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Bulletin of the North - Eastern Neuroscience Association
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Alteration of Consciousness
Cognitive Deficits and Polymorphism of Apolipoprotein E in
Alzheimer’s Disease
FAQs
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ÃÙÊé ¡Ö µÑÇ «Ö§è ¤ÇÒÁÃعáç¢Í§ÍÒ¡ÒùÕàé »ç¹ä»ä´éµ§éÑ áµè¹Íé Â仨¹¶Ö§ÁÒ¡´Ñ§¹Õé ¤×Í drowsy ,
Alteration of Consciousness stupor , semicoma ¨¹¶Ö§ coma µÒÁÅӴѺ ÀÒÇйÕàé »ç¹ÀÒÇЩءà©Ô¹·Ò§»ÃÐÊÒ·ÇÔ·ÂÒ
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¡ÅØÁè §Ò¹ÍÒÂØáÃÃÁ âç¾ÂÒºÒÅÊÃþÊÔ·¸Ô»ÃÐʧ¤ì ÍÓàÀÍàÁ×ͧ ¨Ñ§ËÇÑ´ÍغÅÃÒª¸Ò¹Õ ÇÔ¹¨Ô ©ÑÂáÅСÒÃÃÑ¡ÉÒä´é¶¡Ù µéͧáÅзѹàÇÅÒ ¡ç¨ÐÊÒÁÒöŴÍѵÃÒµÒÂËÃ×ͤÇÒÁ¾Ô¡Ò÷Õè
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»ÃÐÊÒ·ÇÔ·ÂÒ á¾·Âì¼ãéÙ Ëé¡ÒôÙáÅÃÑ¡ÉҨеéͧµÃǨÇÔ¹¨Ô ©ÑÂËÒÊÒà˵ط·èÕ ÓãËé¼»éÙ Çè ÂÁÕÃдѺ tical alerting system ·ÕÃè ¨éÙ ¡Ñ ¡Ñ¹´Õ㹪×Íè ÇèÒ reticular activating system (RAS) ¾ÂÒ¸ÔÊÀÒ¾
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àÍç¡«àÃÂì¤ÍÁ¾ÔÇàµÍÃìÊÁͧ ¤Ç÷Óã¹ÃÒ·ÕÊè §ÊÑÂÇèÒ¨ÐÁÕ¾ÂÒ¸ÔÊÀÒ¾ã¹ÊÁͧËÃ×ÍʧÊÑ «Ö§è ÍÒ¨à»ç¹¨Ò¡ÂÒ , ÊÒþÔÉ ËÃ×ͤÇÒÁ¼Ô´»¡µÔ·Ò§àÁµÒºÍÅÔ¡ à»ç¹µé¹
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ÊÒà˵ط¨èÕ Óà¾ÒÐ¹Ñ¹é ¨ÐªèÇÂãËé¼Å¡ÒÃÃÑ¡ÉÒ´ÕáÅÐÅ´¡ÒÃà¡Ô´ÀÒÇÐá·Ã¡«é͹ä´é Approach to the patient
ÀÒÇзÕÁè ¡Õ ÒÃà»ÅÕÂè ¹á»Å§ÃдѺ¤ÇÒÁÃÙÊé ¡Ö µÑÇËÃ×ÍËÁ´ÊµÔ ÁÑ¡¨Ð¾ºÁÕ¤ÇÒÁ¼Ô´
Abstract »¡µÔà¡ÕÂè Çà¹×Íè §¡ÑºÃкº»ÃÐÊÒ· ¡Ò÷ըè ÐÊ׺¤é¹ËÒÊÒà˵آͧÀÒÇйըé ÓµéͧÍÒÈÑ·ѡÉÐ
Alteration of consciousness is a common emergency condition that needs ·Ò§´éÒ¹¡Òëѡ»ÃÐÇÑµÔ ¡ÒõÃǨÃèÒ§¡ÒÂÍÂèÒ§ÅÐàÍÕ´ÃÇÁ¶Ö§¡ÒõÃǨ·Ò§Ãкº»ÃÐÊÒ·
prompt medical attention. There are many etiologies of this condition, therefore the ¨Ò¡¹Ñ¹é ¨Ö§µÃǨ·Ò§Ëéͧ»¯ÔºµÑ ¡Ô ÒÃà¾×Íè ÇÔ¹¨Ô ©Ñ¶֧ÊÒà˵ط¹èÕ Òè ¨Ðà»ç¹»Ñ-ËÒ·Õ·è ÓãËé¼»éÙ Çè Â
physicians should recognize and find out its cause in every patients. The general äÁèÃÊéÙ ¡Ö µÑÇ
physicians especially who work in the emergency room should have the basic concept »ÃÐÇѵ·Ô ¤èÕ ÇöÒÁà¾×Íè Ê׺ËÒÊÒà赯 ä´éá¡è »ÃÐÇѵ¡Ô ÒÃä´éÃºÑ ÍغµÑ àÔ ËµØËÃ×ͺҴ
of principle in diagnosis, investigation and management of this condition correctly. à¨çº ¡ÒáԹÂÒËÃ×Í¡ÒÃãªéÂÒ ÍÒ¡Ò÷Õàè ¡Ô´ÃèÇÁ¡ÑºÀÒÇÐäÁèÃÊéÙ ¡Ö µÑǢͧ¼Ù»é Çè  ¡ÒÃÍè͹áç
Complete history taking , physical examination and neurologic assessment ¢Í§á¢¹¢Ò »Ç´ÈÕÃÉÐ ä¢é ÍÒ¡Òêѡ ¤Å×è¹äÊéÍÒà¨Õ¹ ÇÔ§àÇÕ¹ÈÕÃÉÐ àËç¹ÀÒ¾«é͹
help us to identify its cause. Proper investigations and specific treatment are the goal »ÃÐÇѵ¡Ô ÒÃãªéÊÒÃàʾµÔ´ ¡Òô×Áè ÊØÃÒ áÅлÃÐÇѵâÔ Ã¤»ÃШӵÑÇ à»ç¹µé¹
of management leading to good outcome.
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¡ÒõÃǨÃèÒ§¡ÒÂã¹¼Ù»é Çè ·Õäè ÁèÃÊéÙ ¡Ö µÑÇ¹Ñ¹é ¤ÇûÃÐàÁÔ¹ÊÑ--Ò³ªÕ¾ÍÂèÒ§ÃÇ´àÃçÇ ¡ÒõÃǨÍ×¹è ·Õ¾è ¨Ô ÒóҵÃǨà»ç¹ÃÒÂæä» ¤×Í ¡ÒõÃǨ CT ËÃ×Í MRI brain,
¶éÒ¾ºÇèÒÁÕÀÒÇÐä¢é¨Ð·ÓãËé¹¡Ö ¶Ö§ÀÒÇеԴàª×Íé ÁÒ¡¢Ö¹é àªè¹ systemic infection , meningitis electroencephalogram áÅÐ cerebrospinal fluid (CSF) examination
ËÃ×Í encephalitis à»ç¹µé¹ ÊèǹÀÒÇÐ hypothermia ¾ºÇèÒÍÒ¨ÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸ì¡ºÑ hypogly-
cemia , hypothyroidism , peripheral circulatory failure , alcoholic barbiturate sedative ¡ÒÃÇÔ¹Ô¨©ÑÂá¡âä
ËÃ×Í phenothiazine intoxication, ¤ÇÒÁ´Ñ¹µèÓËÃ×ÍÊÙ§¼Ô´»¡µÔ ¨Ò¡¹Ñ¹é »ÃÐàÁÔ¹ÃкºËÒÂ㨠¡ÒÃÇÔ¹¨Ô ©ÑÂá¡âä㹼ٻé Çè ·Õäè ÁèÃÊéÙ ¡Ö µÑǹѹé ÊÒÁÒö¨Óṡä´éà»ç¹ 3 ¡ÅØÁè
ÃкºËÑÇã¨áÅÐËÅÍ´àÅ×Í´ ¡ÒõÃǨÃèÒ§¡ÒÂÃкºÍ×¹è æ áÅСÒõÃǨÃèÒ§¡Ò·ҧÃкº ´Ñ§¹Õé ¤×Í
»ÃÐÊÒ· 1. âä·Õµè ÃǨäÁ辺ÅѡɳФÇÒÁ¼Ô´»¡µÔ¢Í§Ãкº»ÃÐÊҷ੾ÒзÕè (¡ÒÃ
¡ÒõÃǨÃèÒ§¡Ò·ҧÃкº»ÃÐÊÒ· àÃÔèÁ´éÇ¡ÒûÃÐàÁÔ¹¤ÇÒÁÃعáç¢Í§¡Òà µÃǨàÍç¡«àÃÂì¤ÍÁ¾ÔÇàµÍÃì ¢Í§ÊÁͧáÅмŵÃǨ¹éÓä¢ÊѹËÅѧ»¡µÔ)
ÃÙÊé ¡Ö µÑÇÇèÒà»ç¹ÁÒ¡¹éÍÂà¾Õ§㴠â´Âãªé Glasglow coma scale «Ö§è ÁÕ¤Ðá¹¹àµçÁ 15 ¤Ðá¹¹ 1.1 intoxication : alcohol , sedative drugs , opiates , etc.
¡ÒÃãËé¤Ðá¹¹áºè§à»ç¹ 3 Êèǹ ¤×Í motor response ( 6 ¤Ðá¹¹) , verbal response 1.2 metabolic disturbance : anoxic , uremia , hepatic coma ,
(5 ¤Ðá¹¹) áÅÐ eye opening (4 ¤Ðá¹¹) àÁ×Íè »ÃÐàÁÔ¹ÃдѺ¤ÇÒÁÃÙÊé ¡Ö µÑÇáÅСÒõͺ hypoglycemia à»ç¹µé¹
ʹͧáÅéÇ ¨Ö§µÃǨÃèÒ§¡Ò·ҧÃкº»ÃÐÊÒ··Ñ§é ËÁ´µÑ§é áµè cranial nerve , motor system , 1.3 severe systemic infection : pneumonia , malaria , septicemia
sensory system, meningeal áÅÐ cerebellar signs ·Ñ駹Õéà¾×èÍ»ÃÐ⪹ì㹡ÒÃÇÔ¹Ô¨©ÑÂÇèÒ à»ç¹µé¹
¹èÒ¨ÐÁÕ¤ÇÒÁ¼Ô´»¡µÔã¹Ãкº»ÃÐÊÒ··ÕÃè дѺ㴠ã¹Êèǹ¢Í§ cerebral hemisphere , brain 1.4 shock
stem ËÃ×Í cerebellum áÅФÇÒÁ¼Ô´»¡µÔ·¾èÕ º¹Ñ¹é à»ç¹¢éҧ㴢éҧ˹֧è ËÃ×͹èÒ¨Ðà»ç¹·Ñ§é 2 1.5 postseizure state , subclinical epilepsy , status epilepticus
¢éÒ§ 1.6 hypertensive encephalopathy
¡ÒõÃǨ eye ground à¾×Íè ´Ù fundus ÊÒÁÒöºÍ¡¤ÇÒÁ¼Ô´»¡µÔä´éËÅÒÂâä àªè¹ 1.7 severe hyperthermia , hypothermia
µÃǨ¾º subhyaloid hemorrhage ºè§¶Ö§ subarachnoid hemorrhage , µÃǨ¾º exudate 1.8 concussion
hemorrhage, vessel – crossing change áÅÐ papilledema ÍÒ¨ªèÇÂ㹡ÒÃÇÔ¹Ô¨©Ñ 1.9 acute hydrocephalus
hypertensive encephalopathy , µÃǨ¾ºÁÕ papilledema ºè§¶Ö§ÇèÒÁÕ increased intracranial 2. âä·Õµè ÃǨ¾ºÁÕ¡ÒÃÃФÒÂà¤×ͧ¢Í§àÂ×Íè ËØÁé ÊÁͧ (ÁÑ¡¨ÐäÁ辺¤ÇÒÁ¼Ô´
pressure »¡µÔ¢Í§Ãкº»ÃÐÊҷ੾ÒзÕè áÅСÒõÃǨàÍç¡«àÃÂì¤ÍÁ¾ÔÇàµÍÃìÊÁͧäÁ辺
ÅѡɳТͧ¡é͹à¹×éÍ)
¡ÒõÃǨ·Ò§Ëéͧ»¯ÔºµÑ ¡Ô Òà (Laboratory studies and imaging) 2.1 subarachnoid hemorrhage
¡ÒõÃǨ·Ò§Ëéͧ»¯ÔºÑµÔ¡ÒÃà¾×èͪèÇÂ㹡ÒÃÇÔ¹Ô¨©ÑÂËÒÊÒà˵طÕè¹èҨзÓãËéà¡Ô´ 2.2 acute bacterial meningitis
¡ÒÃà»ÅÕÂè ¹á»Å§ÃдѺ¤ÇÒÁÃÙÊé ¡Ö µÑÇÁÒ¡·ÕÊè ´Ø µÃǨ»ÃÐàÁÔ¹¤ÇÒÁ¼Ô´»¡µÔ·Ò§àÁµÒºÍÅÔ¡ 2.3 viral encephalitis
ä´éá¡è blood sugar , BUN , creatinine , liver function test , calcium , electrolyte áÅÐ 2.4 meningitis ¨Ò¡ÊÒà˵Ø͹è× æ
toxicologic analysis 㹡óշÊèÕ §ÊÑÂÇèÒä´éÃºÑ ÊÒþÔÉËÃ×Íä´éÃºÑ ÂÒà¡Ô¹¢¹Ò´ 2.5 miscellaneous : fat embolism, cholesterol embolism , cerebritis
à»ç¹µé¹
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3. âä·ÕèµÃǨ¾ºÁÕ¤ÇÒÁ¼Ô´»¡µÔ¢Í§Ãкº»ÃÐÊҷ੾ÒзÕèËÃ×ͤÇÒÁ¼Ô´ ¡ÒôÙáÅÃÑ¡ÉÒ¼Ù»é Çè ·Õäè ÁèÃÊéÙ ¡Ö µÑÇÁÕ¤ÇÒÁÊÓ¤Ñ-ÍÂèÒ§ÁÒ¡·Ò§¡ÒÃá¾·Âì á¾·Âì


