神經(jīng)系統(tǒng)體查與腰椎穿刺

1、中南大學(xué)湘雅二醫(yī)院神經(jīng)內(nèi)科申向民神經(jīng)系統(tǒng)體格檢查神經(jīng)系統(tǒng)體格檢查u一般檢查一般檢查u意識障礙檢查意識障礙檢查u精神狀態(tài)和高級皮質(zhì)功能檢查精神狀態(tài)和高級皮質(zhì)功能檢查u腦神經(jīng)檢查腦神經(jīng)檢查u運動系統(tǒng)檢查運動系統(tǒng)檢查u感覺系統(tǒng)檢查感覺系統(tǒng)檢查u反射檢查反射檢查u自主神經(jīng)檢查自主神經(jīng)檢查腰椎穿刺腰椎穿刺u腰椎穿刺腰椎穿刺u腦脊液檢查腦脊液檢查Neurological Examination神經(jīng)系統(tǒng)體格檢查檢查順序l病房：臥位-坐位-立位l門診：坐位-立位-臥位l體格檢查時檢查者一般在病人的右邊神經(jīng)系統(tǒng)體格檢查概述 l 神經(jīng)病學(xué)研究范圍：神經(jīng)系統(tǒng)疾病及骨骼肌疾病l 神經(jīng)系統(tǒng)疾病診斷的特點：定位診斷定位診

2、斷加定性診斷定性診斷l(xiāng) 定位診斷：體征是重點體征是重點+結(jié)合神經(jīng)解剖知識l 定性診斷：病史+輔助檢查等神經(jīng)系統(tǒng)體格檢查一般檢查 l 生命體征l 體味或呼吸氣味l 發(fā)育和體形 l 營養(yǎng)狀態(tài) l 面容表情l 體位l 語言、語調(diào)、語態(tài)和構(gòu)音l 姿勢和步態(tài)l 皮膚黏膜l 頭頸部l 胸腹部l 軀干和四肢 神經(jīng)系統(tǒng)體格檢查體溫 l 正常體溫l 體溫過高l 體溫過低 神經(jīng)系統(tǒng)體格檢查脈搏l 脈搏增快l 細(xì)數(shù)或不規(guī)則l 急性顱內(nèi)壓增高l 心源性因素 神經(jīng)系統(tǒng)體格檢查呼吸l Kussmual呼吸l 淺快呼吸l 呼吸緩慢l 呼吸節(jié)律改變 潮式呼吸：間腦 中樞神經(jīng)源性過度呼吸：中腦被蓋部 長吸式呼吸：中腦下部和橋腦

3、上部 叢集式呼吸：腦橋下部 共濟(jì)失調(diào)式呼吸：延髓上部 神經(jīng)系統(tǒng)體格檢查神經(jīng)系統(tǒng)體格檢查血壓l 血壓顯著升高l 血壓過低神經(jīng)系統(tǒng)體格檢查體味或呼吸氣味l 酒味l 爛蘋果味l 肝臭味l 氨味或尿味l 大蒜味神經(jīng)系統(tǒng)體格檢查發(fā)育和體形l 發(fā)育正常：胸圍、上肢展開、坐高l 身材矮小神經(jīng)系統(tǒng)體格檢查營養(yǎng)狀態(tài)l 評估l 檢查方法神經(jīng)系統(tǒng)體格檢查面容表情l 正常人l 特殊表情：帕金森病神經(jīng)系統(tǒng)體格檢查體位l 自主體位l 被動體位l 強迫體位神經(jīng)系統(tǒng)體格檢查語言、語調(diào)、語態(tài)和構(gòu)音l 語言l 語調(diào)：語音和聲調(diào)l 語態(tài)：節(jié)奏l(xiāng) 構(gòu)音神經(jīng)系統(tǒng)體格檢查姿勢與步態(tài)l 姿勢：舉止l 步態(tài)：行走神經(jīng)系統(tǒng)體格檢查皮膚黏膜l

4、黃染、蒼白、發(fā)紺l 櫻紅色、潮紅l 多汗：有機(jī)磷中毒、甲亢危象或低血糖l 面部黃色瘤神經(jīng)系統(tǒng)體格檢查頭頸部l 頭顱部l 面部及五官l 頸部l 頭顱外傷： 眶周瘀斑 鼓膜血腫 腦脊液鼻漏或耳漏神經(jīng)系統(tǒng)體格檢查胸腹部l 胸部異常l 心律異常l 肝、脾大合并腹水l 腹部膨隆并壓痛神經(jīng)系統(tǒng)體格檢查軀干和四肢l 脊柱異常l 翼狀肩胛、四肢、指趾畸形l 皮下瘤結(jié)節(jié)和牛奶咖啡斑l 肌束震顫l 撲翼樣震顫意識障礙檢查概述 l 大腦功能的綜合表現(xiàn)，人對自身和外界環(huán)境進(jìn)行認(rèn)識和做出適宜反應(yīng)的基礎(chǔ)，包括覺醒狀態(tài)和意識內(nèi)容。l 覺醒狀態(tài)l 意識內(nèi)容l 意識障礙意識障礙檢查概述 l 采集病史l 全身和神經(jīng)系統(tǒng)檢查 意識

