病史和神经系统检查课件.pptx

1、 history and neurological exam symptoms signs qualitative anatomic( topographic) diagnosis diagnosis other data lab test pathologic(etiologic) diagnosis patients trust and cooperation reliable history and accurate exam correct diagnosisTaking the history Purpose:primary information of the disease wh

2、ere,what,whyguide to the exam and Lab test Taking the history Notice: good attitude while patient saying avoiding suggestionaccurate comprehension of what he/she saytaking care to negative or other systems symptomsobtaining from a relative or friend (coma,child,mental disorder) Structure of the hist

3、oryThe complaintThe presenting historyPast historyPersonal historyFamily historyThe complaint What is the main problem?What was it that caused you to come here?Use the patients language.The presenting historyInformation of onsetNature of the main symptomProcess of the diseaseAssociated symptomsPrece

4、ding treatment Information of onsetWhen it was first noted by the patient?Inducing factors of onset.Was the onset sudden,subacute,insidious or gradual? acute: vascular,poison,trauma,infectionchronic: tumor,metabolism,degeneration Nature of the main symptomWhat is its distribution? unilateral,bilater

5、al,frontal,occipital etc.What is its nature and severity? e.g.headache:throbbing,stabbing,tensingIs there anything that makes it better or worse? e.g. movement,posture,sleep,coughing How long does it take for every attack? has itProcess of the diseaseIs the symptom episodic or constant?Has it worsen

6、ed,improved,or stayed the same since?Associated symptomsAre there any associated symptoms?Have any other symptoms developed since?Neurological symptoms are important, not ignoring the symptoms of other systems. Preceding TreatmentHave any tests already been performed?Has any therapy ever been given?

7、The results of treatmentPast historyThe following may be relevant in neurologyHP、DM、rheumatic valvular heart diseaseinfections during childhoodhead injuries and poisona systemic disorderbirth and early developmentdrug allergiesPersonal historyhome circumstanceeducation and occupationdietsmoking hist

8、ory and alcohol intakeFamily historyare there any family illnesses? hereditary ataxia .muscular dystrophy epilepsy.migraine(susceptible)are parents,siblings,and children alive? if not,what did they die from?Neurological examinationNotice:preparation of tools ophthalmoscope 、hammer、tuning-forkgood at

9、titude and gentle behaviourproceeding from the head downwardsbeginning while taking the historytreating while examining an alarming caseNeurological examinationTesting categoryhigher cortical functioncranial nervesmotor functionsensory functionreflex functionautonomic nervesmeningeal irritation sign

10、s higher cortical functionlevel of consciousnesscognitive functionlanguage skillsemotional stateconsciousnessThe level of arousal normal-full awakefulness and responsiveness somnolent-asleep but rousable when stimulated stupor-difficult in arousal and co-operation coma-unresponsive and unrousableThe

11、 content of consciousness confusion-inattentiveness and disorientation delirium-extreme agitation with hallucinationcognitive function orientation-to person、time、place memory-immediate 、recent 、remote comprehension calculation-serial sevens 、real-life problem Language skillsfluency:non-fluency,error

12、s of grammar,paraphrasiacomprehension:to do following commandsrepetition:to repeat three common nounswriting:aphasia is often together with agraphianaming:difficulty in naming familiar objects(anomia) Language impairment with normal cognitive function always suggests a focal lesionemotional stateNot

13、e:anxiety or excitementdepression or apathyemotional or uninhibited behaviourslowness of movement or responsesCranial nerve examinationOlfactory nerve()Test using aromatic non-irritant materialOne nostril closed while sniffing with the otherOptic nerve()visual acuitydeficit ? mild or severe?visual f

14、ieldsgross testing by confrontationoptic fundusnote:clarity of disc edge hemorrhage arteriolosclerosis Oculomotor(),trochlear(), abducens() nervesptosisocular movement 6 directions,diplopiaconjugate movementnystagmuspupilnote:size,shape,equality,reaction to lightTrigeminal nerve()sensation over whol

15、e face pain,temperature,light touch compare each sidecorneal reflex touch with wisp of cotton wool the most sensitive indicatormotor examination temporalis and masseter musclesFacial nerve()wrinkle forehead flattening of forehead fold?close eyes weakness of closure?purse lips asymmetrical elevation

16、of one corner?show teeth flattening of nasolabial fold?Distinguish central or peripheral facial palsy! Auditory nerve()cochlear component assessing gross hearing tuning-fork test Webers test,Rinnes test differentiate conductive deafness from perceptive(nerve) deafnessvestibular component Glossophary

17、ngeal(), vague() nerveNote: voice-dysphonia swallowing-dysphagiaasymmetry of palatal movement?gag reflex compare sensitivity on each sideAccessory nerve()Sternmastoid rotate head against resistanceTrapezius shrug shoulders against resistanceHypoglossal nerve()evidence of atrophyfasciculationnote: an

18、y difficulty or deviation of protruding tongue (三)Motor systemMuscle bulkMuscle toneMuscle strengthCo-ordinationInvoluntary movementPosture and gaitMuscle bulk(appearance)Note:any asymmetry or deformity muscle wasting(atrophy) muscle hypertrophycomparing sides or measuring if in doubt.Muscle fascicu