»¡µÔ¢Í§¡Ò÷ӧҹ¢Í§¡éÒ¹ÊÁͧ (ÍÒ¨¾ºÁÕ¤ÇÒÁ¼Ô´»¡µÔ¢Í§¹éÓã¹ä¢ÊѹËÅѧ ¡ÒõÃǨ ¨ÐµéͧÊÒÁÒöãËé¡Òô٠áÅÃÑ¡ÉÒàº×Íé §µé¹ä´éÍÂèÒ§¶Ù¡µéͧàËÁÒÐÊÁ ¢éÍÁÙŨҡ»ÃÐÇѵáÔ ÅÐ
àÍç¡«àÃÂì¤ÍÁ¾ÔÇàµÍÃìÊÁͧ¾ºÇèÒÁÕ¤ÇÒÁ¼Ô´»¡µÔ) ¡ÒõÃǨÃèÒ§¡Ò·ÕèÅÐàÍÕ´¶Õè¶éǹ¨ÐªèÇÂ㹡ÒÃá¡ÇèÒÊÒà˵عèÒ¨Ðà¡Ô´¨Ò¡ÀÒÇÐã´ à¾×èÍ
3.1 hemispheric hemorrhage or infarction ¨Ðä´éÊ§è µÃǨ·Ò§Ëéͧ»¯ÔºµÑ ¡Ô ÒÃãËéàËÁÒÐÊÁ ¡ÒÃÃÑ¡ÉÒ·ÕÃè Ç´àÃçǶ١µéͧàËÁÒÐÊÁ¨ÐªèÇÂ
3.2 brainstem hemorrhage or infarction ãËé¼»éÙ Çè ÂËÒÂáÅÐÅ´¡ÒÃà¡Ô´ÀÒÇÐá·Ã¡«é͹ä´é
3.3 brain abscess , subdural empyema
3.4 epidural and subdural hematoma , brain contusion References
3.5 brain tumor 1. Ropper AH. Acute confusional states and coma. In: Fauci AS , Braunwald E ,
3.6 cerebellar infarction and hemorrhage Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, et al , eds. Principles of
3.7 widespread traumatic brain injury internal medicine. New York : McGraw Hill 1998:132–40.
3.8 miscellaneous : cortical vein thrombosis , cerebral vasculitis, 2. Plum F, Posner JB. The diagnosis of stupor and coma, 3rd ed. Philadelphia: F.A.
pituitary apoplexy à»ç¹µé¹ Davis ,1980.
3. Bateman DE. Neurological assessment of coma. J Neurol Neurosurg Psychiatry
ËÅÑ¡¡ÒôÙáżÙé»èÇ 2001;71(suppl 1):i13-i17.
1. Assess and manage : Airway Breathing Circulation 4. Andrefsky JC , Frank JI. Approach to the patient with acute confusional state
2. Draw blood sample and establish IV fluid (Delirium / Encephalopathy). In: Biller J, ed. Practical Neurology. New York:
3. IV glucose if hypoglycemia Lippincott – Heinemann, 1997:3–14.
4. History taking and physical examination 5. Ashla MFM. Delirium. In: Bradley W, Daroff RB, Fenichel GM, Marsden CD,
5. Classify : eds. Neurology in clinical practice. Boston: Butterworth – Heinemann, 2000:25–36.
5.1 diffuse lesion
- nonstructural
- structural or meningeal involvement
5.2 localized lesion
6. Relevant laboratory investigations
7. Give specific treatment
10 ¨ØÅÊÒêÁÃÁ»ÃÐÊÒ·ÇÔ·ÂÒÈÒʵÃìÀÒ¤µÐÇѹÍÍ¡à©Õ§à˹×Í »Õ·èÕ 3 ©ºÑº·Õè 3-4 ( ¡Ã¡®Ò¤Á – ¸Ñ¹ÇÒ¤Á ¾.È. 2545 ) 11

