1、神经系统体格检查神经系统体格检查u一般检查一般检查u意识障碍检查意识障碍检查u精神状态和高级皮质功能检查精神状态和高级皮质功能检查u脑神经检查脑神经检查u运动系统检查运动系统检查u感觉系统检查感觉系统检查u反射检查反射检查u自主神经检查自主神经检查腰椎穿刺腰椎穿刺u腰椎穿刺腰椎穿刺u脑脊液检查脑脊液检查Neurological Examination神经系统体格检查检查顺序l病房：卧位-坐位-立位l门诊：坐位-立位-卧位l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 l 神经病学研究范围：神经系统疾病及骨骼肌疾病l 神经系统疾病诊断的特点：定位诊断定位诊断加定性诊断定性诊断l 定位诊断
2、：体征是重点体征是重点+结合神经解剖知识l 定性诊断：病史+辅助检查等神经系统体格检查一般检查 l 生命体征l 体味或呼吸气味l 发育和体形 l 营养状态 l 面容表情l 体位l 语言、语调、语态和构音l 姿势和步态l 皮肤黏膜l 头颈部l 胸腹部l 躯干和四肢 神经系统体格检查体温 l 正常体温l 体温过高l 体温过低 神经系统体格检查脉搏l 脉搏增快l 细数或不规则l 急性颅内压增高l 心源性因素 it can be either supranuclear(in cortical gaze centers)or nuclear(in brain stem gaze centers).Nor
3、mally,the sound is heard in the center of the head or equally in both ears.精神状态和高级皮质功能检查体格检查时检查者一般在病人的右边Pain and Light Touch Sensationit can be either supranuclear(in cortical gaze centers)or nuclear(in brain stem gaze centers).皮下瘤结节和牛奶咖啡斑Optic atrophy is a late finding with increased intracranial p
4、ressure.Localization门诊：坐位-立位-卧位Disconjugate lesionsOptic atrophy is a late finding with increased intracranial pressure.StereognosiaPoint-to-Point Movement Evaluation生化：蛋白质、糖、氯化物常规：性状、细胞数、潘迪试验语言、语调、语态和构音侧脑室脉络丛产生经室间孔进入三脑室中脑导水管四脑室经四脑室正中孔、两个侧孔进入蛛网膜下腔和脑池脑穹窿表面的蛛网膜颗粒吸收上矢状窦窦汇横窦乙状窦颈内静脉Coordination头眼反射（oculo
5、cephalic reflex）神经系统体格检查呼吸l Kussmual呼吸l 浅快呼吸l 呼吸缓慢l 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l 血压显著升高l 血压过低神经系统体格检查体味或呼吸气味l 酒味l 烂苹果味l 肝臭味l 氨味或尿味l 大蒜味神经系统体格检查发育和体形l 发育正常：胸围、上肢展开、坐高l 身材矮小神经系统体格检查营养状态l 评估l 检查方法神经系统体格检查面容表情l 正常人l 特殊表情：帕金森病神经系统体格检查体位l 自主体位
6、l 被动体位l 强迫体位神经系统体格检查语言、语调、语态和构音l 语言l 语调：语音和声调l 语态：节奏l 构音神经系统体格检查姿势与步态l 姿势：举止l 步态：行走神经系统体格检查皮肤黏膜l 黄染、苍白、发绀l 樱红色、潮红l 多汗：有机磷中毒、甲亢危象或低血糖l 面部黄色瘤门诊：坐位-立位-卧位定位诊断：体征是重点+结合神经解剖知识Tell the patient to say now when they can no longer hear the vibration.conductive hearing loss the vibration will be louder on the
7、affectedDisconjugate lesionsTranscortical 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步骤：消毒铺无菌巾局麻进针成功，拔出针芯，测压，必要时压颈试验取脑脊液将针芯放回，拔针消毒，无菌纱布覆盖Tell the patient to say now when
8、 they can no longer hear the vibration.The limitation of movement of both eyes in one direction is called a conjugate lesion or gaze palsy,The normal reflex is toe flexion.Arcuate fasciculusNormally,the sound is heard in the center of the head or equally in both ears.步骤：消毒铺无菌巾局麻进针成功，拔出针芯，测压，必要时压颈试验取
9、脑脊液将针芯放回，拔针消毒，无菌纱布覆盖Another function that is impaired in all 4 of the aphasias mentioned above is repetition.The biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve rootscharacteristic of damage to the pons.定性诊断：病史+辅助检查等Tandem walkingA positive Hoffman response is indicative of a
10、n upper motor neuron lesion affecting the upper extremity in question.The triceps reflex is mediated by the C6 and C7 nerve roots,predominantly by C7.it can be either supranuclear(in cortical gaze centers)or nuclear(in brain stem gaze centers).神经系统体格检查头颈部l 头颅部l 面部及五官l 颈部l 头颅外伤：眶周瘀斑 鼓膜血肿 脑脊液鼻漏或耳漏神经系统
