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 神经病学研究范围：神经系统疾病及骨骼肌疾病Ethanol and barbiturates(recreational or therapuetic)are the most common cau
3、se of nystagmusMental State and Cognitive FunctionMotor and sensory functionsThe knee jerk reflex is mediated by the L3 and L4 nerve roots,mainly L4.conductive hearing loss the vibration will be louder on the affected常规：性状、细胞数、潘迪试验Broca and Wernicke areasJackson征、下肢轻瘫试验定位诊断：体征是重点+结合神经解剖知识Comprehensi
4、onIt is an indicative of an UMN lesionDownbeat nystagmus indicate a lesion compressing on the cervicomedullary junctionWhen repetition is preserved in a patient with Broca aphasia,it signifies transcortical motor aphasia,and the lesion is anterior to the Broca area.Rapidly Alternating Movement Evalu
5、ationThe biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve roots翼状肩胛、四肢、指趾畸形共济失调式呼吸：延髓上部颅内感染：脑膜炎、脑炎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Dysdiadochokinesis is the clinical term
6、 for an inability to perform rapidly alternating movements.The Weber test(256Hz).Jackson征、下肢轻瘫试验internuclear ophthalmoplegia(INO).If the bone conduction is the same or greater than the air conduction,there is a conductive hearing impairment on that side.If the bone conduction is the same or greater
7、than the air conduction,there is a conductive hearing impairment on that side.The Weber test(256Hz).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Arise from brain stem颅内感染：脑膜炎、脑炎Lumbar PunctureRhomberg Test穿刺部位：L3-4，L4-5Jackson征、下肢轻瘫试验Normally,the sound is heard in the center of the head or equally in both ears.常规：性状、细
8、胞数、潘迪试验isolated impairment of adduction of one eye,nystagmus is often presentBroca and Wernicke areasLevel of ConsciousnessRapidly Alternating Movement Evaluation语言、语调、语态和构音area results in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
9、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Mental State and Cognitive Function
10、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。Jackson征、下肢轻瘫试验颅内感染：脑膜炎、脑炎意识内容的改变proprioceptive and vestibular input),and眼前庭反射（oculovestibular reflex）Broca and Wernicke areas意识内容的改变Jackson征、下肢轻瘫试验口语表达：流畅，语音障碍，找词，错语、新语等，语法障碍If the toes extend and separate,this is an abnormal finding called a positive B
11、abinskis sign.共济失调式呼吸：延髓上部定位诊断：体征是重点+结合神经解剖知识The Weber test(256Hz).Downbeat nystagmus indicate a lesion compressing on the cervicomedullary junctionRapidly Alternating Movement Evaluationa normally functioning cerebellum.性功能障碍的电生理检查视空间技能和执行功能Level of Consciousness精神状态和高级皮质功能检查神经系统体格检查躯干和四肢l 脊柱异常l 翼状
12、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 眼底l 眼球位置l 眼球运动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
13、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常规：性状、细胞数、潘迪试验意识障碍的觉醒水平Rapidly Alternating Movement Evaluation共济失调式呼吸：延髓上部穿刺部位：L3-4，L4-5CoordinationWernicke areaRhomberg
14、TestAutonomic NerveTandem walking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。ipsilateral median longitudinal fasciculus(MLF)lesion.定位诊断：体征是重点+结合神经解剖知识GraphesthesiaThe Weber test(256Hz).精神状态和高级皮质功能检查Downbeat nystagmus indicate a lesion compressing on the cervicomedullary junctionDysdiadochokinesis
15、is the clinical term for an inability to perform rapidly alternating movements.The Rinne testThe knee jerk reflex is mediated by the L3 and L4 nerve roots,mainly L4.精神状态和高级皮质功能检查Localization精神状态和皮质功能概述 l 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
16、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 languagecomprehension精神状态和皮质功能LocalizationNamingComprehensionFluencyType of DysphasiaBroca areaImpairedInta
17、ctNonfluentBrocaWernicke areaImpairedImpairedFluentWernickeArcuate fasciculusImpairedIntactFluentConductionBroca and Wernicke areasImpairedImpairedNonfluentGlobalTranscortical aphasiasAnother function that is impaired in all 4 of the aphasias mentioned above is repetition.This finding is important i
18、n 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 repetition is preserved in Wernicke aphasia,it is called transcortical sensory aphasia,and the lesion is p
19、osterior 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 areas,respectivelyThe Sensory System ExaminationWhen repetition is preserved in a patient with Broca
20、 aphasia,it signifies transcortical motor aphasia,and the lesion is anterior to the Broca area.精神状态和高级皮质功能检查Rhomberg TestArise from brain stemTranscortical mixed aphasia and global aphasia are similar except for the preservation of repetition,and results from combined lesions anterior to the Broca a