Journal reading ÇÔ¸¡Õ ÒÃÈÖ¡ÉÒ


¼Ù»é Çè  probable AD µÒÁ DSM-IV áÅÐ NINCDS-ADRDA ¨Ó¹Ç¹ 57 ¤¹
¨Ò¡ 150 ¤¹ ä´é¼Òè ¹¡Ãкǹ¡ÒäѴ¡Ãͧâ´Â
Cognitive Deficits and Polymorphism of Apolipoprotein E in Alzheimer’s Disease
1. Polymerase chain reaction method : »ÃÐàÁÔ¹ Apo E genotype
2. GDS, MMSE : screening test
â´Â E.Luezywek áÅФ³Ð ¨Ò¡ medical research center áÅÐ Nenckin institute of
3. Neuropsychological test : cognitive activity
experimental biology, Warsaw, Poland. Dementia and geriatric cognitive disorders
2002;13:171-7.
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1. ¨Ò¡¡ÒûÃÐàÁÔ¹ÊÒÁÒöáºè§¼Ù»é Çè Âà»ç¹ 2 ¡ÅØÁè ¤×Í E4- ¨Ó¹Ç¹ 20 ¤¹ E4+
ÊÃØ»â´Â á¾·ÂìË-ԧ˷ÑÂÇѹ ʹÑè¹àÍ×éÍ
¨Ó¹Ç¹ 37 ¤¹ àÁ×èÍ·Ó¡ÒûÃÐàÁÔ¹à¡ÕèÂǡѺ education level, ÍÒÂØ ¢Í§·Ñé§ 2 ¡ÅØèÁ´éÇÂ
á¾·Âì»ÃШӺéÒ¹»Õ·èÕ 1 ÀÒ¤ÇÔªÒ¨ÔµàǪÈÒʵÃì ¤³Ðá¾·ÂÈÒʵÃì ÁËÒÇÔ·ÂÒÅÑ¢͹á¡è¹
Chi-square áÅéÇäÁ辺ÇèÒÁÕ¤ÇÒÁᵡµèÒ§ÍÂèÒ§ÁÕ¹ÑÂÊÓ¤Ñ-áÅоºÇèÒ¼Ùé»èÇ¡ÅØèÁ E4-
ÊÒÁÒö·Ó¤ÐṹẺ·´Êͺä´é´¡Õ ÇèÒ E4+ ã¹´éÒ¹ similarity test, digits backward
Isoforms µèÒ§æ ¢Í§ Apolipoprotein E ÁÕº·ºÒ··Õáè µ¡µèÒ§¡Ñ¹µèÍÃкº»ÃÐÊÒ·
recall test, immediate recall áÅзÑé§ 2 ¡ÅØèÁ·Ó¤Ðá¹¹ä´éÊÙ§ÊØ´ã¹ part ¢Í§ Boston
ã¹ AD ¾ºÇèÒ¶éÒ¼Ù»é Çè ÂÁÕ apolipoprotein E-4 ¨Ð·ÓãËéà¡Ô´ amyloid plagues ÁÒ¡ã¹ÊÁͧ
naming test
áÅÐÊè§àÊÃÔÁ¡ÒÃÊÃéÒ§ fibrous insoluble amyloid and aggregation Êèǹ apolipoprotein
2. ¤ÇÒÁÊÑÁ¾Ñ¹¸ì¢Í§¤èÒẺ·´ÊͺµèÒ§æ 㹡ÅØèÁ E4- ¾ºÇèÒäÁèÁÕ¤ÇÒÁ
E-3 ¨Ð»éͧ¡Ñ¹¡ÒÃà¡Ô´ neurofibrous degeneration 㹤¹·ÕÁè Õ genotype à»ç¹ apolipoprotein
ÊÑÁ¾Ñ¹¸ì¡¹Ñ àÅÂÃÐËÇèÒ§ learning in the first trial test ¡Ñº¡Ò÷´ÊͺÍ×¹è æ Êèǹ E4+ ¾ºÇèÒ
E ¨ÐÁռŵèÍ¡Ãкǹ¡ÒÃà¡Ô´âäáÅФÇÒÁÃعáç㹡ÒÃà»ÅÕÂè ¹á»Å§¢Í§ÊÁͧ ã¹´éÒ¹
verbal fluency test ÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸ìÍÂèÒ§ÁÒ¡¡Ñº test Í×¹è æ â´Â੾ÒÐ three learning test
¤ÇÒÁ¨ÓàÊ×Íè Á ´Ñ§¹Ñ¹é ¡ÒÃÈÖ¡ÉÒà¡ÕÂè ǡѺ gene ã¹ AD ¨Ö§à»ç¹¤ÇÒÁÃÙ·é ÊèÕ Ó¤Ñ-µèÍ prognosis
3. ã¹¼Ù»é Çè Â·Õ¶è ¡Ù »ÃÐàÁÔ¹ÇèÒà»ç¹ early stage of AD ¼Ù»é Çè ÂÂѧ¤§·Ó¤Ðá¹¹
ä´é´ãÕ ¹ part ¢Í§ Boston naming test ·Ñ§é E4- áÅÐ E4+ ·Ó¤Ðá¹¹µèÒ§¡Ñ¹ÍÂèÒ§ÁÕ¹ÂÑ
Çѵ¶Ø»ÃÐʧ¤ì
ÊÓ¤Ñ-ã¹àÃ×Íè § digits backward recall test áÅÐ learning test â´Â digit backward ¡ÅØÁè
à¾×Íè »ÃÐàÁÔ¹¤ÇÒÁÊÑÁ¾Ñ¹¸ìÃÐËÇèÒ§ÃٻẺ¢Í§ cognitive deficits â´Â੾ÒÐ
E4+ ·Óä´é´¡Õ ÇèÒ Êèǹ E4- ·Óä´é´¡Õ ÇèÒã¹Êèǹ learning test
¡Ãкǹ¡ÒäÇÒÁ¨Ó ¡Ñº apolipoprotein E genotype ã¹¼Ùé»èÇ·Õèä´éÃѺ¡ÒÃÇÔ¹Ô¨©ÑÂÇèÒ
4. ¤èÒ¤ÇÒÁÊÑÁ¾Ñ¹¸ì¢Í§ test µèÒ§æ ã¹ early stage ¾ºÇèÒ E4- naming test ÁÕ
probable AD ã¹ÃÐÂÐáá
¤ÇÒÁÊÑÁ¾Ñ¹¸ìÍÂèÒ§ÁÒ¡¡Ñº three learning tests Êèǹ E4+ fluency test ¨ÐÊÑÁ¾Ñ¹¸ìÍÂèÒ§
ÁÒ¡¡Ñº learning in the first and eighth trial, naming test, similarity test áÅÐ backward
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digits recall test
¼Ù»é Çè  AD ·ÕÁè ¤Õ ÇÒÁº¡¾Ãèͧ¢Í§¡ÒÃàÃÕ¹ÃÙáé ÅФÇÒÁ¨Ó ¨ÐÁÕ¤ÇÒÁº¡¾Ãèͧ
¤ÅéÒÂæ ¡Ñ¹ã¹ AD ·ÕÁè Õ genotype ¢Í§ apolipoprotein E µèÒ§æ ¡Ñ¹
12 ¨ØÅÊÒêÁÃÁ»ÃÐÊÒ·ÇÔ·ÂÒÈÒʵÃìÀÒ¤µÐÇѹÍÍ¡à©Õ§à˹×Í »Õ·èÕ 3 ©ºÑº·Õè 3-4 ( ¡Ã¡®Ò¤Á – ¸Ñ¹ÇÒ¤Á ¾.È. 2545 ) 13