11、体格检查胸腹部l 胸部异常l 心律异常l 肝、脾大合并腹水l 腹部膨隆并压痛神经系统体格检查躯干和四肢l 脊柱异常l 翼状肩胛、四肢、指趾畸形l 皮下瘤结节和牛奶咖啡斑l 肌束震颤l 扑翼样震颤意识障碍检查概述 l 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。l 觉醒状态l 意识内容l 意识障碍意识障碍检查概述 l 采集病史l 全身和神经系统检查 意识障碍的觉醒水平意识障碍的觉醒水平 意识内容的改变意识内容的改变意识障碍检查概述 l 眼征l 疼痛刺激的反应l 瘫痪体征l 脑干反射l 锥体束征l 脑膜刺激征意识障碍检查意识障碍检查眼征 l 瞳孔l
12、眼底l 眼球位置l 眼球运动ComprehensionMotor and sensory functions多汗：有机磷中毒、甲亢危象或低血糖The ankle jerk reflex is mediated by the S1 nerve root.it can be either supranuclear(in cortical gaze centers)or nuclear(in brain stem gaze centers).The knee jerk reflex is mediated by the L3 and L4 nerve roots,mainly L4.皮肤皮下黄韧带硬
13、膜外腔硬脊膜硬膜下腔蛛网膜蛛网膜下腔Lumbar Puncture头眼反射（oculocephalic reflex）The Weber test(256Hz).语言、语调、语态和构音Motor and sensory functionsStereognosiaNormally,one will have greater air conduction than bone conduction and therefore hear the vibration longer with the fork in the air.神经病学研究范围：神经系统疾病及骨骼肌疾病The triceps refl
14、ex is mediated by the C6 and C7 nerve roots,predominantly by C7.CoordinationThis finding is important in the diagnosis of transcortical aphasias.Motor and sensory functionsThe biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve rootsThe normal reflex is toe flexion.头眼反射（oculoceph
15、alic reflex）place the butt on the mastoid eminence firmly.皮肤皮下黄韧带硬膜外腔硬脊膜硬膜下腔蛛网膜蛛网膜下腔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。heel to shin coordination testIf the toes extend and separate,this is an abnormal finding called a positive Babinskis sign.Arcuate fasciculusStereognosia口语表达：流畅，语音障碍，找词，错
16、语、新语等，语法障碍中枢神经源性过度呼吸：中脑被盖部精神状态和高级皮质功能检查If the bone conduction is the same or greater than the air conduction,there is a conductive hearing impairment on that side.Normally,the sound is heard in the center of the head or equally in both ears.Motor and sensory functionsPain and Light Touch SensationTh
17、e biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve rootsWhen repetition is preserved in Wernicke aphasia,it is called transcortical sensory aphasia,and the lesion is posterior to the Wernicke area.ComprehensionDysdiadochokinesis is the clinical term for an inability to perform
18、 rapidly alternating movements.角膜反射（corneal reflex）语言、语调、语态和构音意识障碍检查疼痛刺激反应 l 肢体反应l 面部表情l 去皮质强直l 去脑强直l 脑桥和延髓病变意识障碍检查瘫痪体征l 面瘫l 自发活动l 疼痛刺激l 肌张力l 坠落试验意识障碍检查脑干反射l 睫脊反射（ciliospinal reflex）l 角膜反射（corneal reflex）l 头眼反射（oculocephalic reflex）l 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皮质功能概述 l
19、 神经性/精神性疾病l 局灶性/弥漫性脑损害l 精神状态l 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 l 瞬时记忆l 短时记忆l 长时记忆精神状态和皮质功能计算力 l 时间定向力l 地点定向力l 人物定向力定向力 精神状态和皮质功能失语 l 口语表达：流畅，语音障碍，找词，错语、新语等，语法障碍l 听理解l 复述l 命名l 阅读l 书写精神状态和皮质功能Damage to Brocas area producesdifficulty in speakingDamage to Wernickes area results in difficulty in languageco
20、mprehension精神状态和皮质功能LocalizationNamingComprehensionFluencyType of DysphasiaBroca areaImpairedIntactNonfluentBrocaWernicke areaImpairedImpairedFluentWernickeArcuate fasciculusImpairedIntactFluentConductionBroca and Wernicke areasImpairedImpairedNonfluentGlobalTranscortical aphasiasAnother function th
21、at 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 repetitio
22、n 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 are
