病史和神經(jīng)系統(tǒng)檢查

病史和神經(jīng)系統(tǒng)檢查第1頁(yè)/共61頁(yè)

historyandneurologicalexamsymptomssigns

qualitative

anatomic(topographic)diagnosisdiagnosis

otherdatalabtest

pathologic(etiologic)diagnosis

第2頁(yè)/共61頁(yè)

patient’strustandcooperationreliablehistoryandaccurateexamcorrectdiagnosis第3頁(yè)/共61頁(yè)TakingthehistoryPurpose:primaryinformationofthediseasewhere,what,why…guidetotheexamandLabtest

第4頁(yè)/共61頁(yè)TakingthehistoryNotice:

goodattitudewhilepatientsayingavoidingsuggestionaccuratecomprehensionofwhathe/shesaytakingcaretonegativeorothersystems’symptomsobtainingfromarelativeorfriend(coma,child,mentaldisorder)

第5頁(yè)/共61頁(yè)StructureofthehistoryThecomplaintThepresentinghistoryPasthistoryPersonalhistoryFamilyhistory第6頁(yè)/共61頁(yè)ThecomplaintWhatisthemainproblem?Whatwasitthatcausedyoutocomehere?Usethepatient’slanguage.第7頁(yè)/共61頁(yè)ThepresentinghistoryInformationofonsetNatureofthemainsymptomProcessofthediseaseAssociatedsymptomsPrecedingtreatment第8頁(yè)/共61頁(yè)InformationofonsetWhenitwasfirstnotedbythepatient?Inducingfactorsofonset.Wastheonsetsudden,subacute,insidiousorgradual?

acute:vascular,poison,trauma,infectionchronic:tumor,metabolism,degeneration

第9頁(yè)/共61頁(yè)Natureofthemainsymptom

Whatisitsdistribution?unilateral,bilateral,frontal,occipitaletc.Whatisitsnatureandseverity?e.g.headache:throbbing,stabbing,tensing…Isthereanythingthatmakesitbetterorworse?e.g.movement,posture,sleep,coughing…Howlongdoesittakeforeveryattack?…h(huán)asit第10頁(yè)/共61頁(yè)P(yáng)rocessofthediseaseIsthesymptomepisodicorconstant?Hasitworsened,improved,orstayedthesamesince?第11頁(yè)/共61頁(yè)Associatedsymptoms

Arethereanyassociatedsymptoms?Haveanyothersymptomsdevelopedsince?Neurologicalsymptomsareimportant,notignoringthesymptomsofothersystems.第12頁(yè)/共61頁(yè)P(yáng)recedingTreatment

Haveanytestsalreadybeenperformed?Hasanytherapyeverbeengiven?Theresultsoftreatment第13頁(yè)/共61頁(yè)P(yáng)asthistoryThefollowingmayberelevantinneurologyHP、DM、rheumaticvalvularheartdiseaseinfectionsduringchildhoodheadinjuriesandpoisonasystemicdisorderbirthandearlydevelopmentdrugallergies第14頁(yè)/共61頁(yè)P(yáng)ersonalhistoryhomecircumstanceeducationandoccupationdietsmokinghistoryandalcoholintake第15頁(yè)/共61頁(yè)Familyhistoryarethereanyfamilyillnesses?hereditaryataxia.musculardystrophyepilepsy.migraine(susceptible)areparents,siblings,andchildrenalive?ifnot,whatdidtheydiefrom?第16頁(yè)/共61頁(yè)NeurologicalexaminationNotice:preparationoftoolsophthalmoscope、hammer、tuning-forkgoodattitudeandgentlebehaviourproceedingfromtheheaddownwardsbeginningwhiletakingthehistorytreatingwhileexamininganalarmingcase第17頁(yè)/共61頁(yè)NeurologicalexaminationTestingcategoryhighercorticalfunctioncranialnervesmotorfunctionsensoryfunctionreflexfunctionautonomicnervesmeningealirritationsigns第18頁(yè)/共61頁(yè)㈠highercorticalfunctionlevelofconsciousnesscognitivefunctionlanguageskillsemotionalstate第19頁(yè)/共61頁(yè)consciousnessThelevelofarousal

normal-fullawakefulnessandresponsiveness

somnolent-asleepbutrousablewhenstimulated

stupor-difficultinarousalandco-operation

coma-unresponsiveandunrousableThecontentofconsciousness

confusion-inattentivenessanddisorientation

delirium-extremeagitationwithhallucination第20頁(yè)/共61頁(yè)cognitivefunction

orientation-toperson、time、place

memory-immediate、recent、remote

comprehensioncalculation-serialsevens、real-lifeproblem

第21頁(yè)/共61頁(yè)Languageskillsfluency:non-fluency,errorsofgrammar,paraphrasiacomprehension:todofollowingcommandsrepetition:torepeatthreecommonnounswriting:aphasiaisoftentogetherwithagraphianaming:difficultyinnamingfamiliarobjects(anomia)