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¨Ó áÅÐàÃÕ¹ÃÙéÊÔè§ãËÁè àËç¹ä´é¨Ò¡¤Ðá¹¹·ÕèµèÓã¹ part learning Êèǹ¤ÇÒÁ¨Ó¢Í§à´ÔÁ·Õè â´Â ÍÒ¨ÒÃÂì¹ÒÂá¾·Âìà´ªÒ »ÔÂÐÇѲ¹ì¡ÙÅ
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temporal lobes «Ö§è à»ç¹·ÕÂè ÍÁÃѺ¡Ñ¹ã¹»Ñ¨¨Øº¹Ñ ÇèÒ hippocampus à»ç¹â¤Ã§ÊÃéÒ§·ÕÊè Ó¤Ñ-
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figure áÅÐ similarity test ã¹¢³Ð¹Õé E4- ¨ÐàÊÕ working memory, visuospatial memory ¹Í¡¨Ò¡ apolipoprotein E genotype ¨ÐÁռŵèÍ onset ¢Í§ pathological
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µèÍÊÁͧ·ÑÇè æ ä» ¨Ö§ÁռšÃзºµèÍ cognitive deficits ä´éáµè¨Ð¾ºã¹ late stage «Ö§è ¡Òà ªØ´§Ò¹ÇÔ¨ÑÂà¡ÕèÂǡѺàÃ×èͧ¹ÕéµèÍà¹×èͧÁÒÃÐÂÐ˹Öè§áÅéÇ ¨Ö§ÂÔè§à»ç¹·Õè¹èÒʹã¨ÂÔ觢Öé¹ä»ÍÕ¡
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ÂÒ¡ÅØÁè ¹Õ¨é Ðà¡ÕÂè Ç¢éͧ¡Ñº¡ÒÃà¡Ô´ÀÒÇÐÊÁͧàÊ×Íè Á´éÇÂËÃ×ÍäÁè ´Ñ§¹Ñ¹é »Ñ¨¨Øº¹Ñ ¨Ö§¤Ò´ÇèÒ¡Òà àÍ¡ÊÒÃÍéÒ§ÍÔ§


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Textbook of Therapeutics : Drug and Disease Management. 7th ed. Baltimore:
3. ¼Ù»é Çè Ââä¾ÒÃì¡¹Ô Êѹ·ÕÁè ÍÕ Ò¡ÒäÃÖ§è «Õ¡ 㹡óշÁèÕ Ò´éÇ ipsilateral weakness ¹Ñ¹é Lippincott Williams & Wilkins, 2000.
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Alteration of Consciousness 1. ¨Ó¹Ç¹¼Ùàé ¢éÒÃèÇÁ»ÃЪØÁ á¡à»ç¹¡ÅØÁè µèÒ§æ ´Ñ§¹Õé
- ºØ¤¤ÅÀÒ¹͡ 43 ¤¹
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- ºØ¤¤ÅÀÒÂã¹ 61 ¤¹
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- ¾ÂÒºÒÅ 35 ¤¹
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»ÃÐÊÒ·ÇÔ·ÂÒ á¾·Âì¼ãéÙ Ëé¡ÒôÙáÅÃÑ¡ÉҨеéͧµÃǨÇÔ¹¨Ô ©ÑÂËÒÊÒà˵ط·èÕ ÓãËé¼»éÙ Çè ÂÁÕÃдѺ - ÇÔ·ÂÒ¡Ã 19 ¤¹
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ÊÒà˵ط¨èÕ Óà¾ÒÐ¹Ñ¹é ¨ÐªèÇÂãËé¼Å¡ÒÃÃÑ¡ÉÒ´ÕáÅÐÅ´¡ÒÃà¡Ô´ÀÒÇÐá·Ã¡«é͹ä´é

Abstract
Alteration of consciousness is a common emergency condition that needs
prompt medical attention. There are many etiologies of this condition, therefore the
physicians should recognize and find out its cause in every patients. The general
physicians especially who work in the emergency room should have the basic concept
of principle in diagnosis, investigation and management of this condition correctly.
Complete history taking , physical examination and neurologic assessment
help us to identify its cause. Proper investigations and specific treatment are the goal
of management leading to good outcome.
20 ¨ØÅÊÒêÁÃÁ»ÃÐÊÒ·ÇÔ·ÂÒÈÒʵÃìÀÒ¤µÐÇѹÍÍ¡à©Õ§à˹×Í »Õ·èÕ 3 ©ºÑº·Õè 3-4 ( ¡Ã¡®Ò¤Á – ¸Ñ¹ÇÒ¤Á ¾.È. 2545 ) 5

Alteration of consciousness ËÁÒ¶֧ÀÒÇзÕÁè ¡Õ ÒÃà»ÅÕÂè ¹á»Å§¢Í§ÃдѺ¤ÇÒÁ


ÃÙÊé ¡Ö µÑÇ «Ö§è ¤ÇÒÁÃعáç¢Í§ÍÒ¡ÒùÕàé »ç¹ä»ä´éµ§éÑ áµè¹Íé Â仨¹¶Ö§ÁÒ¡´Ñ§¹Õé ¤×Í drowsy ,
stupor , semicoma ¨¹¶Ö§ coma µÒÁÅӴѺ ÀÒÇйÕàé »ç¹ÀÒÇЩءà©Ô¹·Ò§»ÃÐÊÒ·ÇÔ·ÂÒ
á¾·Âì¼ãéÙ Ëé¡ÒôÙáÅÃÑ¡ÉÒ¼Ù»é Çè ¨еéͧµÃǨÇÔ¹¨Ô ©ÑÂËÒÊÒà˵ط·èÕ ÓãËé¼»éÙ Çè ÂÁÕÃдѺ¤ÇÒÁ
ÃÙÊé ¡Ö µÑÇËÃ×ÍÃÙÊé µÔŴŧãËé·ÃÒºâ´ÂàÃçÇ·ÕÊè ´Ø à¾ÃÒÐâäËÃ×ÍÊÒà˵غҧÍÂèÒ§ ¶éÒãËé¡ÒÃ
ÇÔ¹¨Ô ©ÑÂáÅСÒÃÃÑ¡ÉÒä´é¶¡Ù µéͧáÅзѹàÇÅÒ ¡ç¨ÐÊÒÁÒöŴÍѵÃÒµÒÂËÃ×ͤÇÒÁ¾Ô¡Ò÷Õè
¨Ðà¡Ô´¢Ö¹é ªèÇÂãËé¼»éÙ Çè ¡ÅѺÁÒà»ç¹»¡µÔä´é
¡Ò÷ÕÁè ÃÕ Ð´Ñº¤ÇÒÁÃÙÊé ¡Ö µÑÇËÃ×Í¡ÒÃÃѺÃÙÊé µÔà»ÅÕÂè ¹á»Å§ä»ÊÒÁÒöà¡Ô´ä´éà¹×Íè §
¨Ò¡¤ÇÒÁ¼Ô´»¡µÔ¢Í§ÊÁͧâ´Â·ÑÇè ä» ËÃ×ÍÁÕ¤ÇÒÁ¼Ô´»¡µÔ㹡Ò÷ӧҹ¢Í§ thalamocor-
tical alerting system ·ÕÃè ¨éÙ ¡Ñ ¡Ñ¹´Õ㹪×Íè ÇèÒ reticular activating system (RAS) ¾ÂÒ¸ÔÊÀÒ¾
·Õ·è ÓãËéà¡Ô´¡ÒÃà»ÅÕÂè ¹á»Å§¢Í§ÃдѺ¤ÇÒÁÃÙÊé ¡Ö µÑǹѹé ÊÒÁÒö¨Óṡä´éà»ç¹ 3 »ÃÐàÀ·
´Ñ§¹Õé
1. ¾ÂÒ¸ÔÊÀÒ¾·Õàè ¡Ô´áÅзÓÅÒÂã¹Êèǹ¢Í§ RAS
2. ¾ÂÒ¸ÔÊÀÒ¾·Õàè ¡Ô´áÅÐÁÕ¡Ò÷ÓÅÒÂã¹ÊèǹÊÁͧ·Ñ§é 2 ¢éÒ§
3. ¾ÂÒ¸ÔÊÀÒ¾·Õàè ¡Ô´¨Ò¡¡Òá´¡Ò÷ӧҹ¢Í§ thalamocerebral pathway
«Ö§è ÍÒ¨à»ç¹¨Ò¡ÂÒ , ÊÒþÔÉ ËÃ×ͤÇÒÁ¼Ô´»¡µÔ·Ò§àÁµÒºÍÅÔ¡ à»ç¹µé¹

