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The neurologic examination

The neurologic examination. From Department of Neurology of ZJU Pro.Dr.Zhang BR Director (email-brzhang@zju.edu.cn). 主要内容. 概论 (Concept) 意识的评估及分类 (Conscoiusness and evaluation and classification)

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The neurologic examination

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  1. The neurologic examination From Department of Neurology of ZJU Pro.Dr.Zhang BR Director (email-brzhang@zju.edu.cn)

  2. 主要内容 • 概论(Concept) • 意识的评估及分类(Conscoiusness and evaluation and classification) • 12对脑神经检查(12 paires cranial nerve examination) • 感觉系统检查(Sensory system examination)： • 浅感觉检查(facial sensory test) • 深感觉检查(Deep sensory test) • 高级皮层功能检查(High cortical function examination)

  3. 主要内容(Outline) （五）运动系统检查(Motor system examination) • 肌力(muscle strength) • 肌张力(muscle tone) （六）反射检查(reflex test) • 深反射(deep reflex) • 病理发射(pathologic reflex) （七）基厎神经节症状 与体证介绍(Basal ganglia symptoms and test) （八）脑膜刺激征(Signs of meningeal irritation)

  4. （一）A doctor clinical thinking Location Characteristics Diagnosis Different diagnosis

  5. （二）Eevaluation of Consciousness Awareness Dementia Coma Vegetative State Lock-in-State Brain death

  6. Consciousness Consciousness: is awareness of the internal or external world, and disorder of conciousness can affect either the level or the content of consciousness Abnormal of the level of consciousness: Is characterized by impaired wakefulness

  7. level of conciousness and the anatomy of awareness Awareness of level of conciousness Including open eyes,temperature,respiratory blood pressure stability Coma results from acute lesions of the ascending reticular activating system or both cerebral hemispheres

  8. Definition of Coma State of eyes closed unresponsiveness Profound unresponsiveness, in which the subject cannot be aroused.

  9. Levels of Altered Mental Status Delirium awake but confused Obtundation lethargic and confused Stupor awakens only with painful stimulus Coma

  10. What is coma? What are the common causes of coma? What are the mechanisms of coma? How do we assess coma? First steps in treatment?

  11. How do we assess coma The Glasgow coma score The Neurological exam Neuroimaging EEG

  12. Glasgow Coma Scale 3-15 Eye Opening Never 1 To pain 2 To verbal 3 Spontaneous 4 Best Verbal Response None 1 Sounds 2 Inapp words 3 disoriented 4 oriented 5 Best Motor Response None 1 Extensor 2 Flexor 3 Withdrawal 4 Localization 5 Obeys Commands 6

  13. GCS and Prognosis Low GCS (3 - 60 tend to be correlated with poor outcome High GCS (13-15) tend to be correlated with better outcomes

  14. How do we assess coma The Glasgow coma score The Neurological exam Neuroimaging EEG

  15. The exam can help you differentiate

  16. Check Vitals Fever Irregular Breathing Examine the neck Meningitis Subarachnoid hemorrhage Examine for signs of trauma Ecchymosis over orbit or mastoid Look for Papilledema Evidence of increased pressure

  17. Pupils A Unilateral Dilated Pupil May indicate…

  18. Oculo-vestibular Response(Doll’s Eyes) Purpose: To test the integrity of the brainstem from the medulla to midbrain.

  19. Motor response (GCS) Normal-6 Localize to pain- 5 Withdraw to pain-4 Decortication-3 Decerebration-2 No response-1 A B Lippincott Williams 2005 Porth’s Pathophysiology

  20. How do we assess coma The Glasgow coma score The Neurological exam Neuroimaging EEG

  21. Neuroimaging in Coma Epidural Hemorrhage with herniation

  22. Neuroimaging in Coma Subarachnoid Hemorrhage

  23. Neuroimaging in Coma Hydrocephalus

  24. How do we assess coma The Glasgow coma score The Neurological exam Neuroimaging EEG

  25. Normal EEG

  26. EEG in Anoxia or Herpes

  27. EEG in Brain Death

  28. Coma and delirium The most severe degree of depressed conciousness is coma Less severe depression of conciousness results in an acute confusional state(Lethargy,attention dulled,perception impaired,memory defective,general awareness of surroundings limited) or delirium(谵妄)

  29. Delirium The patients respond to at least some stimuli in a purposeful manner but is sleepy,disoriented,and inattentive Sometimes is confusion with hallucination or agitation and violent emotional response (patients may quiet and withdrawn)

  30. Mental state Stupor: a somnolent state (may momentarily aroused by questions or painful stimulation) Syncope: a brief loss of consciousness

  31. Vegetative State Comtose paients maintain a state: consist of sleep-wake cycles, intact cardiorespiratory function, primitive response to stimuli (including reflexes mediated through the brain stem and behavioral fragments such as screaming or even single word utterances) but no evidence of inner or outer awareness

  32. Lock-in-State Lesion (infarction) of the basis descending corticospinal tracts Preserve tegmental sensory and respiratory pathways Preserve reticular activating system Paralysis of lower cranial nerve and limb muscles

  33. Lock-in-State Preserve alertness and respirations Preserve vertical eye movments controlled by oculomotor nerve there may be horizontal eye movements and blinking Comunication may by blinking or eye movements and yes or no questions

  34. Lock-in-State case(infarction) VCDVCD2

  35. Dementia Definition: Impair the content.赵父亲 035.mpgof consciousness without altering the level conscoiusness Eexamples impair language or memory

  36. Brain death Neither the cerebrum nor brainstem is functioning • Only spontaneous activity cardiovascular • Apnea persists in the presence of hypercarbic respiratory drive • Only reflex mediate by the spinal cord

  37. Cerebral hemisheres.brainstem and spinal location

  38. Olfactory nerve-Cranial nerve I Close eye Identified familiar odors: coffee, cloves and peppermint Noxious substances not suggested Such as ammonia or achol. (false positive response)

  39. Optic nerve Visual acuity: Fingers 1m Movements of hand Words or letter Flash a light Snellen charts testing 20/20 feet and 6/6 meters normal

  40. Optic nerve Visual fields: Finger confrontation Face and hand confrontation Fundi: Ophthalmoscope Optic disc,retinal vessels and macula

  41. Right posterior cerebral artery occlusion

  42. Occipital infarction

  43. Funduscopic Examination

  44. Normalhttp://webvision.med.utah.edu/sretina.html

  45. Oculomotor nerve,trochlear nerve and abducens nerve Palpebral fissures and possition of the globe Protrusion or recession From different direction (front, profile and downward) Examine the ocular movements (following 6 cardinal positions)

  46. Oculomotor nerve,trochlear nerve and abducens nerve Examine nystagmus: pause for a moment Double vision and diplopia Convergence Examine the pupils Direct and consenual light reflex

  47. Eye movements to the left (above) and to the right (side)

  48. Abducen nerve dysfunction

  49. Trigeminal nerve Sensory division Ophthalmic branch, maxillary branch and mandibular branch Motor division Corneal reflex Jaw jerk

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