5、障礙的覺醒水平意識障礙的覺醒水平 意識內(nèi)容的改變意識內(nèi)容的改變意識障礙檢查概述 l 眼征l 疼痛刺激的反應(yīng)l 癱瘓體征l 腦干反射l 錐體束征l 腦膜刺激征意識障礙檢查意識障礙檢查眼征 l 瞳孔l 眼底l 眼球位置l 眼球運動意識障礙檢查疼痛刺激反應(yīng) l 肢體反應(yīng)l 面部表情l 去皮質(zhì)強直l 去腦強直l 腦橋和延髓病變意識障礙檢查癱瘓體征l 面癱l 自發(fā)活動l 疼痛刺激l 肌張力l 墜落試驗意識障礙檢查腦干反射l 睫脊反射（ciliospinal reflex）l 角膜反射（corneal reflex）l 頭眼反射（oculocephalic reflex）l 眼前庭反射（oculovest

6、ibular reflex）意識障礙檢查呼吸形式腦膜刺激征意識障礙的其他體征精神狀態(tài)和皮質(zhì)功能概述 l 神經(jīng)性/精神性疾病l 局灶性/彌漫性腦損害l 精神狀態(tài)l 高級皮質(zhì)功能檢查 認(rèn)知功能 非認(rèn)知功能精神狀態(tài)和皮質(zhì)功能記憶 l 瞬時記憶l 短時記憶l 長時記憶精神狀態(tài)和皮質(zhì)功能計算力 l 時間定向力l 地點定向力l 人物定向力定向力 精神狀態(tài)和皮質(zhì)功能失語 l 口語表達(dá)：流暢，語音障礙，找詞，錯語、新語等，語法障礙l 聽理解l 復(fù)述l 命名l 閱讀l 書寫精神狀態(tài)和皮質(zhì)功能Damage to Brocas area producesdifficulty in speakingDamage to

7、 Wernickes area results in difficulty in languagecomprehension精神狀態(tài)和皮質(zhì)功能Type of DysphasiaFluencyComprehensionNamingLocalizationBrocaNonfluentIntactImpairedBroca areaWernickeFluentImpairedImpairedWernicke areaConductionFluentIntactImpairedArcuate fasciculusGlobalNonfluentImpairedImpairedBroca and Wern

8、icke areasTranscortical aphasiasAnother function that is impaired in all 4 of the aphasias mentioned above is repetition. This finding is important in the diagnosis of transcortical aphasias. When repetition is preserved in a patient with Broca aphasia, it signifies transcortical motor aphasia, and

9、the lesion is anterior to the Broca area. When repetition is preserved in Wernicke aphasia, it is called transcortical sensory aphasia, and the lesion is posterior to the Wernicke area. Transcortical mixed aphasia and global aphasia are similar except for the preservation of repetition, and results

10、from combined lesions anterior to the Broca and Wernicke areas, respectively精神狀態(tài)和皮質(zhì)功能精神狀態(tài)和皮質(zhì)功能精神狀態(tài)和皮質(zhì)功能失用 l 口頭和書面命令l 觀察患者 執(zhí)行命令 模仿動作 實物演示能力精神狀態(tài)和皮質(zhì)功能失認(rèn) l 視覺失認(rèn)l 聽覺失認(rèn)l 觸覺失認(rèn)精神狀態(tài)和皮質(zhì)功能視空間技能和執(zhí)行功能 l 畫鐘面l 填數(shù)字l 指定時間畫出表針顱神經(jīng)檢查l 12 Pairsl Arise from brain steml Motor and sensory functions顱神經(jīng)檢查顱神經(jīng)檢查嗅神經(jīng) l 特殊感覺神經(jīng)l 檢

11、查方法l 異常表現(xiàn)和定位 嗅覺喪失和減退 嗅覺過敏 幻嗅顱神經(jīng)檢查視神經(jīng) l 視力l 視野l(fā) 眼底l 異常表現(xiàn)和定位 視力障礙和視野缺損 視乳頭異常顱神經(jīng)檢查顱神經(jīng)檢查顱神經(jīng)檢查Papilledema. Note swelling of the disc, hemorrhages, and exudates, with preservation of the physiologic cup Optic Atrophy. Note the chalky white disc with discrete margins. Optic atrophy is a late finding with i

12、ncreased intracranial pressure. 顱神經(jīng)檢查動眼、滑車、展神經(jīng) l 外觀l 眼球運動l 瞳孔及其反射l 異常表現(xiàn)和定位 眼瞼下垂 眼外肌麻痹 眼球震顫 瞳孔Note extra-ocular muscle palsies and horizontal or vertical nystagmus.The limitation of movement of both eyes in one direction is called a conjugate lesion or gaze palsy, and is indicative of a central lesio

13、n it can be either supranuclear (in cortical gaze centers) or nuclear (in brain stem gaze centers). Disconjugate lesionsinternuclear ophthalmoplegia (INO). isolated impairment of adduction of one eye, nystagmus is often present ipsilateral median longitudinal fasciculus (MLF) lesion.Gaze-evoked nyst