Approach to the patient


ÀÒÇзÕÁè ¡Õ ÒÃà»ÅÕÂè ¹á»Å§ÃдѺ¤ÇÒÁÃÙÊé ¡Ö µÑÇËÃ×ÍËÁ´ÊµÔ ÁÑ¡¨Ð¾ºÁÕ¤ÇÒÁ¼Ô´
»¡µÔà¡ÕÂè Çà¹×Íè §¡ÑºÃкº»ÃÐÊÒ· ¡Ò÷ըè ÐÊ׺¤é¹ËÒÊÒà˵آͧÀÒÇйըé ÓµéͧÍÒÈÑ·ѡÉÐ
·Ò§´éÒ¹¡Òëѡ»ÃÐÇÑµÔ ¡ÒõÃǨÃèÒ§¡ÒÂÍÂèÒ§ÅÐàÍÕ´ÃÇÁ¶Ö§¡ÒõÃǨ·Ò§Ãкº»ÃÐÊÒ·
¨Ò¡¹Ñ¹é ¨Ö§µÃǨ·Ò§Ëéͧ»¯ÔºµÑ ¡Ô ÒÃà¾×Íè ÇÔ¹¨Ô ©Ñ¶֧ÊÒà˵ط¹èÕ Òè ¨Ðà»ç¹»Ñ-ËÒ·Õ·è ÓãËé¼»éÙ Çè Â
äÁèÃÊéÙ ¡Ö µÑÇ
»ÃÐÇѵ·Ô ¤èÕ ÇöÒÁà¾×Íè Ê׺ËÒÊÒà赯 ä´éá¡è »ÃÐÇѵ¡Ô ÒÃä´éÃºÑ ÍغµÑ àÔ ËµØËÃ×ͺҴ
à¨çº ¡ÒáԹÂÒËÃ×Í¡ÒÃãªéÂÒ ÍÒ¡Ò÷Õàè ¡Ô´ÃèÇÁ¡ÑºÀÒÇÐäÁèÃÊéÙ ¡Ö µÑǢͧ¼Ù»é Çè  ¡ÒÃÍè͹áç
¢Í§á¢¹¢Ò »Ç´ÈÕÃÉÐ ä¢é ÍÒ¡Òêѡ ¤Å×è¹äÊéÍÒà¨Õ¹ ÇÔ§àÇÕ¹ÈÕÃÉÐ àËç¹ÀÒ¾«é͹
»ÃÐÇѵ¡Ô ÒÃãªéÊÒÃàʾµÔ´ ¡Òô×Áè ÊØÃÒ áÅлÃÐÇѵâÔ Ã¤»ÃШӵÑÇ à»ç¹µé¹
6 ¨ØÅÊÒêÁÃÁ»ÃÐÊÒ·ÇÔ·ÂÒÈÒʵÃìÀÒ¤µÐÇѹÍÍ¡à©Õ§à˹×Í »Õ·èÕ 3 ©ºÑº·Õè 3-4 ( ¡Ã¡®Ò¤Á – ¸Ñ¹ÇÒ¤Á ¾.È. 2545 ) 19

¡ÒõÃǨÃèÒ§¡ÒÂã¹¼Ù»é Çè ·Õäè ÁèÃÊéÙ ¡Ö µÑÇ¹Ñ¹é ¤ÇûÃÐàÁÔ¹ÊÑ--Ò³ªÕ¾ÍÂèÒ§ÃÇ´àÃçÇ


¶éÒ¾ºÇèÒÁÕÀÒÇÐä¢é¨Ð·ÓãËé¹¡Ö ¶Ö§ÀÒÇеԴàª×Íé ÁÒ¡¢Ö¹é àªè¹ systemic infection , meningitis
ËÃ×Í encephalitis à»ç¹µé¹ ÊèǹÀÒÇÐ hypothermia ¾ºÇèÒÍÒ¨ÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸ì¡ºÑ hypogly-
cemia , hypothyroidism , peripheral circulatory failure , alcoholic barbiturate sedative
ËÃ×Í phenothiazine intoxication, ¤ÇÒÁ´Ñ¹µèÓËÃ×ÍÊÙ§¼Ô´»¡µÔ ¨Ò¡¹Ñ¹é »ÃÐàÁÔ¹ÃкºËÒÂã¨
ÃкºËÑÇã¨áÅÐËÅÍ´àÅ×Í´ ¡ÒõÃǨÃèÒ§¡ÒÂÃкºÍ×¹è æ áÅСÒõÃǨÃèÒ§¡Ò·ҧÃкº
»ÃÐÊÒ·
¡ÒõÃǨÃèÒ§¡Ò·ҧÃкº»ÃÐÊÒ· àÃÔÁè ´éÇ¡ÒûÃÐàÁÔ¹¤ÇÒÁÃعáç¢Í§¡ÒÃ
ÃÙÊé ¡Ö µÑÇÇèÒà»ç¹ÁÒ¡¹éÍÂà¾Õ§㴠â´Âãªé Glasglow coma scale «Ö§è ÁÕ¤Ðá¹¹àµçÁ 15 ¤Ðá¹¹
¡ÒÃãËé¤Ðá¹¹áºè§à»ç¹ 3 Êèǹ ¤×Í motor response ( 6 ¤Ðá¹¹) , verbal response
(5 ¤Ðá¹¹) áÅÐ eye opening (4 ¤Ðá¹¹) àÁ×Íè »ÃÐàÁÔ¹ÃдѺ¤ÇÒÁÃÙÊé ¡Ö µÑÇáÅСÒõͺ
ʹͧáÅéÇ ¨Ö§µÃǨÃèÒ§¡Ò·ҧÃкº»ÃÐÊÒ··Ñ§é ËÁ´µÑ§é áµè cranial nerve , motor system
, sensory system, meningeal áÅÐ cerebellar signs ·Ñ§é ¹Õàé ¾×Íè »ÃÐ⪹ì㹡ÒÃÇÔ¹¨Ô ©ÑÂÇèÒ
¹èÒ¨ÐÁÕ¤ÇÒÁ¼Ô´»¡µÔã¹Ãкº»ÃÐÊÒ··ÕÃè дѺ㴠ã¹Êèǹ¢Í§ cerebral hemisphere , brain
stem ËÃ×Í cerebellum áÅФÇÒÁ¼Ô´»¡µÔ·¾èÕ º¹Ñ¹é à»ç¹¢éҧ㴢éҧ˹֧è ËÃ×͹èÒ¨Ðà»ç¹·Ñ§é 2
¢éÒ§
¡ÒõÃǨ eye ground à¾×Íè ´Ù fundus ÊÒÁÒöºÍ¡¤ÇÒÁ¼Ô´»¡µÔä´éËÅÒÂâä àªè¹
µÃǨ¾º subhyaloid hemorrhage ºè§¶Ö§ subarachnoid hemorrhage , µÃǨ¾º exudate
hemorrhage, vessel – crossing change áÅÐ papilledema ÍÒ¨ªèÇÂ㹡ÒÃÇÔ¹Ô¨©ÑÂ
hypertensive encephalopathy , µÃǨ¾ºÁÕ papilledema ºè§¶Ö§ÇèÒÁÕ increased intracranial
pressure

¡ÒõÃǨ·Ò§Ëéͧ»¯ÔºµÑ ¡Ô Òà (Laboratory studies and imaging)


¡ÒõÃǨ·Ò§Ëéͧ»¯ÔºµÑ ¡Ô ÒÃà¾×Íè ªèÇÂ㹡ÒÃÇÔ¹¨Ô ©ÑÂËÒÊÒà˵ط¹èÕ Òè ¨Ð·ÓãËéà¡Ô´
¡ÒÃà»ÅÕÂè ¹á»Å§ÃдѺ¤ÇÒÁÃÙÊé ¡Ö µÑÇÁÒ¡·ÕÊè ´Ø µÃǨ»ÃÐàÁÔ¹¤ÇÒÁ¼Ô´»¡µÔ·Ò§àÁµÒºÍÅÔ¡
ä´éá¡è blood sugar , BUN , creatinine , liver function test , calcium , electrolyte áÅÐ
toxicologic analysis 㹡óշÊèÕ §ÊÑÂÇèÒä´éÃºÑ ÊÒþÔÉËÃ×Íä´éÃºÑ ÂÒà¡Ô¹¢¹Ò´
18 ¨ØÅÊÒêÁÃÁ»ÃÐÊÒ·ÇÔ·ÂÒÈÒʵÃìÀÒ¤µÐÇѹÍÍ¡à©Õ§à˹×Í »Õ·èÕ 3 ©ºÑº·Õè 3-4 ( ¡Ã¡®Ò¤Á – ¸Ñ¹ÇÒ¤Á ¾.È. 2545 ) 7

