人體結(jié)構(gòu)與功能 27-Clinical examination學(xué)習(xí)資料

NeurologicalExamination神經(jīng)系統(tǒng)檢查

DepartmentofNeurology

QiLuHospital,ShandongUniversityDr.ShengjunWangPatientevaluationHistoryExaminationSymptomsSignsAnatomicallocalizationLaboratorytestsCTorMRICSFElectrophysiologyAngiographyMoleculargenetics

PathologicalDiagnosisTreatmentplanEtiologicalDiagnosisPrognosis

ClinicalApproachtoNeurologicalDisease

StructureofthehistoryName、Age、Occupation姓名、年齡、職業(yè)Complaint主訴Historyofpresentingcomplaint現(xiàn)病史Pastmedicalhistory既往病史Reviewofsystems全身各系統(tǒng)回顧Drughistory藥物史Familyhistory家族史Socialhistory生活史

TakingaHistory病史采集神經(jīng)系統(tǒng)檢查TheNeurologicExaminationReflexHammer128(or512)HzTuningForksASnellenEyeChartPenLightorOtoscopeWoodenHandledCottonSwabsPaperClipsEquipmentsforNeurologicExaminationMentalStatus(精神智能狀態(tài))CranialNerves（顱神經(jīng)）MotorExam（運動）Reflexes（反射）Coordination&Gait(共濟運動與步態(tài))SensoryExam（感覺）ContentoftheNeurologicalExamAlertness/ConsciousnessAttentionOrientationPerson,Place,Time,&SituationCognitivefunctionPerceptionIllusions=misinterpretationsofrealexternalstimuliHallucinations=subjectivesensoryperceptionsintheabsenceofstimuliJudgmentMoodAnxiety&DepressionSpeechRate&rhythmSpontaneityFluencySimplevs.complexMentalStatus精神意識狀態(tài)NORMAL:Thepatientawakeandalert,attentivetosurroundingandtotheexaminerDEPRESSED:(1)Drowsiness:(somnolence)嗜睡:Arousestovoiceandcanrespondverbally(2)Stupor昏睡:Noresponsetovoice,nospontaneousspeech.Incompletebutpurposefulresponsetopain(3)Coma昏迷:Nonpurposefulornoresponsetopain

1)Mildcoma:sensitivenessoflightresponse,steadyofrespirationandcirculationfunctions

2)Moderatecoma:limbpalsy,weaknessoflightresponse,steadyofrespirationandcirculationfunctions3)Severecoma:Dilationofpupil,disappearoflightresponse,limbsoftpalsy,respirationandcirculationdysfunctionsConsciousness意識I.MotorResponse6-Obeyscommandsfully5-Localizestonoxiousstimuli4-Withdrawsfromnoxiousstimuli3-Abnormalflexion,i.e.decorticateposturing2-Extensorresponse,i.e.decerebrateposturing1-NoresponseII.VerbalResponse5-AlertandOriented4-Confused,yetcoherent,speech3-Inappropriatewords,andjarbledphrasesconsistingofwords2-Incomprehensiblesounds1-NosoundsIII.EyeOpening4-Spontaneouseyeopening3-Eyesopentospeech2-Eyesopentopain1-Noeyeopening

GlascowComeScaleRecentmemory:Askthepatienttorecallthreeitemsorabriefstoryafteradelayof3to5minutes.Besuretheinformationhasbeenregisteredbyaskingthepatienttorepeatitimmediatelybeforeinitiatingthedelay.Providedistractersduringthedelaytopreventthepatientfromrehearsingtheitemsrepeatedly.Remotememory:Askthepatientabouthistoricalorverifiablepersonalevents.TestofMemory記憶力檢查WordComprehensionComprehensionofspokenlanguagethroughrecognition(“pointtoyournose”)orunderstanding(“Candogsfly?”).RepetitionRepeatitemsofincreasingcomplexity.Notethefluencyandaccuracyoftheresponses.NamingNameaseriesofobjectsorcolors.Graduallyincreasedifficulty.Notethefluencyandaccuracyoftheresponses.ReadingComprehensionHavethepatientfollowseveralsimplewrittencommands.WritingAskthepatienttomakeupandwriteasentence.

