神经系统体查与腰椎穿刺

神经系统体查与腰椎穿刺Neurological Examination and Lumbar Puncture,中南大学湘雅二医院神经内科申向民,outline,神经系统体格检查一般检查意识障碍检查精神状态和高级皮质功能检查脑神经检查运动系统检查感觉系统检查反射检查自主神经检查腰椎穿刺腰椎穿刺脑脊液检查,神经系统体格检查,Neurological Examination,神经系统体格检查,检查顺序,病房：卧位-坐位-立位门诊：坐位-立位-卧位体格检查时检查者一般在病人的右边,神经系统体格检查,概述,神经病学研究范围：神经系统疾病及骨骼肌疾病神经系统疾病诊断的特点：定位诊断加定性诊断定位诊断：体征是重点+结合神经解剖知识定性诊断：病史+辅助检查等,神经系统体格检查,一般检查,生命体征体味或呼吸气味发育和体形 营养状态 面容表情体位语言、语调、语态和构音姿势和步态皮肤黏膜头颈部胸腹部躯干和四肢,神经系统体格检查,体温,正常体温体温过高体温过低,神经系统体格检查,脉搏,脉搏增快细数或不规则急性颅内压增高心源性因素,神经系统体格检查,呼吸,Kussmual呼吸浅快呼吸呼吸缓慢呼吸节律改变 潮式呼吸：间脑 中枢神经源性过度呼吸：中脑被盖部 长吸式呼吸：中脑下部和桥脑上部 丛集式呼吸：脑桥下部 共济失调式呼吸：延髓上部,神经系统体格检查,神经系统体格检查,血压,血压显著升高血压过低,神经系统体格检查,体味或呼吸气味,酒味烂苹果味肝臭味氨味或尿味大蒜味,神经系统体格检查,发育和体形,发育正常：胸围、上肢展开、坐高身材矮小,神经系统体格检查,营养状态,评估检查方法,神经系统体格检查,面容表情,正常人特殊表情：帕金森病,神经系统体格检查,体位,自主体位被动体位强迫体位,神经系统体格检查,语言、语调、语态和构音,语言语调：语音和声调语态：节奏构音,神经系统体格检查,姿势与步态,姿势：举止步态：行走,神经系统体格检查,皮肤黏膜,黄染、苍白、发绀樱红色、潮红多汗：有机磷中毒、甲亢危象或低血糖面部黄色瘤,神经系统体格检查,头颈部,头颅部面部及五官颈部头颅外伤： 眶周瘀斑 鼓膜血肿 脑脊液鼻漏或耳漏,神经系统体格检查,胸腹部,胸部异常心律异常肝、脾大合并腹水腹部膨隆并压痛,神经系统体格检查,躯干和四肢,脊柱异常翼状肩胛、四肢、指趾畸形皮下瘤结节和牛奶咖啡斑肌束震颤扑翼样震颤,意识障碍检查,Level of Consciousness,意识障碍检查,概述,大脑功能的综合表现，人对自身和外界环境进行认识和做出适宜反应的基础，包括觉醒状态和意识内容。觉醒状态意识内容意识障碍,意识障碍检查,概述,采集病史全身和神经系统检查 意识障碍的觉醒水平 意识内容的改变,意识障碍检查,概述,眼征疼痛刺激的反应瘫痪体征脑干反射锥体束征脑膜刺激征,意识障碍检查,意识障碍检查,眼征,瞳孔眼底眼球位置眼球运动,意识障碍检查,疼痛刺激反应,肢体反应面部表情去皮质强直去脑强直脑桥和延髓病变,意识障碍检查,瘫痪体征,面瘫自发活动疼痛刺激肌张力坠落试验,意识障碍检查,脑干反射,睫脊反射（ciliospinal reflex）角膜反射（corneal reflex）头眼反射（oculocephalic reflex）眼前庭反射（oculovestibular reflex）,意识障碍检查,呼吸形式,脑膜刺激征,意识障碍的其他体征,精神状态和高级皮质功能检查,Mental State and Cognitive Function,精神状态和皮质功能,概述,神经性/精神性疾病局灶性/弥漫性脑损害精神状态高级皮质功能检查 认知功能 非认知功能,精神状态和皮质功能,记忆,瞬时记忆短时记忆长时记忆,精神状态和皮质功能,计算力,时间定向力地点定向力人物定向力,定向力,精神状态和皮质功能,失语,口语表达：流畅，语音障碍，找词，错语、新语等，语法障碍听理解复述命名阅读书写,精神状态和皮质功能,Damage to Brocas area producesdifficulty in speaking,Damage to Wernickes area results in difficulty in languagecomprehension,精神状态和皮质功能,Transcortical 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 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 from combined lesions anterior to the Broca and Wernicke areas, respectively,精神状态和皮质功能,精神状态和皮质功能,精神状态和皮质功能,失用,口头和书面命令观察患者 执行命令 模仿动作 实物演示能力,精神状态和皮质功能,失认,视觉失认听觉失认触觉失认,精神状态和皮质功能,视空间技能和执行功能,画钟面填数字指定时间画出表针,颅神经检查,Cranial Nerves,颅神经检查,12 PairsArise from brain stemMotor and sensory functions,颅神经检查,颅神经检查,嗅神经,特殊感觉神经检查方法异常表现和定位 嗅觉丧失和减退 嗅觉过敏 幻嗅,颅神经检查,视神经,视力视野眼底异常表现和定位 视力障碍和视野缺损 视乳头异常,颅神经检查,颅神经检查,颅神经检查,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 increased intracranial