilt table testing. | 診斷暈厥的關(guān)鍵是病史、體格檢查和ECG，診斷率可達(dá)45%。病史和體檢的重點(diǎn)是心臟、神經(jīng)和藥物相關(guān)問(wèn)題。定向檢查可使診斷效率提高5%，進(jìn)一步區(qū)分年齡和有無(wú)器質(zhì)性心臟病有助于突出評(píng)價(jià)和治療。如有器質(zhì)性心臟病或ECG異常，住院患者可進(jìn)行遠(yuǎn)程監(jiān)測(cè)和電生理檢查。如器質(zhì)性心臟病不明顯就需要進(jìn)行環(huán)路動(dòng)態(tài)ECG和精神病學(xué)評(píng)估，可能的話再進(jìn)行傾斜試驗(yàn)。 |
| Although most syncope patients can be evaluated in the outpatient setting, hospitalization is recommended for those with organic heart disease, chest pain, a history or suspicion of arrhythmia, or presence of neurologic symptoms or signs suggesting transient ischemic attack or stroke. The extent of severity of the organic heart disease is the key determinant of mortality and should direct evaluation and therapy. Despite extensive evaluation and testing, the diagnosis may still be elusive in approximately 40% of patients with recurrent syncope, but fortunately these patients have a low incidence of morbidity and mortality. | 雖然多數(shù)暈厥患者可在門(mén)診部檢查，但對(duì)器質(zhì)性心臟病、胸痛、有或疑有心律失?；颊?、或神經(jīng)學(xué)癥狀體征提示有暫短性心肌局部缺血和中風(fēng)發(fā)生，建議住院檢查。器質(zhì)性心臟病嚴(yán)重程度是死亡率的決定因素，應(yīng)指導(dǎo)檢查并治療。盡管有廣泛的評(píng)估檢查，但仍有40%的復(fù)發(fā)性暈厥患者會(huì)漏診，幸運(yùn)的是，這些病人的死亡率和發(fā)病率都很低。 |
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