【App】神經科必備神器－Neuro Localizer
讀書嘅時候，neuro嘅PE我覺得係為內科四大system（其餘為abdominal，cardi，respi）之中最難掌握好嘅一門學問。佢嘅難處在於唔似其他系統嘅sign通常都比較容易理解，有冇hepatomegaly，有冇murmur，有冇wheeze等等都係比較客觀嘅sign，而又相對容易interpret；而neuro就係做完一大餐exam之後，重要諗諗諗去組織究竟點樣interpret啲signs。你捉到個sign都要識脫角先有用。回想當時上某教授（佢都喺呢個blog出現過XD）嘅bedside或者lecture，每次都獲益良多，除咗學手勢，重要學諗嘢嘅方法，點樣做只係基本要求，點樣諗先係精髓所在。
今日趁年尾又差唔多要進入大直路準備考final MB嘅時間啦，又介紹一個無論student或者in practice醫生都會啱用嘅neurology app－Neuro Localizer. 簡單嚟講呢個由The University of Michigan設計嘅app就係可以俾你輸入病人嘅clinical signs／symptoms而佢會幫你推斷出病人邊度有問題。
例子：57／F HT DM presented with left hemiparesis and UMN left facial palsy.
你可以喺薑餅人上面選擇有問題嘅部份，在選擇問題性質。
可以選擇嘅地方包括eye，face，upper同lower limbs。每個地方通常都係有weakness，numbness同reflex嘅選擇。Weakness就有得揀邊組動作weak，而numbness就有得揀邊種sensation出問題 ie. pain/temperature vs vibration/proprioception, 再揀埋dermatome或者area。eye就因為多啲嘢睇，例如pupil同gaze，所以會有比較多sign揀。
輸入完之後可以到view／delete sign確認。留意當你每輸入一個sign，個app都會顯示出該地方嘅neural pathway。撳去localizations就可以睇到有機會出問題嘅地方，當然呢個例子就好簡單啦，right cerebral hemisphere, midbrain同pons都有可能。
如果想進一步確認病灶，你可以撳去suggestions，佢會提議你做更多嘅檢查去確認有問題嘅地方。如果呢個case你發現到both eyes deviated to the left，咁個app就會答你個問題好有可能出自right pons。通常如果係cortical problem patient looks towards the lesioned side，所以clinically left sided lesion。如果佢唔望住right side，咁就好有可能係right pons。
其實做做下見識多啲，隨著經驗嘅累積，好多時候呢啲檢查都已經熟能生巧，唔駛諗好耐都interpret到。
最後送上我做學生時好鍾意用嘅"Brainstem rules of 4s"，對於當時未有app嘅我要interpret brainstem嘅sign都好有幫助。考試都無app架，唯有記下啲rules啦！
呢個app有得對答案，對學習neurology嘅過程好有幫助，互相出啲題目考下大家抽下書，訓練下腦袋，用熟咗啲rules，慢慢唔使靠個app都interpret到啦！
rule 1. 4 midline structures starting with "m"
1. motor corticospinal tract (contralateral weakness)
2. medial lemniscus (contralateral proprioception)
3. medial longitudinal fasciculus (ipsilateral internuclear ophthalmoplegia)
4. motor cranial nerve nuclei (3, 4, 6, 12; factors of 12)
rule 2. 4 side structures starting with "s"
1. spinocerebellar (ipsilateral ataxia)
2. spinothalamic (contralateral pinprick)
3. sensory cranial nerve 5
4. sympathetics (ipsilateral Horner's syndrome)
rule 3. 4 cranial nerves in medulla, 4 in pons, 4 above pons (2 in midbrain)
* above pons: 1, 2, 3, 4 (3 and 4 in midline of midbrain)
* pons: 5, 6, 7, 8 (5 on side, 6 in midline)
* medulla: 9, 10, 11, 12 (12 in midline)
rule 4. 3, 4, 6, 12 are in midline
Gates, P. (2005), The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular syndromes for the non-neurologist. Internal Medicine Journal, 35: 263–266. doi: 10.1111/j.1445-5994.2004.00732.x
http://lifeinthefastlane.com/brainstem-rules-of-4/
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