Testingforlanguage語言檢查IOlfactorysenseofsmellIIOpticvisionIIIOculomotorpupillaryconstriction,openingofeye,mostextraocularmovementIVTrochleardownward,inwardmovementofeyeVTrigeminalMotor-temporal&masseterm.(jawclenching)lateralmovementofjawSensory-facial(V1,V2,V3)VIAbducenslateraldeviationofeyeVIIFacialMotor-facialmovementSensory-taste(tongueant.2/3)VIIIVestibulo-cochlearHearing(cochleardivision)&balance(vestibulardivision)IXGlosso-pharyngealMotor-pharynxSensory-post.portionofeardrum&earcanal,pharynx,post.tongueXVagusMotor-palate,pharynx,larynxSensory-pharynx,larynxXIAccessoryMotor-sternocleidomastoid.trapeziusXIIHypoglossalMotor-tongueCranialnerveexam腦神經(jīng)檢查Testbyaskingifpatientscansmell,coffee,vanilla,orcinnamonineachnostril.AvoidnoxiousodorsⅠ.Olfactoralnerve嗅神經(jīng)指數(shù)與手動視力表光感Ⅱ.Opticnerve視神經(jīng)①PatientistestedbyaSnellenchart6mawayfromhiminawell-litroom②Ifthepatientisunabletoreadcharactersofline,assesshisabilitytocountyourfingersorperceiveatorchlight.

(1)Visualacuity（視力）(2)Visualfield視野Askpatienttolookintoyoureyes;holdyourhandshalfwaybetweenyouandthepatient.Compareyourownvisualfieldswiththepatient’s.Assesstheshapeandcolorofopticdisc,andtheclarityofitsmarginAssesstheretinalvessels.Thearteriesarenarrowerthantheveinsandbrighterincolor.Assesstherestoftheretina,notinganyevidenceofdiscoloration,haemorrhages.(3)Fundoscopicexam

眼底檢查Inspectthepositionoftheeyelidsandthepresenceofanystrabismus(misalignmentofthevisualaxes)Ⅲ,Ⅳ,Ⅵ.Oculomotor,Trochlear&AbducensⅢ.Oculomotornerve動眼神經(jīng)

Ⅳ.Trochlearnerve滑車神經(jīng)Ⅵ.Abducensnerve外展神經(jīng)Keeptheheadstillandhavethepatientfollowanobjectmovedacrosstheirfullrangeofhorizontalandverticaleyemovements.Assessthevelocityandaccuracyofthemovement.Eyemovement

眼球運動Ⅲ,Ⅳ,Ⅵ.Oculomotor,Trochlear&AbducensAssessthesizeandshapeofpupilNormal:cirlular\symmetrical\3~4mmindiameterconstrictedpupil:<2mm,dilatedpupil:>5mmD直徑:3~4mmPupil瞳孔Ⅲ,Ⅳ,Ⅵ.Oculomotor,Trochlear&AbducensLightresponse（對光反射）

Askpatienttofixateonandistanttarget,andshinethelightintoeacheyeinturn,bringingthetorchbeamquicklyontothepupilfromthelateralside.Observethedirectandtheconsensualresponses.directresponse:constrictionoftheilluminatedpupilconsensualresponse:constrictionoftheoppositepupilTestlighttouch,pinprick,andtemperatureovertheforehead,themedialaspectsofthecheeks,andthechinwhichcorrespondtotheophthalmic,maxillary,andmandibularbranchesofthenerve.Ⅴ.Trigeminalnerve三叉神經(jīng)熱水冷水大頭針(痛覺)棉簽(觸覺)(溫度覺)Sensory-V1,V2,V3cornealreflex（角膜反射）Thecornealreflex,whichinvolvesbothⅤandⅦ,istestedbytouchingeachcorneagentlywithacottonwispandobservinganyasymmetriesintheblinkresponse.Ⅴ.Trigeminalnerve三叉神經(jīng)Lookforasymmetryinfacialshapeorindepthoffurrowssuchasthenasolabialfold.Alsolookforasymmetriesinspontaneousfacialexpressionsandblinking.Askpatienttoelevatehiseyebrow;Clenchhiseyestightlyandresistyourattempttoopenthem;Puffouthischeeks;Showhisteeth;Smile.

