神经系统体格检查

1、神经系统体格检查神经系统体格检查神经系统体格检查V:1.0精细整理，仅供参考 神经系统体格检查日期：20 xx年X月 Nervous SystemCranial nerve: I Olfactory nerve: left not measured, right not measured II Optic nerve:leftrighteyesightnormalnormalVisual fieldNo defectNo defectfundusnormalnormal III, IV, VI HYPERLINK C:/Users/Administrator/AppData/Local/You

2、dao/Dict/Application/0/resultui/frame/javascript:void(0); Oculomotor HYPERLINK C:/Users/Administrator/AppData/Local/Youdao/Dict/Application/0/resultui/frame/javascript:void(0); nerve, HYPERLINK C:/Users/Administrator/AppData/Local/Youdao/Dict/Application/0/resultui/frame/javascript:void(0); trochlea

3、r HYPERLINK C:/Users/Administrator/AppData/Local/Youdao/Dict/Application/0/resultui/frame/javascript:void(0); nerve, abducens nerve HYPERLINK C:/Users/Administrator/AppData/Local/Youdao/Dict/Application/0/resultui/frame/javascript:void(0); palpebral HYPERLINK C:/Users/Administrator/AppData/Local/You

4、dao/Dict/Application/0/resultui/frame/javascript:void(0); fissure: left: normal right: normal Eyelid: left: no ptosis right:no ptosis Diplopia: no accommodation reflex: exist Nystagmus: left: no right: no Eye movement: left:normal right: normalPupils: left: round, diameter , direct light reflex sens

5、itive, indirect light reflex sensitive right: round, diameter , direct light reflex sensitive, indirect light reflex sensitiveV Trigeminal nerve:Facial sensory： Left facial pain：normal；Temperature： normal；Touch： normal. Right facial pain：normal；Temperature： normal；Touch： normal.Movement: Left tempor

6、alis, HYPERLINK C:/Users/Administrator/AppData/Local/Yodao/DeskDict/frame/20/javascript:void(0); masseter shrink: no. Mastication: powerful. Right temporalis, HYPERLINK C:/Users/Administrator/AppData/Local/Yodao/DeskDict/frame/20/javascript:void(0); masseter shrink: no. Mastication: powerful. The ja

7、w : no deviation. Left Right Direct corneal reflection: Existence ExistenceIndirect corneal reflection: Existence Existence Jaw reflex: (-) facial nerve：LeftRightWrinkles in the forehNot shallowNot shallowPalpebral fissureNormalNormalNasolabial grooveNot shallow Not shallowClose eyesThewyThewyFrownT

8、hewyThewyCheek bulgingThewyThewyWhistleNormalNormalKnit ones brownsNormalNormalTaste in the anterior 2/3 tongueNo checkNo checkCorner of the mouth： no askew.Show teeth： no askew of corner of the mouth. Auditory Nerve: Auditon: Left: Normal Right: Normal、 Glossopharyngeal Nerve、Vagus Nerve:Pronunciat

9、ion: No rhinolalia, dysarthria, dysphagia, cough when drinking, or hoarseness.Uvula: on the middle line.LeftRightSoft Palate LiftingPowerfullyPowerfullyPharyngeal ReflexNormalNormalTaste on the posterior 1/3 of tongueUnexaminedUnexamined Accessory Nerve: LeftRightSternocleidomastoidNo atropyNo atrop

10、yTrapeziusNo atropyNo atropyShoulderdropNoNoTorticollisNoNoNeck RotationPowerfullyPowerfullyShrugPowerfullyPowerfully = 12 * ROMAN XII Hypoglossal nerve Tongue： in the middle Lingualis：no atrophy Lingualis fibrillation: noneLocomotor system:muscle forceUpper limbLower limbNear-endFar-endNear-endFar-

11、endleftLevel 5Level 5Level 5Level 5rightLevel 5Level 5Level 5Level 5 muscular tension Left upper limbRight upper limbLeft lower limbRight lower limbnormalnormalnormalnormal muscular atrophy: no fasciculation: no coordination motorleftrightfinger-to-nose testnormalnormaldiadochokinetic testnormalnorm

12、alheel-knee-tibia testnormalnormalmuscle rebound phenomenonnegativenegative Romberg sign: eyes open:(-) eyes close:(-) posture & gait: normalSensory systemSuperficial sensation: algesia of trunk and all fours exists symmetrically, temperature sensation exists symmetrically, tactile sensation exists

13、symmetrically.Deep sensation: topesthesia exists symmetrically, cinesthesia exists symmetrically, seismesthesia exists symmetrically.Complex sensation: skin topethesia exists symmetrically, two points discrimination exists symmetrically, weight sensation exists symmetrically, stereognosis exists sym

14、metrically, graphics sensation exists symmetrically.Reflex system:Deep reflex: left rightBiceps reflex: normal normalTriceps reflex: normal normalRadial reflex: normal normalKnee reflex: normal normalAnkle reflex: normal normalRossolimo sign: negative negativeHoffmann sign: negative negativeClonusle

15、ftrightpatella-ankle-Superficial reflexAbdominal reflexsuperiormediumunderneathleftnormalnormalnormalrightnormalnormalnormalPlantar reflexLeft normal Right normalAnal reflexnormalPathological signLeft - Right Autonomic nerve system: Normal skin, normal perspiration, normal hair, normal nails and toenails. No edema, ulcer and decubitus. No abnormality of urination and defecation. Autonomic nerve reflex: Oculocardiac r