14、agmus (nystagmus that is apparent only when the patient looks to the side or down) may be caused by many drugs, including ethanol, barbiturates, and phenytoin (Dilantin). Ethanol and barbiturates (recreational or therapuetic) are the most common cause of nystagmusOcular bobbing is the rhythmical con

15、jugate deviation of the eyes downward. characteristic of damage to the pons. Downbeat nystagmus indicate a lesion compressing on the cervicomedullary junction 顱神經(jīng)檢查三叉神經(jīng) l 混合神經(jīng)l 面部感覺l 咀嚼肌運動l 反射l 異常表現(xiàn)和定位 顱神經(jīng)檢查面神經(jīng) l 混合神經(jīng)l 面肌運動l 感覺l 反射l 副交感l(wèi) 異常表現(xiàn)和定位 顱神經(jīng)檢查位聽神經(jīng) l 蝸神經(jīng) Rinne試驗試驗 Weber試驗試驗l 前庭神經(jīng)l 異常表現(xiàn)和定位 The

16、 Weber test(256Hz). Normally, the sound is heard in the center of the head or equally in both ears. conductive hearing loss the vibration will be louder on the affectedThe Rinne test place the butt on the mastoid eminence firmly. Tell the patient to say now when they can no longer hear the vibration

17、. Normally, one will have greater air conduction than bone conduction and therefore hear the vibration longer with the fork in the air. If the bone conduction is the same or greater than the air conduction, there is a conductive hearing impairment on that side. If there is a sensineuronal hearing lo

18、ss, then the vibration is heard substantially longer than usual in the air. 顱神經(jīng)檢查舌咽、迷走神經(jīng) l 運動l 感覺l 味覺l 反射l 異常表現(xiàn)和定位 真性球麻痹 假性球麻痹 迷走神經(jīng)刺激癥狀 顱神經(jīng)檢查副神經(jīng) l 運動神經(jīng)l 胸鎖乳突肌l 斜方肌上部 顱神經(jīng)檢查舌下神經(jīng) l 運動神經(jīng)l 核下性病變l 核性病變l 核上性病變 運動系統(tǒng)檢查l肌容積肌容積l肌張力肌張力l肌力肌力l不自主運動不自主運動l共濟(jì)運動共濟(jì)運動l姿勢與步態(tài)姿勢與步態(tài) 運動系統(tǒng)檢查肌容積 l肌萎縮l假性肥大l肌肉束顫 運動系統(tǒng)檢查肌張力 l肌張力減

19、低l肌張力增高 錐體系損傷 錐體外系損傷 運動系統(tǒng)檢查肌力 l 六級肌力記錄法l 肌群肌力測定l 單塊肌肉檢查l 輕癱檢查法 上肢平伸試驗、Barre分指試驗、小指征 Jackson征、下肢輕癱試驗 運動系統(tǒng)檢查不自主運動 l 舞蹈樣動作l 手足徐動l 肌束顫動l 肌痙攣l 震顫l 肌張力障礙運動系統(tǒng)檢查共濟(jì)運動 l 指鼻試驗l 反擊征l 跟膝脛試驗l 輪替試驗l 起坐試驗l 閉目難立試驗 Coordination, Gait and Rhomberg TestCoordinationRapidly Alternating Movement Evaluation Dysdiadochokine

20、sis is the clinical term for an inability to perform rapidly alternating movements. Point-to-Point Movement Evaluation The clinical term: Dysmetriaheel to shin coordination test Rhomberg Test To achieve balance, a person requires 2 out of the following 3 inputs to the cortex: 1. visual confirmation

21、of position, 2. non-visual confirmation of position (including proprioceptive and vestibular input), and 3. a normally functioning cerebellum. 運動系統(tǒng)檢查姿勢與步態(tài) l姿勢l步態(tài)l起步情況l步幅l速度Gait Tandem walkingOn ToesOn Heels感覺系統(tǒng)檢查感覺系統(tǒng) l淺感覺l深感覺l復(fù)合感覺 感覺系統(tǒng)檢查淺感覺 l痛覺l觸覺l溫度覺 The Sensory System Examination Pain and Light To

22、uch Sensation感覺系統(tǒng)檢查深感覺 l運動覺l位置覺l振動覺 感覺系統(tǒng)檢查復(fù)合感覺 l定位覺l兩點辨別覺l圖形覺l實體覺Position Sense Stereognosia Graphesthesia Extinction 反射檢查反射檢查 l深反射l淺反射l病理反射 反射檢查深反射 l上肢反射l下肢反射l陣攣lHoffmann征lRossolimo征 The biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve roots The triceps reflex is mediated by

23、the C6 and C7 nerve roots, predominantly by C7. The knee jerk reflex is mediated by the L3 and L4 nerve roots, mainly L4. The ankle jerk reflex is mediated by the S1 nerve root.The normal reflex is toe flexion. If the toes extend and separate, this is an abnormal finding called a positive Babinskis sign. It is an indicative of an UMN lesionA positive Hoffman response is indicative of an upper motor neuron lesion affecting the upper extremity in question. Finally, test clonus 反射