Languageimpairmentwithnormalcognitivefunctionalwayssuggestsafocallesion第22頁(yè)/共61頁(yè)emotionalstateNote:anxietyorexcitementdepressionorapathyemotionaloruninhibitedbehaviourslownessofmovementorresponses第23頁(yè)/共61頁(yè)㈡Cranialnerve

examination第24頁(yè)/共61頁(yè)Olfactorynerve(Ⅰ)Testusingaromaticnon-irritantmaterialOnenostrilclosedwhilesniffingwiththeother第25頁(yè)/共61頁(yè)Opticnerve(Ⅱ)visualacuitydeficit?mildorsevere?visualfieldsgrosstestingbyconfrontationopticfundusnote:clarityofdiscedgehemorrhagearteriolosclerosis

第26頁(yè)/共61頁(yè)Oculomotor(Ⅲ),trochlear(Ⅳ),abducens(Ⅵ)nervesptosisocularmovement6directions,diplopiaconjugatemovementnystagmuspupilnote:size,shape,equality,reactiontolight第27頁(yè)/共61頁(yè)Trigeminalnerve(Ⅴ)sensationoverwholeface

pain,temperature,lighttouchcompareeachsidecornealreflextouchwithwispofcottonwoolthemostsensitiveindicatormotorexamination

temporalisandmassetermuscles第28頁(yè)/共61頁(yè)Facialnerve(Ⅶ)wrinkleforeheadflatteningofforeheadfold?closeeyesweaknessofclosure?purselipsasymmetricalelevationofonecorner?showteethflatteningofnasolabialfold?Distinguishcentralorperipheralfacialpalsy!第29頁(yè)/共61頁(yè)Auditorynerve(Ⅷ)cochlearcomponentassessinggrosshearingtuning-forktestWeber’stest,Rinne’stestdifferentiateconductivedeafnessfromperceptive(nerve)deafnessvestibularcomponent

第30頁(yè)/共61頁(yè)Glossopharyngeal(Ⅸ),vague(Ⅹ)nerveNote:voice-dysphoniaswallowing-dysphagiaasymmetryofpalatalmovement?gagreflex

comparesensitivityoneachside第31頁(yè)/共61頁(yè)Accessorynerve(Ⅺ)SternmastoidrotateheadagainstresistanceTrapeziusshrugshouldersagainstresistance第32頁(yè)/共61頁(yè)Hypoglossalnerve(Ⅻ)evidenceofatrophyfasciculationnote:anydifficultyordeviationofprotrudingtongue第33頁(yè)/共61頁(yè)(三)MotorsystemMusclebulkMuscletoneMusclestrengthCo-ordinationInvoluntarymovementPostureandgait第34頁(yè)/共61頁(yè)Musclebulk(appearance)Note:anyasymmetryordeformitymusclewasting(atrophy)musclehypertrophycomparingsidesormeasuringifindoubt.Musclefasciculation

irregular,non-rhythmicalcontractionofgroupsofmotorunits,inducedaftersmacking

第35頁(yè)/共61頁(yè)Muscletone(tension)ToneisdefinedresistanceofMtopassivemovementnormal,decreased,increasedDecreasedintonelowermotorneuronlesion,cerebellardisorderincreasedintone

clasp-knife:uppermotorneuronlesion

lead-pipe:extrapyramidallesion

cog-wheel:extrapyramidallesion第36頁(yè)/共61頁(yè)Musclestrength(power)TheabilitytocontractMagainstforceorgravitytheclassicgradingsystemscores:

