病史采集和神经系统检查.ppt

1、History-taking And Examinations of Neurology,Dr.Ying Peng Dept. of Neurology, the 2nd Affiliated Hospital of Sun Yat-sen University,Brief Introduction,Definition of Neurology： Science of investigations for neurological diseases (evolved the central, peripheral and autonomic nervous systems) and the

2、muscular diseases. Diagnosis of neurologic diseases： Localization: Anatomy and physiologyNS examination and signs Etiological diagnosis: History signs laboratory investigations,Our goals in this lecture,1, Comprehend: the significance of neurological examination. 2, Acquaint: the value of history-ta

3、king and NS Exam on diagnosis of NS diseases. 3, Grasp: the key point and method of history-taking the procedure & method of neurological examination.,History-taking,Main complains Present history 1, onset of disease, 2, nature of the main symptom 3, course of disease 4, accompany symptoms and 5, th

4、e course of diagnosis and treatments.,The Past history: History of other diseases, The personal history: Personal life and development. The Family history,Vital symptoms,Headache Pain Numbness Convulsion Paralysis Sphincter disorder Dizzy Sensory disorder Seizure Weakness Visual disturbance Psychiat

5、ric and intellectual disturbance,We want to know: Onset Site Timing Character Frequency Severity Duration Relieving factors Precipitating factors Associated features,Some special courses of disease,An abrupt onset followed by gradual improvement e.g: Cerebrovascular disease Acute inflammatory diseas

6、e A gradual onset of symptoms e.g: Chronic, progressing and degenerative disease, tumors, Congenital disease Sudden onset or exacerbation e.g: hemorrhage Remission-recurrence e.g: multiple sclerosis,Progress of Science and Technology:,CT (Computerized Tomography) MRI (Magnetic Resonance imaging) SPE

7、CT (Single Photon Emission Computerized Tomography) PET (Positron Emission Tomography) DSA (Digital Substraction Angiography),1, Neurologic diagnosis is a deductive process and is reached by a synthesis of all the details from the history, examination and laboratory investigations.,2, A good clinica

8、l history and examination often hold the key to diagnosis. 3, Laboratory investigations cant replace history taking and examination forever.,Examinations of nervous system,General physical examination Neurologic examination,General examination,Vital signs and general appearance Head and neck Vertebr

9、a and limbs,Neurologic examination,Mental status Cranial nerves Motor findings Sensory findings Tendon reflexes Autonomic nerves Meningeal and neural roots irritation signs,Neurologic examination,Mental status Cranial nerves Motor findings Sensory findings Tendon reflexes Autonomic nerves Meningeal

10、and neural roots irritation signs,Mental status,Examination of Consciousness Psychiatric status examination Examination of language and speech,Mental status,Examination of Consciousness Psychiatric status examination Examination of language and speech,Consciousness,Defined as patients apparent state

11、 of wakefulness and response to stimuli. Abnormalities of consciousness result from acute lesions of the ascending reticular activating system or both cerebral hemispheres.,Disturbance of Consciousness,Level of consciousness: somnolence(嗜睡): long time sleep stupor(昏睡): cant wake up by normal stimula

12、tion coma(昏迷): Any stimulation cant wake up Disturbance of the content of consciousness: confusion(意识模糊): cant focus on something, no direction delirium(谵妄): no ability of comprehension, response and recognition, often over exciting,Mental status,Examination of Consciousness Psychiatric status exami

13、nation Examination of language and speech,Psychiatric status examination,Orientation Memory Calculation Mood and behavior Content of thought Self-recognition Intelligence,Mental status,Examination of Consciousness Psychiatric status examination Examination of language and speech,Disturbance of langu

14、age,Aphasia: impairments of speech, reading ,comprehension and written caused by lesions of special cortical regions. Dysarthria: a disorder of articulation, it always spares oral and written language comprehension and written expression.,Neurologic examination,Mental status Cranial nerves Motor fin