Ⅶ.Facialnerve面神經(jīng)contralateralfaceweaknesssparingtheforehead(upmotorneuron--central)UMNweaknessLMNweaknessweaknessinvolvingthewholeipsilateralface(lowmotorneuron--peripheral)Ⅶ.Facialnerve面神經(jīng)Ⅷ.Vestibulocochlearnerve位聽神經(jīng)(1)Cochlearnerve蝸神經(jīng)

TesttoseecanthepatienthearfingersrubbedtogetherorwordswhisperedjustoutsideoftheauditorycanalandidentifywhichearhearsthesoundAtuningforkcanbeusedtoperformtheWeberandRinnetesttoevaluatesensorineuralandconductivehearinglossrespectively①Rinne’stestThebaseofavibratingtuningforkisheldfirstagainstthemastoidprocess,andthen,whenthetonehasdisappeared,about2.5cmfromtheexternalauditorymeatus.

conductive:

decreaseofairconduction

sensorineural:

decreaseofbone&airconductionⅧ.Vestibulocochlearnerve位聽神經(jīng)(1)Cochlearnerve蝸神經(jīng)②WebertestVibratingtuningforkisplacedinthemiddleoftheforehead,soundisnormallyheardequallyinbothears.conductive:affectedearsensorineural:normalearⅧ.Vestibulocochlearnerve位聽神經(jīng)(1)Cochlearnerve蝸神經(jīng)

Calorictest

Patientliessupine,headisraised30degreefromhorizon.Externalmeatusisirrigatedfor30secondswithwater,firstat30,then44degreewaterresultsinnystagmus,withfastphaseoppositetothesideirrigatedⅧ.Vestibulocochlearnerve(2)Vestibularnerve前庭神經(jīng)

Checkthepatient’sspeechtoassessfordysphoniaAskpatienttosay"Ah”toassessifthepalateelevatesymmetrically?、?Vagalnerve迷走神經(jīng)Ⅸ.Glossopharyngealnerve舌咽神經(jīng)Gagreflex咽反射

TouchingtheposteriorpharyngealwallObservingthenormalresponseofasysmmetricalriseofsoftpalateandmovementofthepharyngealmusculesⅨ&Ⅹ.Glossopharyngeal&VagusnerveTouchingtheposteriorpharyngealwallwiththestickonbothsides

AskthepatienttoshrugtheirshouldersupwardsagainstresistanceAskthepatienttoturntheirheadtoeachsideagainsttheforceofyourhandsⅪ.Accessorynerve副神經(jīng)Trapeziusmuscle

斜方肌Sternocleidomastoidmuscle胸鎖乳突肌

AskthepatienttosticktheirtonguestraightoutandnotewhetheritcurvestoonesideortheotherAskthepatienttomovetheirtonguefromsidetosideandpushitforcefullyagainsttheinsideofeachcheekⅫ.Hypoglossalnerve舌下神經(jīng)motorsystemexam運動系統(tǒng)檢查Lookforanytremors,abnormalmovementsorposturesPalpatemusclesincasesofsuspectedmyopathytocheckformuscletendernessInspectionTremor震顫:Steadyrhythmicoscillatorymovementsofthemuscles.

Muscletone肌張力motorsystemexam運動系統(tǒng)檢查Increasetone:

clasp-knifephenomenon(uppermotorneuron)lead-pipeorcog-wheelingrigidity(extrapyramidalsystem)Tone:

activityofthestretchreflexesassessedbythedegreeofresistancethatoccursonstretchingmuscles.Askthepatienttorelax.Flexandextendthepatient'sfingers,wrist,elbow,ankleandknee.Thereisnormallyasmall,continuousresistancetopassivemovement.Observefordecreased(flaccid)orincreased(rigid/spastic)toneMuscletoneMuscleforce—Power

Poweristestedineachofthemainmusclegroupsandgradedagainstresistanceappliedbytheexaminer.