pressure.,颅神经检查,动眼、滑车、展神经,外观眼球运动瞳孔及其反射异常表现和定位 眼睑下垂 眼外肌麻痹 眼球震颤 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 lesion 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 nystagmus (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 nystagmus,Ocular bobbing is the rhythmical conjugate deviation of the eyes downward. characteristic of damage to the pons. Downbeat nystagmus indicate a lesion compressing on the cervicomedullary junction,颅神经检查,三叉神经,混合神经面部感觉咀嚼肌运动反射异常表现和定位,颅神经检查,面神经,混合神经面肌运动感觉反射副交感异常表现和定位,颅神经检查,位听神经,蜗神经 Rinne试验 Weber试验前庭神经异常表现和定位,The 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 affected,The Rinne test place the butt on the mastoid eminence firmly. Tell the patient to say now when they can no longer hear the vibration.,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 loss, then the vibration is heard substantially longer than usual in the air.,颅神经检查,舌咽、迷走神经,运动感觉味觉反射异常表现和定位 真性球麻痹 假性球麻痹 迷走神经刺激症状,颅神经检查,副神经,运动神经胸锁乳突肌斜方肌上部,颅神经检查,舌下神经,运动神经核下性病变核性病变核上性病变,运动系统检查,Motor System,运动系统检查,肌容积肌张力肌力不自主运动共济运动姿势与步态,运动系统检查,肌容积,肌萎缩假性肥大肌肉束颤,运动系统检查,肌张力,肌张力减低肌张力增高 锥体系损伤 锥体外系损伤,运动系统检查,肌力,六级肌力记录法肌群肌力测定单块肌肉检查轻瘫检查法 上肢平伸试验、Barre分指试验、小指征 Jackson征、下肢轻瘫试验,运动系统检查,不自主运动,舞蹈样动作手足徐动肌束颤动肌痉挛震颤肌张力障碍,运动系统检查,共济运动,指鼻试验反击征跟膝胫试验轮替试验起坐试验闭目难立试验,Coordination, Gait and Rhomberg TestCoordination,Rapidly Alternating Movement Evaluation,Dysdiadochokinesis is the clinical term for an inability to perform rapidly alternating movements.,Point-to-Point Movement Evaluation The clinical term: Dysmetria,heel 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 of position, 2. non-visual confirmation of position (including proprioceptive and vestibular input), and 3. a normally functioning cerebellum.,运动系统检查,姿势与步态,姿势步态起步情况步幅速度,Gait,Tandem walking,On Toes,On Heels,感觉系统检查,Sensory System,感觉系统检查,感觉系统,浅感觉深感觉复合感觉,感觉系统检查,浅感觉,痛觉触觉温度觉,The Sensory System Examination Pain and Light Touch Sensation,感觉系统检查,深感觉,运动觉位置觉振动觉,感觉系统检查,复合感觉,定位觉两点辨别觉图形觉实体觉,Position Sense,Stereognosia,Graphesthesia,Extinction,反射检查,Reflex,反射检查,反射检查,深反射浅反射病理反射,反射检查,深反射,上肢反射下肢反射阵挛Hoffmann征Rossolimo征,The biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve roots,The triceps reflex is mediated by 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 lesion,A positive Hoffman response is indicative of an upper motor neuron lesion affecting the upper extremity in question.,Finally, test clonus,反射检查,浅反射,腹壁反射提睾反射跖反射肛门反射,反射检查,病理反射,巴彬斯