¡ÒõÃǨÍ×¹è ·Õ¾è ¨Ô ÒóҵÃǨà»ç¹ÃÒÂæä» ¤×Í ¡ÒõÃǨ CT ËÃ×Í MRI brain,


electroencephalogram áÅÐ cerebrospinal fluid (CSF) examination

¡ÒÃÇÔ¹Ô¨©ÑÂá¡âä
¤ÃÑ駷Õè 5 Çѹ·Õè 9-10 Á¡ÃÒ¤Á ¾.È. 2546 ¢Í§ªÁÃÁÏ ¡ÒÃÇÔ¹¨Ô ©ÑÂá¡âä㹼ٻé Çè ·Õäè ÁèÃÊéÙ ¡Ö µÑǹѹé ÊÒÁÒö¨Óṡä´éà»ç¹ 3 ¡ÅØÁè
´Ñ§¹Õé ¤×Í
1. âä·Õµè ÃǨäÁ辺ÅѡɳФÇÒÁ¼Ô´»¡µÔ¢Í§Ãкº»ÃÐÊҷ੾ÒзÕè (¡ÒÃ
µÃǨàÍç¡«àÃÂì¤ÍÁ¾ÔÇàµÍÃì ¢Í§ÊÁͧáÅмŵÃǨ¹éÓä¢ÊѹËÅѧ»¡µÔ)
1.1 intoxication : alcohol , sedative drugs , opiates , etc.
1.2 metabolic disturbance : anoxic , uremia , hepatic coma ,
hypoglycemia à»ç¹µé¹
1.3 severe systemic infection : pneumonia , malaria , septicemia
à»ç¹µé¹
1.4 shock
1.5 postseizure state , subclinical epilepsy , status epilepticus
1.6 hypertensive encephalopathy
1.7 severe hyperthermia , hypothermia
1.8 concussion
1.9 acute hydrocephalus
2. âä·Õµè ÃǨ¾ºÁÕ¡ÒÃÃФÒÂà¤×ͧ¢Í§àÂ×Íè ËØÁé ÊÁͧ (ÁÑ¡¨ÐäÁ辺¤ÇÒÁ¼Ô´
»¡µÔ¢Í§Ãкº»ÃÐÊҷ੾ÒзÕè áÅСÒõÃǨàÍç¡«àÃÂì¤ÍÁ¾ÔÇàµÍÃìÊÁͧäÁ辺
ÅѡɳТͧ¡é͹à¹×éÍ)
2.1 subarachnoid hemorrhage
2.2 acute bacterial meningitis
2.3 viral encephalitis
2.4 meningitis ¨Ò¡ÊÒà˵Ø͹è× æ
2.5 miscellaneous : fat embolism, cholesterol embolism , cerebritis
à»ç¹µé¹
8 ¨ØÅÊÒêÁÃÁ»ÃÐÊÒ·ÇÔ·ÂÒÈÒʵÃìÀÒ¤µÐÇѹÍÍ¡à©Õ§à˹×Í »Õ·èÕ 3 ©ºÑº·Õè 3-4 ( ¡Ã¡®Ò¤Á – ¸Ñ¹ÇÒ¤Á ¾.È. 2545 ) 17

3. âä·ÕèµÃǨ¾ºÁÕ¤ÇÒÁ¼Ô´»¡µÔ¢Í§Ãкº»ÃÐÊҷ੾ÒзÕèËÃ×ͤÇÒÁ¼Ô´ àÍ¡ÊÒÃÍéÒ§ÍÔ§
»¡µÔ¢Í§¡Ò÷ӧҹ¢Í§¡éÒ¹ÊÁͧ (ÍÒ¨¾ºÁÕ¤ÇÒÁ¼Ô´»¡µÔ¢Í§¹éÓã¹ä¢ÊѹËÅѧ ¡ÒõÃǨ 1. Chen JJ, Shimomura SK. Parkinsonism. In Gerfindal ET, Gourley DR, eds.
àÍç¡«àÃÂì¤ÍÁ¾ÔÇàµÍÃìÊÁͧ¾ºÇèÒÁÕ¤ÇÒÁ¼Ô´»¡µÔ) Textbook of Therapeutics : Drug and Disease Management. 7th ed. Baltimore:
3.1 hemispheric hemorrhage or infarction Lippincott Williams & Wilkins, 2000.
3.2 brainstem hemorrhage or infarction 2. Fahn S, Przedborski S. Parkinsonism. In Rowland LP, ed. Merritt’s Neurology.
3.3 brain abscess , subdural empyema 10th ed. Philadelphia : Lippincott Williams & Wilkins, 2000.
3.4 epidural and subdural hematoma , brain contusion
3.5 brain tumor
3.6 cerebellar infarction and hemorrhage µÍºâ´Â
3.7 widespread traumatic brain injury ¼È.À-.¹ÅÔ¹ ¾ÂѤ¦ªÒµÔ
3.8 miscellaneous : cortical vein thrombosis , cerebral vasculitis, È.¹¾.ÊØ·¸Ô¾¹Ñ ¸ì ¨Ôµ¾ÔÁÅÁÒÈ
pituitary apoplexy à»ç¹µé¹

ËÅÑ¡¡ÒôÙáżÙé»èÇÂ
1. Assess and manage : Airway Breathing Circulation
2. Draw blood sample and establish IV fluid
3. IV glucose if hypoglycemia
4. History taking and physical examination
5. Classify :
5.1 diffuse lesion
- nonstructural
- structural or meningeal involvement
5.2 localized lesion
6. Relevant laboratory investigations
7. Give specific treatment
16 ¨ØÅÊÒêÁÃÁ»ÃÐÊÒ·ÇÔ·ÂÒÈÒʵÃìÀÒ¤µÐÇѹÍÍ¡à©Õ§à˹×Í »Õ·èÕ 3 ©ºÑº·Õè 3-4 ( ¡Ã¡®Ò¤Á – ¸Ñ¹ÇÒ¤Á ¾.È. 2545 ) 9