Ⅴfullstrength

Ⅳmovementagainstpartialresistance

Ⅲmovementagainstgravityonly

Ⅱmovementonlyifgravityeliminated

Ⅰlittlevisiblemovement

0nocontractionslightweaknesstest:Barre’stest,pronatordrift,Jacksonsign第37頁(yè)/共61頁(yè)Co-ordination(cerebellarhemisphericfuntion)Finger-to-nose:dysmetriaHeel-knee-shinRapidalternatingmovement:

dysdiadochokinesiaReboundRomberg’stest:lossofbalance(+)wheneyesopenorclosed:cerebellarataxia(+)onlywheneyesclosed:sensoryataxia第38頁(yè)/共61頁(yè)InvoluntarymovementTremor:arhythmicoscillatorymovement

statictremor:(+)atrestposturaltremor:(+)duringsustainedpostureintensiontremor:(+)duringmovementChorea:rapidirregularMjerks

hemiballismusAthetosis:slow,sinuous,writhingmovementMyoclonus:sudden,rapid,twitchlikeMcontraction第39頁(yè)/共61頁(yè)P(yáng)ostureandgaitSteppagegait(asifchicken)Cerebellargait(asifdrunk)Hemiplegicgait(circumduction)Paraplegicgait(scissoring)Swayinggait(asifduck)Parkinsoniangait(festination)

第40頁(yè)/共61頁(yè)(四)Sensoryfunction

Notice:(5C)

Co-operationCarefulnessComparisonConfirmedbypatientComingagain第41頁(yè)/共61頁(yè)(四)SensoryfunctionSuperficialsensationpain(pin)lighttouch(wispofcottonwool)temperature(coldorhottesttubes)Deepsensationjointpositionsensationvibrationsensation(tuningfork)Compoundsensation

towpointdiscriminationstereognosisgraphesthesia第42頁(yè)/共61頁(yè)(五)Reflexfunction

DeeptendonreflexesSuperficialcutaneousreflexesBabinski’ssignanditsequivalentsignsFrontalreleasesigns

(particularifasymmetric)第43頁(yè)/共61頁(yè)DeeptendonreflexesthereactionofMtobeingpassivelystretchedbypercussiononthetendon.gradedonascale:clonus(┼┼┼┼),brisk(┼┼┼),normal(┼┼),minimal(┼),absent(-)upperlimb:Biceps,triceps,radialreflexlowerlimb:patellar,anklereflexHoffmann’ssign,Rossolimo’ssignhyperactiveorthesigns(+):lesionofUMNhypoactive:lesionofLMN

第44頁(yè)/共61頁(yè)SuperficialcutaneousreflexesAbdominalreflexupper(T7-8),middle(T9-10),lower(T11-12)Cremastericreflex(L1)Analreflex(S4-5)hypoactiveorabsent:lesionofsegmentalspinalcord第45頁(yè)/共61頁(yè)Babinski’ssignanditsequivalentsignsplantarflexionofthetoes:(-)extensionupwardofthegreattoe:(+)asensitivebutnonspecificsignofCNSdiseasepathologicreflex第46頁(yè)/共61頁(yè)Frontalreleasesigns

primitivereflexeswhichdisappearasbrainmatures.diffuseneuronaldysfunction,especiallyfrontallobedamage,releasethemfrominhibitiongraspsignglabellarsignsnoutsignsucksign第47頁(yè)/共61頁(yè)(六)Autonomicnervesgeneralobservation:nutritureofskinandhair,hidrosissphincterfunctionincontinence,retentionautonomicnervereflexskin-striatedtest第48頁(yè)/共61頁(yè)(七)meningealirritationsignsneckstiffnessKernig’ssignstretchingnerverootsbyextendingthekneecausepainBrudzinski’ssign第49頁(yè)/共61頁(yè)Approachtocomaemergencymanagementhistoryandexaminationdifferentialdiagnosis第50頁(yè)/共61頁(yè)emergencymanagementA:ensurepatencyoftheAirwayIntubation,tracheostomyB:adequacyofBreathingC:adequacyofCirculationD:administrationofDrugs第51頁(yè)/共61頁(yè)historyandexaminationobtainahistoryfromarelativeorfriend.themostcrucialaspectisthetimewhichcomadevelopsgeneralphysicalexaminationSignsoftrauma,T,BP,P,Rneurologicexaminationconsciousnesspupils(asymmetric)opticfundi(papilledema)extraocularmovement(oculocephalicreflex)motorresponsetopainmeningealirritationLabexamination第52頁(yè)/共61頁(yè)differentialdiagnosisIntracranialdiseasesinfection,tumour,CVD,injuryMetabolicDM,liverfailure,renalfailureToxicdrugintoxication,alcoholexcess,CO2第53頁(yè)/共61頁(yè)InfectionTumorInjuryStroke(CVD)CO,CO2Opiate(drug)MetabolicdiseasesAlco