19、lation irregular,non-rhythmical contraction of groups of motor units,induced after smacking Muscle tone(tension) Tone is defined resistance of M to passive movement normal,decreased,increasedDecreased in tone lower motor neuron lesion,cerebellar disorderincreased in tone clasp-knife:upper motor neur

20、on lesion lead-pipe: extrapyramidal lesion cog-wheel: extrapyramidal lesion Muscle strength(power) The ability to contract M against force or gravitythe classic grading system scores: full strength movement against partial resistance movement against gravity only movement only if gravity eliminated

21、little visible movement 0 no contractionslight weakness test: Barres test, pronator drift,Jackson signCo-ordination (cerebellar hemispheric funtion)Finger-to-nose: dysmetriaHeel-knee-shinRapid alternating movement: dysdiadochokinesiaReboundRombergs test: loss of balance (+) when eyes open or closed:

22、cerebellar ataxia(+) only when eyes closed:sensory ataxiaInvoluntary movementTremor: a rhythmic oscillatory movement static tremor :(+) at rest postural tremor:(+) during sustained posture intension tremor:(+) during movementChorea: rapid irregular M jerks hemiballismusAthetosis: slow,sinuous,writhi

23、ng movementMyoclonus: sudden,rapid,twitchlike M contraction Posture and gaitSteppage gait(as if chicken)Cerebellar gait(as if drunk)Hemiplegic gait(circumduction)Paraplegic gait(scissoring)Swaying gait(as if duck)Parkinsonian gait(festination) (四)Sensory function Notice:(5C) Co-operation Carefulness

24、 Comparison Confirmed by patient Coming again(四)Sensory functionSuperficial sensation pain(pin) light touch(wisp of cotton wool) temperature(cold or hot test tubes)Deep sensation joint position sensation vibration sensation(tuning fork)Compound sensation tow point discrimination stereognosis graphes

25、thesia(五)Reflex functionDeep tendon reflexesSuperficial cutaneous reflexesBabinskis sign and its equivalent signsFrontal release signs (particular if asymmetric)Deep tendon reflexes the reaction of M to being passively stretched by percussion on the tendon. graded on a scale: clonus(),brisk(),normal

26、(),minimal(),absent(-)upper limb:Biceps,triceps,radial reflexlower limb:patellar,ankle reflexHoffmanns sign,Rossolimos sign hyperactive or the signs(+):lesion of UMN hypoactive:lesion of LMN Superficial cutaneous reflexesAbdominal reflex upper(T7-8),middle(T9-10),lower(T11-12)Cremasteric reflex(L1)A

27、nal reflex(S4-5) hypoactive or absent:lesion of segmental spinal cordBabinskis sign and its equivalent signsplantar flexion of the toes:(-) extension upward of the great toe:(+)a sensitive but nonspecific sign of CNS diseasepathologic reflexFrontal release signs primitive reflexes which disappear as

28、 brain matures. diffuse neuronal dysfunction, especially frontal lobe damage,release them from inhibitiongrasp signglabellar sign snout signsuck sign(六)Autonomic nervesgeneral observation: nutriture of skin and hair,hidrosissphincter function incontinence,retention autonomic nerve reflex skin-striat

29、ed test(七)meningeal irritation signsneck stiffnessKernigs sign stretching nerve roots by extending the knee cause painBrudzinskis signApproach to comaemergency managementhistory and examinationdifferential diagnosisemergency managementA:ensure patency of the Airway Intubation,tracheostomyB:adequacy

30、of BreathingC:adequacy of CirculationD:administration of Drugshistory and examinationobtain a history from a relative or friend.the most crucial aspect is the time which coma developsgeneral physical examination Signs of trauma ,T,BP,P,Rneurologic examination consciousness pupils(asymmetric) optic f

31、undi(papilledema) extraocular movement(oculocephalic reflex ) motor response to pain meningeal irritationLab examinationdifferential diagnosisIntracranial diseases infection,tumour,CVD,injuryMetabolic DM,liver failure,renal failureToxic drug intoxication,alcohol excess,CO2InfectionTumorInjuryStroke(

32、CVD)CO,CO2Opiate(drug)Metabolic diseasesAlcohol IT IS COMA!Conditions that mimic comapsychogenic unresponsiveness catatonia,malingering,mutismlocked-in syndrome ARAS lying above the level of the midponspersistent vegetative state spontaneous eye opening,sleep-wake cyclesSpeech dysfunctionphonation:d

33、ysphonia lesion of recurrent laryngeal N, respiratory M weaknessarticulation:dysarthria cerebellar,extrapyramidal,(pseudo)bulbarlanguage production:dysphasia lesion of the dominant hemisphere expressive(Brocas),receptive(Wernickes)Assistant investigationsimaging of NS computerized tomography(CT) sca

34、nning magnetic resonance imaging(MRI)angiography digital subtractive angiography(DSA),CTA,MRAtranscranial doppler(TCD)electrophysiology EEG,EMG,EPcerebrospinal fluidCSF investigationIndication:infection of CNSCVDspinal disordersGuillain-Barre syndromemyelographytherapeuticsCSF investigationContraind

35、ication:intracranial hyperpressure with prominent occupationfocal infection of puncturing severe casesleakage of CSFCSF investigationConsequent syndromes:headachecerebral hernialumbar painfocal infectionCSF investigationContent:Pressure and Queckenstebt test routine of CSFbiochemistry of CSFetiology of CSF