PowerineachmuscleisgivenagradedefinedbytheMedicalResearchCouncil(MRC)scale.

Muscleforce肌力Motorsystemexam運動系統(tǒng)檢查0Nocontraction1Flickerortracecontraction2Activemovementwithgravityeliminated3Activemovementagainstgravity4Activemovementagainstgravityandresistance5NormalpowerMRCScaleMuscleforce肌力0級--完全癱瘓1級--肌肉可收縮,但不能產(chǎn)生動作2級--肢體能在床面上移動,不能抵抗自身重力(不能抬起)3級--肢體能抵抗重力離開床面,但不能抵抗阻力4級--肢體能作抗阻力動作,但不完全5級--正常肌力肌力(muscleforce)

肌力六級記錄法①shoulder:abduction\adduction②elbow:flexion\extension③wrist:flexion\extension④finger:flexion\extension⑤neck:flexion\extension⑥hip:abduction\adduction\flexion\extension⑦knee:flexion\extension⑧ankle:dorsiflexion\plantarflexion⑨t(yī)oe:dorsiflexion\plantarflexionMusclegrouptestingMuscleforce肌力

Muscleforce

localizingdiagnosisofparalysis(1)Reflexesarethebody’sintrinsicstimulus-responsesystemsformaintaininghomeostasis.(2)Areflexarccontains2ormoreneuronsthroughwhichnervousimpulsesaretransmittedfromareceptortothebrainorspinalcord,andthentoaneffector.ReflexExam反射檢查Adeeptendonreflexisthereactionofamuscletobeingpassivelystretchedbypercussiononthetendon.Thesereflexesareameasureoftheintegritybothoftheafferentandefferentperipheralnervesandoftheircentralinhibitorycontrols.ReflexExam反射檢查DeepTendonReflexes深反射

Grade

DTRResponse 4+ Verybrisk,hyperactive,withclonus 3+ Briskerthanaverage,slightlyhyperreflexic 2+ Average,expectedresponse;normal 1+ Somewhatdiminished,lownormal 0 Noresponse,absentDeepTendonReflexesGrading深反射分級ThebicepsandbrachioradialisreflexesaremediatedbytheC5andC6nerveroots

ThetricepsreflexismediatedbytheC6andC7nerveroots,predominantlybyC7.ThekneejerkreflexismediatedbytheL3andL4nerveroots,mainlyL4.

TheanklejerkreflexismediatedbytheS1nerveroot.Ankleclonus踝陣攣Holdtherelaxedlowerleginhand,andsharplydorsiflexthefootandholditdorsiflexed.TheoscillationsbetweenflexionandextensionofthefootindicatingclonusSuperficialreflexesareusuallyelicitedbystrokingtheskinormucousmembranesSuperficialreflexesincludecornealreflex,gagreflex,uvularreflex.Superficialreflex淺反射ReflexExam反射檢查Action:Askpatientsupine,relaxabdominalmuscles.Mediallystrokeeachsideofabdomenaboveandbelowtheumbilicus.[Costalarch(T7~8)\Umbilicus(T9~10)\Inguinalligament(T11~12)]Response:UmbilicaldeviationtowardthestimulusAbdominalreflexes腹壁反射Superficialreflex淺反射Action:Testtheplantarresponsebyscrapinganobjectacrossthesoleofthefootbeginningfromtheheel,movingforwardtowardthesmalltoe,andthenarcingmediallytowardthebigtoeResponse:PlantarflexionoftoesPlantarreflex跖反射Superficialreflex淺反射

