病史和神經(jīng)系統(tǒng)檢查-醫(yī)藥類課件

1、Taking a history and Neurological examinationTaking a history and NeurologiBeing the essential skill Necessary to learn the clinical methodBeing the essential skill history and neurological exam symptoms signs qualitative anatomic( topographic) diagnosis diagnosis other data lab test pathologic(etio

2、logic) diagnosis history and n patients trust and cooperation reliable history and accurate exam correct diagnosis Taking the history Purpose:primary information of the disease where,what,whyguide to the exam and Lab test Taking the history Purpose:Taking the history Notice: good attitude while pati

3、ent 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) Taking the history Notice:Structure of the historyThe complaintThe presenting historyPast historyPersonal historyFa

4、mily historyStructure of the historyThe coThe complaint What is the main problem?What was it that caused you to come here?Use the patients language.The complaint What is the mainThe presenting historyInformation of onsetNature of the main symptomProcess of the diseaseAssociated symptomsPreceding tre

5、atment The presenting historyInformatInformation 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 Information of onsetWhen it waNature of the main

6、 symptomWhat is its distribution? unilateral,bilateral,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 itNature of the main

7、symptomWhaProcess of the diseaseIs the symptom episodic or constant?Has it worsened,improved,or stayed the same since?Process of the diseaseIs the sAssociated symptomsAre there any associated symptoms?Have any other symptoms developed since?Neurological symptoms are important, not ignoring the sympt

8、oms of other systems. Associated symptomsAre there Preceding TreatmentHave any tests already been performed?Has any therapy ever been given?The results of treatmentPreceding TreatmentHave any tPast historyThe following may be relevant in neurologyHP、DM、rheumatic valvular heart diseaseinfections duri

9、ng childhoodhead injuries and poisona systemic disorderbirth and early developmentdrug allergiesPast historyThe following may Personal historyhome circumstanceeducation and occupationdietsmoking history and alcohol intakePersonal historyhome circumstaFamily historyare there any family illnesses? her

10、editary ataxia .muscular dystrophy epilepsy.migraine(susceptible)are parents,siblings,and children alive? if not,what did they die from?Family historyare there any faNeurological examinationNotice:preparation of tools ophthalmoscope 、hammer、tuning-forkgood attitude and gentle behaviourproceeding fro

11、m the head downwardsbeginning while taking the historytreating while examining an alarming caseNeurological examinationNoticeNeurological examinationTesting categoryhigher cortical functioncranial nervesmotor functionsensory functionreflex functionautonomic nervesmeningeal irritation signs Neurologi

12、cal examinationTestinhigher cortical functionlevel of consciousnesscognitive functionlanguage skillsemotional statehigher cortical functionlevelconsciousnessThe level of arousal normal-full awakefulness and responsiveness somnolent-asleep but rousable when stimulated stupor-difficult in arousal and

13、co-operation coma-unresponsive and unrousableThe content of consciousness confusion-inattentiveness and disorientation delirium-extreme agitation with hallucinationconsciousnessThe level of aroucognitive function orientation-to person、time、place memory-immediate 、recent 、remote comprehension calcula

14、tion-serial sevens 、real-life problem cognitive function orientatiLanguage skillsfluency:non-fluency,errors of grammar,paraphrasiacomprehension:to do following commandsrepetition:to repeat three common nounswriting:aphasia is often together with agraphianaming:difficulty in naming familiar objects(a

15、nomia) Language impairment with normal cognitive function always suggests a focal lesionLanguage skillsfluency:non-fluemotional stateNote:anxiety or excitementdepression or apathyemotional or uninhibited behaviourslowness of movement or responsesemotional stateNote:Cranial nerve examinationCranial n

16、erve examinOlfactory nerve()Test using aromatic non-irritant materialOne nostril closed while sniffing with the otherOlfactory nerve()Test using aOptic nerve()visual acuitydeficit ? mild or severe?visual fieldsgross testing by confrontationoptic fundusnote:clarity of disc edge hemorrhage arteriolosc

17、lerosis Optic nerve()visual acuityOculomotor(),trochlear(), abducens() nervesptosisocular movement 6 directions,diplopiaconjugate movementnystagmuspupilnote:size,shape,equality,reaction to lightOculomotor(),trochlear(), abTrigeminal nerve()sensation over whole face pain,temperature,light touch compa

18、re each sidecorneal reflex touch with wisp of cotton wool the most sensitive indicatormotor examination temporalis and masseter musclesTrigeminal nerve()sensationFacial nerve()wrinkle forehead flattening of forehead fold?close eyes weakness of closure?purse lips asymmetrical elevation of one corner?