15、dings Sensory findings Tendon reflexes Autonomic nerves Meningeal and neural roots irritation signs,Examination of cranial nerves,Olfactory nerve (I)： olfactory sense for odors,Examination of cranial nerves,Optic nerve (II)： Visual acuity: visual charts, numbers of fingers, movement of fingers Visua

16、l field Fundus (Ophthalmoscopic) examination: color of the optic nerve head, vessels and retine,Examination of cranial nerves,Oculomotor, trochlear and abducens nerves (III, IV, VI)： Primary gaze: look for the symmetry of eyes Pupils: shape, size and light reflexes Extraocular movement:,Examination

17、of cranial nerves,Trigenminal nerve (V)： Facial sensation Movement of jaws and mouth Corneal reflex Jaw reflex,Examination of cranial nerves,Facial nerve (VII)： Facial symmetry Movement of expression-related muscles Taste sense (anterior 2/3 area of tongue),Examination of cranial nerves,Vestibular a

18、uditory nerve (VIII)： Auditory nerve: auditory acuity Vestibular nerve: symptoms and tests,Examination of cranial nerves,Glossopharyngeal and vagus nerves (IX, X)： Motor function of pharyngeal muscles Pharyngeal sense (posterior 1/3 area of tongue) Pharyngeal reflex,Examination of cranial nerves,Acc

19、essory nerve (XI)： Sternocleidomastoid and trapezius,Examination of cranial nerves,Hypoglossal nerve (XII)： Tongue movement atrophy or fasciculations? muscular fibrillation?,Neurologic examination,Mental status Cranial nerves Motor findings Sensory findings Tendon reflexes Autonomic nerves Meningeal

20、 and neural roots irritation signs,Motor function,Muscle bulk Muscle tone Decreased Increased: Spastic Rigid lead pipe or cogwheeling Muscle strength Classification: 6 grades Examinations: upper limb (shoulder, elbow, wrist, finger) lower limb (hip, knee, ankle, toe),Muscle strength was classified 6

21、 grades,: full strength : movement against partial resistance : movement against gravity only : movement only if gravity eliminated : little visible movement (trace of contraction, no motion of joint) 0: no contraction,Motor function,Motor coordination Upper limbs: finger-to-nose, rapid alternating

22、movements, rebound, finger-tapping or toe-tapping Lower limbs: heel-knee-shin Others: Romberg sign,Motor function,Stance and gait Cerebellar gait (as if drunk) Hemiplegic gait (circumduction) Paraplegic gait (scissoring) Swaying gait (as if duck) Parkinsonian gait (festination) Involuntary movements

23、,Neurologic examination,Mental status Cranial nerves Motor findings Sensory findings Tendon reflexes Autonomic nerves Meningeal and neural roots irritation signs,Sensory findings,Superficial sensation: pain, touch and temperature Deep sensation: vibration sense, joint position sense Assessment of se

24、nsory interpretation： Graphesthesia, object identification (stereognosis), position sensation, weight sensation,Neurologic examination,Mental status Cranial nerves Motor findings Sensory findings Tendon reflexes Autonomic nerves Meningeal and neural roots irritation signs,Tendon reflexes,Deep tendon

25、 reflexes: Bilateral comparison Upper limbs: Biceps reflex (C5-6) Triceps reflex (C7-8) Radial reflex (C5-6) Lower limbs: Knee reflex (L3-4) Ankle reflex (S1-2) Patellar and ankle clonus,Tendon reflexes,Superficial reflexes Abdominal reflex (T7-12) Cremasteric reflex (L1-2) Plantax reflex (S1-2) Anal reflex (S4-5),Tendon reflexes,Pathologic reflexes: Caused by lesion of pyramid bundle Upper limbs: Hoffmanns sign Rossolims sign Lower limbs: Babinskis sign Chaddocks sign Oppenheims sign Gordons sign Schaeffers sign Gondas sign,Neurologic examination,Mental sta