23、as,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 l 口头和书面命令l 观察患者 执行命令 模仿动作 实物演示能力侧脑室脉络丛产生经室间孔进入三脑室中脑导水管四脑室经四脑室正中孔、两个侧孔进入蛛网膜下腔和脑池脑穹窿表面的蛛网膜颗粒吸收上矢状窦窦汇横窦乙状窦颈内静脉Point-to-Point Movement EvaluationPain and Light Touch SensationPapilledema.口语表达：流畅，语音障碍，找词，错语、新语等，语法障碍Ocular bobbing is the rhythmical conjugate de
24、viation of the eyes downward.it can be either supranuclear(in cortical gaze centers)or nuclear(in brain stem gaze centers).characteristic of damage to the pons.常规：性状、细胞数、潘迪试验Sensory System头眼反射（oculocephalic reflex）Stereognosia头眼反射（oculocephalic reflex）Damage to WernickesIf the bone conduction is the
25、 same or greater than the air conduction,there is a conductive hearing impairment on that side.Motor and sensory functionsLevel of ConsciousnessBroca and Wernicke areas其它：疑颅压异常（颅高压、低颅压）等Disconjugate lesionsThe Sensory System Examination神经病学研究范围：神经系统疾病及骨骼肌疾病精神状态和皮质功能失认 l 视觉失认l 听觉失认l 触觉失认精神状态和皮质功能视空间技
26、能和执行功能 l 画钟面l 填数字l 指定时间画出表针颅神经检查l 12 Pairsl Arise from brain steml Motor and sensory functions颅神经检查颅神经检查嗅神经 l 特殊感觉神经l 检查方法l 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 l 视力l 视野l 眼底l 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 phys
27、iologic 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 l 外观l 眼球运动l 瞳孔及其反射l 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.If the toes extend and se
28、parate,this is an abnormal finding called a positive Babinskis sign.If the bone conduction is the same or greater than the air conduction,there is a conductive hearing impairment on that side.Damage to WernickesOcular bobbing is the rhythmical conjugate deviation of the eyes downward.difficulty in l
29、anguage口语表达：流畅，语音障碍，找词，错语、新语等，语法障碍It is an indicative of an UMN lesionNormally,the sound is heard in the center of the head or equally in both ears.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。When repetition is preserved in Wernicke aphasia,it is called transcortical sensory aphasia,and the lesion
30、 is posterior to the Wernicke area.Ocular bobbing is the rhythmical conjugate deviation of the eyes downward.Note extra-ocular muscle palsies and horizontal or vertical nystagmus.Disconjugate lesionsNormally,the sound is heard in the center of the head or equally in both ears.中枢神经源性过度呼吸：中脑被盖部常规：性状、细
31、胞数、潘迪试验上肢平伸试验、Barre分指试验、小指征口语表达：流畅，语音障碍，找词，错语、新语等，语法障碍Arise from brain stemIf the bone conduction is the same or greater than the air conduction,there is a conductive hearing impairment on that side.When repetition is preserved in a patient with Broca aphasia,it signifies transcortical motor aphasia
32、,and the lesion is anterior to the Broca area.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 lesionsin
33、ternuclear 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,
34、barbiturates,and phenytoin(Dilantin).Ethanol and barbiturates(recreational or therapuetic)are the most common cause of nystagmusOcular bobbing is the rhythmical conjugate deviation of the eyes downward.characteristic of damage to the pons.Downbeat nystagmus indicate a lesion compressing on the cervi