19、show teeth flattening of nasolabial fold?Distinguish central or peripheral facial palsy! Facial nerve()wrinkle foreheaAuditory nerve()cochlear component assessing gross hearing tuning-fork test Webers test,Rinnes test differentiate conductive deafness from perceptive(nerve) deafnessvestibular compon

20、ent Auditory nerve()cochlear compGlossopharyngeal(), vague() nerveNote: voice-dysphonia swallowing-dysphagiaasymmetry of palatal movement?gag reflex compare sensitivity on each sideGlossopharyngeal(), vague() Accessory nerve()Sternmastoid rotate head against resistanceTrapezius shrug shoulders again

21、st resistanceAccessory nerve()SternmastoidHypoglossal nerve()evidence of atrophyfasciculationnote: any difficulty or deviation of protruding tongue Hypoglossal nerve()evidence o(三)Motor systemMuscle bulkMuscle toneMuscle strengthCo-ordinationInvoluntary movementPosture and gait(三)Motor systemMuscle

22、bulkMuscle bulk(appearance)Note:any asymmetry or deformity muscle wasting(atrophy) muscle hypertrophycomparing sides or measuring if in doubt.Muscle fasciculation irregular,non-rhythmical contraction of groups of motor units,induced after smacking Muscle bulk(appearance)Note:Muscle tone(tension) Ton

23、e 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 neuron lesion lead-pipe: extrapyramidal lesion cog-wheel: extrapyramidal lesion Muscle tone(tension) Tone isMuscle stren

24、gth(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 little visible movement 0 no contractionslight weakness test: Barres test, pronator drif

25、t,Jackson signMuscle strength(power) Co-ordination (cerebellar hemispheric funtion)Finger-to-nose: dysmetriaHeel-knee-shinRapid alternating movement: dysdiadochokinesiaReboundRombergs test: loss of balance (+) when eyes open or closed:cerebellar ataxia(+) only when eyes closed:sensory ataxiaCo-ordin

26、ation (cerebellInvoluntary 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,writhing movementMyoclonus: sudden,rapid,twitchl

27、ike M contraction Involuntary movementTremor: a 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) Posture and gaitSteppage gait(四)Sensory function Notice:(5C) Co-oper

28、ation Carefulness Comparison Confirmed by patient Coming again(四)Sensory function No(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 po

29、int discrimination stereognosis graphesthesia(四)Sensory functionSuperficial(五)Reflex functionDeep tendon reflexesSuperficial cutaneous reflexesBabinskis sign and its equivalent signsFrontal release signs (particular if asymmetric)(五)Reflex functionDeep tendonDeep tendon reflexes the reaction of M to

30、 being passively stretched by percussion on the tendon. graded on a scale: clonus(),brisk(),normal(),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 Deep tendon

31、 reflexes the reSuperficial cutaneous reflexesAbdominal reflex upper(T7-8),middle(T9-10),lower(T11-12)Cremasteric reflex(L1)Anal reflex(S4-5) hypoactive or absent:lesion of segmental spinal cordSuperficial cutaneous reflexesBabinskis sign and its equivalent signsplantar flexion of the toes:(-) exten

32、sion upward of the great toe:(+)a sensitive but nonspecific sign of CNS diseasepathologic reflexBabinskis sign and its equivaFrontal release signs primitive reflexes which disappear as brain matures. diffuse neuronal dysfunction, especially frontal lobe damage,release them from inhibitiongrasp signg

33、labellar sign snout signsuck signFrontal release signs primitiv(六)Autonomic nervesgeneral observation: nutriture of skin and hair,hidrosissphincter function incontinence,retention autonomic nerve reflex skin-striated test(六)Autonomic nervesgeneral obs(七)meningeal irritation signsneck stiffnessKernig

34、s sign stretching nerve roots by extending the knee cause painBrudzinskis sign(七)meningeal irritation signsnApproach to comaemergency managementhistory and examinationdifferential diagnosisApproach to comaemergency manaemergency managementA:ensure patency of the Airway Intubation,tracheostomyB:adequ

35、acy of BreathingC:adequacy of CirculationD:administration of Drugsemergency managementA:ensure phistory 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 consci

36、ousness pupils(asymmetric) optic fundi(papilledema) extraocular movement(oculocephalic reflex ) motor response to pain meningeal irritationLab examinationhistory and examinationobtain differential diagnosisIntracranial diseases infection,tumour,CVD,injuryMetabolic DM,liver failure,renal failureToxic drug intoxication,alcohol excess,CO2differential diagnosisIntracraInfectionTumorInjuryStroke(CVD)CO,CO2Opiate(drug)Metabolic diseasesAlcohol IT IS COMA!InfectionConditions that mimic comapsychogenic unresponsiveness catatonia,malingering,mutismlocked-in syndrome ARAS lying above t