病史采集和神经系统检查

1、History-taking And Examinations of NeurologyDr.Ying PengDept. of Neurology, the 2nd Affiliated Hospital of Sun Yat-sen University1Brief IntroductionDefinition of Neurology： Science of investigations for neurological diseases (evolved the central, peripheral and autonomic nervous systems) and the mus

2、cular diseases.Diagnosis of neurologic diseases： Localization: Anatomy and physiologyNS examination and signs Etiological diagnosis: History signs laboratory investigations2Our goals in this lecture 1, Comprehend: the significance of neurological examination.2, Acquaint: the value of history-taking

3、and NS Exam on diagnosis of NS diseases.3, Grasp: the key point and method of history-taking & history-recording; the procedure & method of neurological examination.3History-takingMain complainsPresent history1, onset of disease, 2, nature of the main symptom3, course of disease 4, accompany symptom

4、s and 5, the course of diagnosis and treatments.4The Past history: History of other diseases, The personal history: Personal life and development.The Family history5Vital symptomsHeadachePainNumbness ConvulsionParalysisSphincter disorderDizzySensory disorderSeizureWeaknessVisual disturbancePsychiatr

5、ic and intellectual disturbance6We want to know:Onset SiteTiming CharacterFrequency Severity Duration Relieving factors Precipitating factors Associated features7Some special courses of disease An abrupt onset followed by gradual improvement e.g: Cerebrovascular disease Acute inflammatory disease A

6、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 sclerosis8Progress of Science and Technology: CT (Computerized Tomography)MRI (Magnetic Resonance imaging)SPECT (Si

7、ngle Photon Emission Computerized Tomography) PET (Positron Emission Tomography)DSA (Digital Substraction Angiography) 91, 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 clinical histo

8、ry and examination often hold the key to diagnosis.3, Laboratory investigations cant replace history taking and examination forever.10Examinations of nervous systemGeneral physical examinationNeurologic examination11General examinationVital signs and general appearanceHead and neckVertebra and limbs

9、12Neurologic examinationMental status Cranial nervesMotor findingsSensory findingsTendon reflexesAutonomic nervesMeningeal and neural roots irritation signs13Neurologic examinationMental status Cranial nervesMotor findingsSensory findingsTendon reflexesAutonomic nervesMeningeal and neural roots irri

10、tation signs14Mental statusExamination of ConsciousnessPsychiatric status examinationExamination of language and speech15Mental statusExamination of ConsciousnessPsychiatric status examinationExamination of language and speech16Consciousness Defined as patients apparent state of wakefulness and resp

11、onse to stimuli. Abnormalities of consciousness result from acute lesions of the ascending reticular activating system or both cerebral hemispheres. 1718Disturbance of ConsciousnessLevel of consciousness: somnolence(嗜睡): long time sleep stupor(昏睡): cant wake up by normal stimulation coma(昏迷): Any st

12、imulation 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 19Mental statusExamination of ConsciousnessPsychiatric status examinationExamination of

13、language and speech20Psychiatric status examinationOrientation Memory CalculationMood and behaviorContent of thoughtSelf-recognition Intelligence 21Mental statusExamination of ConsciousnessPsychiatric status examinationExamination of language and speech22Disturbance of language Aphasia: impairments

14、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. 2324Neurologic examinationMental status Cranial nervesMotor findingsSensory findingsTen

15、don reflexesAutonomic nervesMeningeal and neural roots irritation signs25Examination of cranial nervesOlfactory nerve (I)： olfactory sense for odors26Examination of cranial nervesOptic nerve (II)： Visual acuity: visual charts, numbers of fingers, movement of fingers Visual field Fundus (Ophthalmosco

16、pic) examination: color of the optic nerve head, vessels and retine27Examination of cranial nervesOculomotor, trochlear and abducens nerves (III, IV, VI)： Primary gaze: look for the symmetry of eyes Pupils: shape, size and light reflexes Extraocular movement:28Examination of cranial nervesTrigenmina

17、l nerve (V)： Facial sensation Movement of jaws and mouth Corneal reflex Jaw reflex29Examination of cranial nervesFacial nerve (VII)： Facial symmetry Movement of expression-related muscles Taste sense (anterior 2/3 area of tongue)30Examination of cranial nervesVestibular auditory nerve (VIII)： Audito

18、ry nerve: auditory acuity Vestibular nerve: symptoms and tests31Examination of cranial nervesGlossopharyngeal and vagus nerves (IX, X)： Motor function of pharyngeal muscles Pharyngeal sense (posterior 1/3 area of tongue) Pharyngeal reflex32Examination of cranial nervesAccessory nerve (XI)： Sternocle

19、idomastoid and trapezius33Examination of cranial nervesHypoglossal nerve (XII)： Tongue movement atrophy or fasciculations? muscular fibrillation?34Neurologic examinationMental status Cranial nervesMotor findingsSensory findingsTendon reflexesAutonomic nervesMeningeal and neural roots irritation sign

20、s35Motor functionMuscle bulkMuscle tone Decreased Increased: Spastic Rigid lead pipe or cogwheelingMuscle strength Classification: 6 grades Examinations: upper limb (shoulder, elbow, wrist, finger) lower limb (hip, knee, ankle, toe)36Muscle strength was classified 6 grades : full strength: movement

21、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 37Motor functionMotor coordination Upper limbs: finger-to-nose, rapid alternating movements, rebound, finger-tapping or

22、 toe-tapping Lower limbs: heel-knee-shin Others: Romberg sign38Motor functionStance and gaitCerebellar gait (as if drunk)Hemiplegic gait (circumduction)Paraplegic gait (scissoring)Swaying gait (as if duck)Parkinsonian gait (festination)Involuntary movements39Neurologic examinationMental status Crani

23、al nervesMotor findingsSensory findingsTendon reflexesAutonomic nervesMeningeal and neural roots irritation signs40Sensory findingsSuperficial sensation: pain, touch and temperatureDeep sensation: vibration sense, joint position senseAssessment of sensory interpretation： Graphesthesia, object identi

24、fication (stereognosis), position sensation, weight sensation41Neurologic examinationMental status Cranial nervesMotor findingsSensory findingsTendon reflexesAutonomic nervesMeningeal and neural roots irritation signs42Tendon reflexesDeep tendon reflexes: Bilateral comparison Upper limbs: Biceps ref

25、lex (C5-6) Triceps reflex (C7-8) Radial reflex (C5-6) Lower limbs: Knee reflex (L3-4) Ankle reflex (S1-2) Patellar and ankle clonus43Tendon reflexesSuperficial reflexes Abdominal reflex (T7-12) Cremasteric reflex (L1-2) Plantax reflex (S1-2) Anal reflex (S4-5)44Tendon reflexesPathologic 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 sign45Neurologic examinationMent