ÂÒ¡ÅØÁè ¹Õ¨é Ðà¡ÕÂè Ç¢éͧ¡Ñº¡ÒÃà¡Ô´ÀÒÇÐÊÁͧàÊ×Íè Á´éÇÂËÃ×ÍäÁè ´Ñ§¹Ñ¹é »Ñ¨¨Øº¹Ñ ¨Ö§¤Ò´ÇèÒ¡Òà ¡ÒôÙáÅÃÑ¡ÉÒ¼Ù»é Çè ·Õäè ÁèÃÊéÙ ¡Ö µÑÇÁÕ¤ÇÒÁÊÓ¤Ñ-ÍÂèÒ§ÁÒ¡·Ò§¡ÒÃá¾·Âì á¾·Âì
à¡Ô´ÀÒÇÐÊÁͧàÊ×Íè Á¹Ñ¹é ÊÑÁ¾Ñ¹¸ì¡ºÑ ¾ÂÒ¸ÔÊÀÒ¾¢Í§âä¾ÒÃì¡¹Ô ÊѹÁÒ¡¡ÇèÒ ¨ÐµéͧÊÒÁÒöãËé¡Òô٠áÅÃÑ¡ÉÒàº×Íé §µé¹ä´éÍÂèÒ§¶Ù¡µéͧàËÁÒÐÊÁ ¢éÍÁÙŨҡ»ÃÐÇѵáÔ ÅÐ
¡ÒõÃǨÃèÒ§¡Ò·ÕèÅÐàÍÕ´¶Õè¶éǹ¨ÐªèÇÂ㹡ÒÃá¡ÇèÒÊÒà˵عèÒ¨Ðà¡Ô´¨Ò¡ÀÒÇÐã´ à¾×èÍ
3. ¼Ù»é Çè Ââä¾ÒÃì¡¹Ô Êѹ·ÕÁè ÍÕ Ò¡ÒäÃÖ§è «Õ¡ 㹡óշÁèÕ Ò´éÇ ipsilateral weakness ¹Ñ¹é ¨Ðä´éÊ§è µÃǨ·Ò§Ëéͧ»¯ÔºµÑ ¡Ô ÒÃãËéàËÁÒÐÊÁ ¡ÒÃÃÑ¡ÉÒ·ÕÃè Ç´àÃçǶ١µéͧàËÁÒÐÊÁ¨ÐªèÇÂ
ÊÒÁÒöà¡Ô´ÀÒÇйըé Ò¡µÑÇâä, ÂÒ ËÃ×Íà»ç¹ÀÒÇÐá·Ã¡«é͹¢Í§âä ãËé¼»éÙ Çè ÂËÒÂáÅÐÅ´¡ÒÃà¡Ô´ÀÒÇÐá·Ã¡«é͹ä´é
µÍº Motor weakness ËÃ×Í¡ÅéÒÁà¹×Íé Íè͹áç¹Ñ¹é äÁ辺ã¹âä¾ÒÃì¡¹Ô Êѹ ¡ÒÃ
µÃǨÃèÒ§¡Ò¨оºÇèÒ motor power ¨Ð»¡µÔ áµèÍÒ¨¾ºà»ç¹ pseudoweakness ä´é ¨Ò¡¡Òà References
·Õ¼è »éÙ Çè ÂÃÙÊé ¡Ö ÇèÒà¤Å×Íè ¹äËÇÅÓºÒ¡ ÃÙÊé ¡Ö Ë¹Ñ¡á¢¹¢Ò «Ö§è ¤ÅéÒ¡ѺÍÒ¡Òâͧ¡ÅéÒÁà¹×Íé Íè͹ 1. Ropper AH. Acute confusional states and coma. In: Fauci AS , Braunwald E ,
áç áµè¤ÇÒÁ¨ÃÔ§¨ÐµÃǨ¾ºÇèÒ¡ÅéÒÁà¹×Íé ÁÕáçà»ç¹»¡µÔ ¹Í¡¨Ò¡¹Õ¡é ÒÃãªéÂÒÃÑ¡ÉÒâä¾ÒÃì Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, et al , eds. Principles of
¡Ô¹Êѹ äÁ辺ÇèÒÂÒã´·Õ·è ÓãËéà¡Ô´ÀÒÇÐÍè͹áç internal medicine. New York : McGraw Hill 1998:132–40.
㹡óշ¾èÕ ºÇèÒÁÕ motor weakness ¨ÃÔ§ ÍÒ¨µéͧ·Ó¡Òëѡ»ÃÐÇѵÍÔ ÂèÒ§ÅÐàÍÕ´ 2. Plum F, Posner JB. The diagnosis of stupor and coma, 3rd ed. Philadelphia: F.A.
ÇèÒ¡ÒÃà¡Ô´¡ÒÃÍè͹áç¹Ñ¹é ÁÕ¤ÇÒÁà»ç¹ÁÒÍÂèÒ§äà ÍÕ¡·Ñ§é ÍÒ¨µéͧ·Ó¡Ò÷º·Ç¹¡ÒÃÇÔ¹¨Ô ©Ñ Davis ,1980.
âä¾ÒÃì¡¹Ô ÊѹãËÁè´Çé  à¹×Íè §¨Ò¡ã¹¡ÒÃà¡Ô´ stroke ·Õºè Ò§µÓáË¹è§ àªè¹·Õè basal ganglia 3. Bateman DE. Neurological assessment of coma. J Neurol Neurosurg Psychiatry
ÍÒ¨·ÓãËéÁÕ pyramidal involvement 2001;71(suppl 1):i13-i17.
4. Andrefsky JC , Frank JI. Approach to the patient with acute confusional state
4. ÍÒ¡ÒÃÊѹè ËÃ×Í tremor ã¹âä¾ÒÃì¡¹Ô Êѹ ÊÒÁÒöãªéÂÒ¡ÅØÁè beta-blockers á·¹¡ÅØÁè (Delirium / Encephalopathy). In: Biller J, ed. Practical Neurology. New York:
anticholinergics ä´éËÃ×ÍäÁè Lippincott – Heinemann, 1997:3–14.
µÍº ÍÒ¡ÒÃÊÑè¹ËÃ×Í tremor ã¹âä¾ÒÃì¡Ô¹Êѹ¹Ñé¹áºè§ÍÍ¡à»ç¹ 2 subgroup 5. Ashla MFM. Delirium. In: Bradley W, Daroff RB, Fenichel GM, Marsden CD,
¹Ñ¹è ¤×Í resting tremor áÅÐ action tremor «Ö§è ¨Ð¾º action tremor à¾Õ§ 20% à·èÒ¹Ñ¹é «Ö§è eds. Neurology in clinical practice. Boston: Butterworth – Heinemann, 2000:25–36.
ÂÒ¡ÅØèÁ beta-blockers ¹Ñ鹨Ðãªéä´é¼Å㹡óշÕè¡ÒÃÊÑè¹¹Ñé¹à»ç¹áºº action tremor ã¹
¢³Ð·Õäè ´é¼ÅäÁè¤Íè ´չ¡Ñ 㹡ÒÃÊѹè Ẻ resting tremor «Ö§è ¡ÒÃÊѹè Ẻ¹ÕÁé ¡Ñ ¨ÐµÍºÊ¹Í§
´ÕµÍè ÂÒ ¡ÅØÁè anticholinergics ´Ñ§¹Ñ¹é ¡ÒÃãËéÂÒà¾×Íè ÃÑ¡ÉÒÍÒ¡ÒÃÊÑ¹è ¨ÐµéͧµÃǨá¡ÇèÒà»ç¹
¡ÒÃÊѹè Ẻ㴠áÅÐàÅ×Í¡ÂÒãËéµÃ§¡Ñºª¹Ô´¢Í§¡ÒÃÊÑ¹è ¹Ñ¹é
10 ¨ØÅÊÒêÁÃÁ»ÃÐÊÒ·ÇÔ·ÂÒÈÒʵÃìÀÒ¤µÐÇѹÍÍ¡à©Õ§à˹×Í »Õ·èÕ 3 ©ºÑº·Õè 3-4 ( ¡Ã¡®Ò¤Á – ¸Ñ¹ÇÒ¤Á ¾.È. 2545 ) 15