characterizedbyanupgoingbigtoeandfanningoutwardoftheothertoesPlacethetipofasuitableinstrument,onthelateralaspectofthesoleattheheelandsweepitfirmlyforwardtothebaseofthetoesBabinskiSign巴彬斯基征ReflexExam反射檢查Pathologicalreflex病理反射ReflexExam反射檢查LimbweaknessIncreasedtone(spasticity)IncreasedreflexesExtensorplantarresponsesUPPERMOTORNEURONLESIONS上運動神經(jīng)元損傷LimbweaknessWasting(afterseveralweeks)Fasiculations(ifactivedenervation)Reducedtone(ifdetectable)ReducedorabsentreflexesNormal(flexor)plantarresponsesLOWERMOTORNEURONLESIONS下運動神經(jīng)元損傷Walkacrossroom,turnandwalkbackHeel&toewalkingHopinplaceRisingfromsittingpositionorsteppingup

onstoolMotorsystemexamGait步態(tài)Askthepatienttotouchyourfingerheldabout50cminfrontofthepatient,withhisindexfingerandthentotouchhisnose,thenmovebackandforthbetweenyourfingerandhisnoseCoordination共濟運動

finger-nosetest指鼻試驗

Askthesupinepatienttotouchhisheeltotheoppositeknee,andslideitsmoothlydownhisshinofthatleg.Rapidtappingmovementofthefeetisimpaired.heel-knee-shintest跟-膝-脛試驗Coordination共濟運動

AskthepatienttoalternatelypronateandsupinatehisorherarmandcorrespondinglytapthepalmTheinabilitytocarrytherapidalternatingmovementsmeansthespeedofmovementdecreasesandamplitudeofmovementincreases.RapidAlternatingMovements

快復(fù)輪替試驗快復(fù)輪替運動不能Coordination共濟運動Standwithfeettogether-assurepatientstable-havethemcloseeyesRombergispositiveiftheydoworsewitheyesclosed①ProprioceptionFrequentlydoworsewitheyesclosed②CerebellarfunctionFrequentlypoorbalancewitheyesopenandclosedRombergSignSensorySystemExam感覺系統(tǒng)檢查TesteachsensationinturnStarttestwiththefingersortoesandworkproximallyAskthepatienttoindicate“yes”whenheperceiveseachsensationandcomparetherightandleftsidesEnsurethepatient’seyeareclosedduringtheexaminationStartsensorytestingintheabnormalareaandmoveoutfromthere①Pinprick:Useneedleworkpin②Lighttouch:Awispofcottonwoolisused③Temperature:Bottlesofcoldwater(0?~10?C)&hotwater(40?~50?C)Primarysensory淺感覺Localizingdiagnosisofsensorydisturbance

CorticaltypeInternalcapsuleThalamusBrainstemSpinalmarrowPosteriorhornDorsalrootNervetrunkPeripheraltypePositionSense

StereognosiaGraphesthesiaExtinction神經(jīng)系統(tǒng)的輔助檢查TheSpecialTechniquesforNeurologicalDiagnosis

TheexamofCSFincludes:numberandtypeofcells;proteinandglucosecontent;contentofgammaglobulin,oligoclonalbands腦脊液檢查(Cerebrospinalfluidexam)Examinationofthecerebrospinalfluid(CSF)iscrucialinthediagnosisofinfectiousconditions,subarachnoidhemorrhageEEGmeasureselectricalpotentialsgeneratedbytheneuronslyingunderneathanelectrodeonthescalp,andcomparesthesewithrecordingsfromeitherareferenceorneighbouringelectrode腦電圖(Electroencephalography,EEG)Evokedpotentialrecordsresponsescentrallytoperipheralstimuli-visual,auditoryandelectrialstimulifromsensorynervesrespectively腦誘發(fā)電位(EvokedPotential,EP)Electromyographyisperformedtoexaminetheintegrityofmuscles.Duringvoluntarymovement,motorunitpotientialscanbedetected.肌電圖(Electromyography,EMG)Useofelectricalstimulationofanerveandmeasurementoftherateofactionpotentialpropagationalongthenerveandtheamplitudeandtimeoftheresponse.正中神經(jīng)MCV測定R1:記錄作用電極