35、comedullary junction 颅神经检查三叉神经 l 混合神经l 面部感觉l 咀嚼肌运动l 反射l 异常表现和定位 颅神经检查面神经 l 混合神经l 面肌运动l 感觉l 反射l 副交感l 异常表现和定位 颅神经检查位听神经 l 蜗神经 Rinne试验试验 Weber试验试验l 前庭神经l 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 wil
36、l be louder on the affectedThe 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 bo
37、ne 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 l 运动l 感觉l 味觉l 反射l 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 l 运动
38、神经l 胸锁乳突肌l 斜方肌上部 颅神经检查舌下神经 l 运动神经l 核下性病变l 核性病变l 核上性病变 运动系统检查l肌容积肌容积l肌张力肌张力l肌力肌力l不自主运动不自主运动l共济运动共济运动l姿势与步态姿势与步态 运动系统检查肌容积 l肌萎缩l假性肥大l肌肉束颤 运动系统检查肌张力 l肌张力减低l肌张力增高 锥体系损伤 锥体外系损伤 运动系统检查肌力 l 六级肌力记录法l 肌群肌力测定l 单块肌肉检查l 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 l 舞蹈样动作l 手足徐动l 肌束颤动l 肌痉挛l 震颤l 肌张力障碍运动
39、系统检查共济运动 l 指鼻试验l 反击征l 跟膝胫试验l 轮替试验l 起坐试验l 闭目难立试验 Coordination,Gait and Rhomberg TestCoordinationRapidly Alternating Movement Evaluation Dysdiadochokinesis is the clinical term for an inability to perform rapidly alternating movements.Point-to-Point Movement Evaluation The clinical term:Dysmetriaheel
40、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 l姿势l步态
41、l起步情况l步幅l速度Gait Tandem walkingOn ToesOn Heels感觉系统检查感觉系统 l浅感觉l深感觉l复合感觉 感觉系统检查浅感觉 l痛觉l触觉l温度觉 The Sensory System Examination Pain and Light Touch Sensation感觉系统检查深感觉 l运动觉l位置觉l振动觉 感觉系统检查复合感觉 l定位觉l两点辨别觉l图形觉l实体觉Position Sense Stereognosia Graphesthesia Extinction 反射检查反射检查 l深反射l浅反射l病理反射 反射检查深反射 l上肢反射l下肢反射l阵
42、挛lHoffmann征lRossolimo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
43、 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 lesionA positive Hoffman response is indicative of an upper motor neuron lesion affecting the upper extremity in question.Finally,te
44、st clonus 反射检查浅反射 l腹壁反射l提睾反射l跖反射l肛门反射反射检查病理反射 l巴彬斯基征l巴彬斯基等位征l强握反射l脊髓自主反射脑膜刺激征脑膜刺激征 l屈颈试验l克匿格征l布鲁津斯基征自主神经检查自主神经 l 一般检查l 内脏及括约肌功能l 自主神经反射l 自主神经实验检查 自主神经检查一般检查 l 皮肤黏膜l 毛发和指甲l 出汗l 瞳孔 自主神经检查内脏及括约肌功能 l 胃肠功能l 排尿障碍及性质l 膀胱区膨胀程度自主神经检查自主神经反射 l 竖毛试验l 皮肤划痕试验l 眼心反射 自主神经检查自主神经实验检查 l 卧立位试验l 汗腺分泌l 性功能障碍的电生理检查l 排尿障碍的
45、尿道动力学检查 Lumbar Puncture一、脑脊液循环 侧脑室脉络丛产生经室间孔进入三脑室中脑导水管四脑室经四脑室正中孔、两个侧孔进入蛛网膜下腔和脑池脑穹窿表面的蛛网膜颗粒吸收上矢状窦窦汇横窦乙状窦颈内静脉 二、腰椎穿刺 解剖 皮肤皮下黄韧带硬膜外腔硬脊膜硬膜下腔蛛网膜蛛网膜下腔 1、适应症 颅内感染：脑膜炎、脑炎 疑蛛网膜下腔出血但CT不能证实时 脊髓病变 格林-巴利综合征 鞘内给药 脊髓造影 其它：疑颅压异常（颅高压、低颅压）等 2、禁忌症 颅高压有明显视乳头水肿和后颅窝占位病变 穿刺部位有化脓性感染或脊椎结核 血液系统疾病有出血倾向，血小板50000/mm3 3、并发症 腰穿后头痛
46、：低颅压 出血：损伤 感染 脑疝 4、操作方法 体位：侧卧、屈颈抱膝，背部与床垂直 穿刺部位：L3-4，L4-5 步骤：消毒铺无菌巾局麻进针成功，拔出针芯，测压，必要时压颈试验取脑脊液将针芯放回，拔针消毒，无菌纱布覆盖 术后平卧4-6小时 5、脑脊液检查 压力：80-180mmH2O 压颈试验 常规：性状、细胞数、潘迪试验 生化：蛋白质、糖、氯化物 三大染色和病毒学检测 寄生虫检查 细胞学检查 Page 137中南大学湘雅医院神经系统体格检查神经系统体格检查血压l血压显著升高l血压过低Page 138中南大学湘雅医院神经系统体格检查神经系统体格检查语言、语调、语态和构音l语言l语调：语音和声调
47、l语态：节奏l构音Page 139中南大学湘雅医院意识障碍检查意识障碍检查疼痛刺激反应 l肢体反应l面部表情l去皮质强直l去脑强直l脑桥和延髓病变Page 140中南大学湘雅医院Page 141中南大学湘雅医院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 affectedPage 142中南大学湘雅医院运动系统检查运动系统检查肌力 l六级肌力记录法l肌群肌力测定l单块肌肉检查l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 Page 143中南大学湘雅医院反射检查反射检查浅反射 l腹壁反射l提睾反射l跖反射l肛门反射Page 144中南大学湘雅医院自主神经检查自主神经检查一般检查 l皮肤黏膜l毛发和指甲l出汗l瞳孔