Journal reading
Cognitive Deficits and Polymorphism of Apolipoprotein E in Alzheimer’s Disease
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â´Â E.Luezywek áÅФ³Ð ¨Ò¡ medical research center áÅÐ Nenckin institute of 1. ¡ÒÃ᡼ٻé Çè ·Õàè »ç¹âä¾ÒÃì¡¹Ô Êѹã¹ÃÐÂÐàÃÔÁè µé¹ ÍÍ¡¨Ò¡¼Ù»é Çè Ââä«ÖÁàÈÃéÒ
experimental biology, Warsaw, Poland. Dementia and geriatric cognitive disorders µÍº à¹×èͧ¨Ò¡¼Ùé»èÇ·Õèà»ç¹âä¾ÒÃì¡Ô¹Êѹ¨ÐÁÕÅѡɳТͧ masked face ¨ÐäÁèÁÕ
2002;13:171-7. ¡ÒÃáÊ´§ÍÍ¡·Ò§ÍÒÃÁ³ì·Ò§ÊÕ˹éÒÁÒ¡¹Ñ¡ ˹éҵҨйԧè à©Â «Ö§è ¨Ð¤ÅéÒÂã¹¼Ù»é Çè Ââä«ÖÁ
àÈÃéÒ ·Õäè Áè¤Íè ÂÁÕ¡ÒÃáÊ´§ÍÍ¡¢Í§ÊÕ˹éÒàªè¹¡Ñ¹ áµèʧèÔ ·Õáè µ¡µèÒ§¡Ñ¹ã¹¼Ù»é Çè ÂÊͧâä¹Õé ÁÕ
ÊÃØ»â´Â á¾·ÂìË-ԧ˷ÑÂÇѹ ʹÑè¹àÍ×éÍ Êͧ»ÃСÒà »ÃСÒÃáá ¹Ñ¹è ¤×Í¡ÒõÃǨÃèÒ§¡Ò 㹼ٻé Çè ¾ÒÃì¡¹Ô Êѹ¨ÐµÃǨ¾ºÅѡɳÐ
á¾·Âì»ÃШӺéÒ¹»Õ·èÕ 1 ÀÒ¤ÇÔªÒ¨ÔµàǪÈÒʵÃì ¤³Ðá¾·ÂÈÒʵÃì ÁËÒÇÔ·ÂÒÅÑ¢͹á¡è¹ ¢Í§ cogwheel rigidity, bradykinesia, resting tremor (low frequency 3-6 Hz) «Ö§è ¨Ñ´à»ç¹
cardinal clinical features ¢Í§âä¹Õé áµèã¹¼Ù»é Çè Ââä«ÖÁàÈÃéÒÁÑ¡¨ÐÁÕ¡ÒõÃǨÃèÒ§¡Ò»¡µÔ
Isoforms µèÒ§æ ¢Í§ Apolipoprotein E ÁÕº·ºÒ··Õáè µ¡µèÒ§¡Ñ¹µèÍÃкº»ÃÐÊÒ· »ÃСÒ÷ÕÊè ͧ¤×Í ¡ÒÃ·Õ¼è »éÙ Çè Ââä«ÖÁàÈÃéÒäÁè¤Íè ÂÁÕ¡ÒÃáÊ´§ÍÍ¡¢Í§ÍÒÃÁ³ì·Ò§ÊÕ˹éҹѹé
ã¹ AD ¾ºÇèÒ¶éÒ¼Ù»é Çè ÂÁÕ apolipoprotein E-4 ¨Ð·ÓãËéà¡Ô´ amyloid plagues ÁÒ¡ã¹ÊÁͧ ÁÕÊÒà˵Øà¹×Íè §¨Ò¡¤ÇÒÁ¼Ô´»¡µÔ¢Í§ÍÒÃÁ³ì «Ö§è ¤ÇÒÁ¨ÃÔ§áÅéǼٻé Çè ÂÂѧÊÒÁÒöáÊ´§ÍÒÃÁ³ì
áÅÐÊè§àÊÃÔÁ¡ÒÃÊÃéÒ§ fibrous insoluble amyloid and aggregation Êèǹ apolipoprotein ·Ò§ÊÕ˹éÒä´é µèÒ§¨Ò¡¼Ù»é Çè Ââä¾ÒÃì¡¹Ô Êѹ «Ö§è ÍÒ¨äÁèä´éÁÀÕ ÒÇЫÖÁàÈÃéÒáµè¡Ò÷ÕËè ¹éÒµÒ¹Ô§è
E-3 ¨Ð»éͧ¡Ñ¹¡ÒÃà¡Ô´ neurofibrous degeneration 㹤¹·ÕÁè Õ genotype à»ç¹ apolipoprotein à©Â¹Ñ¹é à¡Ô´¨Ò¡¾ÂÒ¸ÔÊÀÒ¾¢Í§âäÁÒ¡¡ÇèÒ (à¡Ô´¨Ò¡ lower-extremity rigidity)
E ¨ÐÁռŵèÍ¡Ãкǹ¡ÒÃà¡Ô´âäáÅФÇÒÁÃعáç㹡ÒÃà»ÅÕÂè ¹á»Å§¢Í§ÊÁͧ ã¹´éÒ¹
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temporal lobes «Ö§è à»ç¹·ÕÂè ÍÁÃѺ¡Ñ¹ã¹»Ñ¨¨Øº¹Ñ ÇèÒ hippocampus à»ç¹â¤Ã§ÊÃéÒ§·ÕÊè Ó¤Ñ-
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¤ÇÒÁ¨Ó «Ö§è ¾ºã¹¼Ù»é Çè  early stage of AD Â×¹Âѹ¨Ò¡ PET, SPECT, CT áÅÐ MRI ¢éͧ¡Ñº¡ÒÃà¡Ô´âä Alzheimer’s ã¹Á¹ØÉÂì â´Â੾ÒзÕèÇèÒ apolipoprotein E ª¹Ô´
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ÊÃØ» ¨Óà»ç¹µéͧ·Ó´éÇÂÇÔ¸¡Õ ÒÃËÃ×Íà·¤â¹âÅÂÕª¹éÑ ÊÙ§·ÕÁè ÃÕ Ò¤Òᾧà¡Ô¹ä»ÊÓËÃѺ»ÃÐà·È¡ÓÅѧ
ÃٻẺ¢Í§ cognitive deficit ã¹ AD à»ç¹áºº¼ÊÁ¼ÊÒ¹à¡Ô´ä´éËÅÒÂæ Ẻ ¾Ñ²¹ÒÍÂèÒ§àÃÒ¡çÊÒÁÒöä´é§Ò¹ÇÔ¨ÂÑ ·ÕÁè ¤Õ ³ Ø ÀÒ¾áÅлÃÐ⪹ìä´éàªè¹¡Ñ¹
áÅТֹé ÍÂÙ¡è ºÑ apolipoprotein E genotype ´éÇ ¤³ÐÇԨѤ³Ð¹ÕéàÅ×Í¡ãªéÇÔ¸Õ¡ÒÃÇÑ´ cognitive functions ËÅÒÂæ subtype
â´Â੾ÒзÕàè ¡ÕÂè Ç¢éͧ¡Ñº¡ÒÃàÃÕ¹ÃÙé â´ÂÍÒÈÑ¢éÍà·ç¨¨ÃÔ§·ÕÇè Òè cognitive functions ã¹¼Ù»é Çè Â
AD ÂèÍÁà»ç¹´Ñª¹Õº§è ªÕ¶é §Ö neuropathological state ã¹ÊÁͧ¢Í§¼Ù»é Çè  ¨Ò¡¼Å¡ÒÃà»ÃÕº
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¹Í¡¨Ò¡ÁÕ scores ¢Í§ learning deficits ã¹ÃдѺà´ÕÂǡѺ¡ÅØÁè E4 áÅéÇ áµè¡ÅѺÁÕ deficits
ã¹´éÒ¹Í×è¹â´Â੾ÒмŢͧ neuropsychological tests ·Õèà¡ÕèÂǡѺ frontal executive
function ÁÒ¡¡ÇèÒ¡ÅØÁè E4 ÍÕ¡´éÇ ËÅѧ¨Ò¡ stratified ËÃ×Í»ÃѺãËéà¡Ô´¡ÒÃà»ÃÕº¢Í§áµèÅÐ
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ÊÙÊè ÁÁص°Ô Ò¹·ÕÇè Òè genotype Ẻ E4 allele (ÂÔ§è â´Â੾ÒСÅØÁè double E4) ¨ÐÊ觼ŵèÍ ¼Ù»é Çè  probable AD µÒÁ DSM-IV áÅÐ NINCDS-ADRDA ¨Ó¹Ç¹ 57 ¤¹
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âä·Ò§¤ÅÔ¹¡Ô ÍÕ¡·Í´ â´ÂÊÁÁص°Ô Ò¹¹Õ¨é еç¡Ñº¼Å·Õäè ´é¨Ò¡¡ÒÃÈÖ¡ÉÒªÔ¹é Í×¹è æ ·Õ¾è ºÇèÒÁÕ 1. Polymerase chain reaction method : »ÃÐàÁÔ¹ Apo E genotype
hippocampal volume ŴŧÁÒ¡¡ÇèÒã¹¼Ù»é Çè ¡ÅØÁè ¹Õàé ªè¹¡Ñ¹ 2. GDS, MMSE : screening test
3. Neuropsychological test : cognitive activity

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¨Ó¹Ç¹ 37 ¤¹ àÁ×èÍ·Ó¡ÒûÃÐàÁÔ¹à¡ÕèÂǡѺ education level, ÍÒÂØ ¢Í§·Ñé§ 2 ¡ÅØèÁ´éÇÂ
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recall test, immediate recall áÅзÑé§ 2 ¡ÅØèÁ·Ó¤Ðá¹¹ä´éÊÙ§ÊØ´ã¹ part ¢Í§ Boston
naming test
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verbal fluency test ÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸ìÍÂèÒ§ÁÒ¡¡Ñº test Í×¹è æ â´Â੾ÒÐ three learning test
3. ã¹¼Ù»é Çè Â·Õ¶è ¡Ù »ÃÐàÁÔ¹ÇèÒà»ç¹ early stage of AD ¼Ù»é Çè ÂÂѧ¤§·Ó¤Ðá¹¹
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4. ¤èÒ¤ÇÒÁÊÑÁ¾Ñ¹¸ì¢Í§ test µèÒ§æ ã¹ early stage ¾ºÇèÒ E4- naming test ÁÕ
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ÁÒ¡¡Ñº learning in the first and eighth trial, naming test, similarity test áÅÐ backward
digits recall test