21、nd Wernicke areas,respectively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。Rhomberg TestGraphesthesiaWernicke area脑脊液鼻漏或耳漏语言、语调、语态和构音Motor and sensory functionsPapilledema.Ocular bobbing is the rhythmical conjugate deviation of the eyes downward.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。proprio
22、ceptive and vestibular input),and神经病学研究范围：神经系统疾病及骨骼肌疾病The limitation of movement of both eyes in one direction is called a conjugate lesion or gaze palsy,area results inMental State and Cognitive FunctionJackson征、下肢轻瘫试验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 实物演示能力精神状态和皮质功能失认 l 视觉失认l
23、 听觉失认l 触觉失认精神状态和皮质功能视空间技能和执行功能 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。共济失调式呼吸：延髓上部Note the chalky
24、 white disc with discrete margins.ipsilateral median longitudinal fasciculus(MLF)lesion.If the bone conduction is the same or greater than the air conduction,there is a conductive hearing impairment on that side.Jackson征、下肢轻瘫试验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。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
25、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non-visual confirmation of position(includingipsilateral median longitudinal fasciculus(MLF)lesion.This finding is important in the diagnosis of transcortical aphasias.conductive hearing loss the vibration will be louder on the affectedExtinction侧脑室脉络丛
26、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Normally,the sound is heard in the center of the head or equally in both ears.长吸式呼吸：中脑下部和桥脑上部Broca and Wernicke areasNormally,the sound is heard in the center of the head or equally in both ears.Ocular bobbing is the rhythmical con
27、jugate deviation of the eyes downward.Pain and Light Touch SensationCoordination精神状态和高级皮质功能检查颅神经检查Papilledema.Note swelling of the disc,hemorrhages,and exudates,with preservation of the physiologic cup Optic Atrophy.Note the chalky white disc with discrete margins.Optic atrophy is a late finding wit
28、h 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 瞳孔性功能障碍的电生理检查The Sensory System Examination神经病学研究范围：神经系统疾病及骨骼肌疾病发育正常：胸围、上肢展开、坐高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Normally,the sound is heard in the center of the head
29、 or equally in both ears.area results ininternuclear ophthalmoplegia(INO).共济失调式呼吸：延髓上部The Weber test(256Hz).精神状态和高级皮质功能检查Tell the patient to say now when they can no longer hear the vibration.共济失调式呼吸：延髓上部ExtinctionAutonomic NervePain and Light Touch SensationThe Weber test(256Hz).The Rinne test丛集式呼吸
30、：脑桥下部中枢神经源性过度呼吸：中脑被盖部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ipsilateral median longitudinal fasciculus(MLF)lesion.Note extra-ocular muscle palsies and horizontal or vertical nystagmus.The limitation of movement of both eyes in one direction is called a conjugate lesion or gaze palsy,and is indicative of a centra
31、l lesion it can be either supranuclear(in cortical gaze centers)or nuclear(in brain stem gaze centers).Disconjugate lesionsinternuclear ophthalmoplegia(INO).isolated impairment of adduction of one eye,nystagmus is often present ipsilateral median longitudinal fasciculus(MLF)lesion.Gaze-evoked nystag
32、mus(nystagmus that is apparent only when the patient looks to the side or down)may be caused by many drugs,including ethanol,barbiturates,and phenytoin(Dilantin).Ethanol and barbiturates(recreational or therapuetic)are the most common cause of nystagmusOcular bobbing is the rhythmical conjugate devi
33、ation of the eyes downward.characteristic of damage to the pons.Downbeat nystagmus indicate a lesion compressing on the cervicomedullary 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 其它：疑颅压异常（颅高压、低颅压）等Disconjugate lesionsJackson征、下肢轻瘫试验This finding is important in the diagnosis of transcortica
34、l aphasias.and is indicative of a central lesionMental State and Cognitive FunctionNote extra-ocular muscle palsies and horizontal or vertical nystagmus.Tell the patient to say now when they can no longer hear the vibration.定位诊断：体征是重点+结合神经解剖知识characteristic of damage to the pons.脑脊液鼻漏或耳漏共济失调式呼吸：延髓上部
35、Ocular bobbing is the rhythmical conjugate deviation of the eyes downward.脑脊液鼻漏或耳漏Downbeat nystagmus indicate a lesion compressing on the cervicomedullary junction定性诊断：病史+辅助检查等排尿障碍的尿道动力学检查语言、语调、语态和构音Papilledema.Rhomberg Test神经病学研究范围：神经系统疾病及骨骼肌疾病病房：卧位-坐位-立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
36、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 will be louder on the affectedThe Rinne test place the butt on the mastoid eminence firmly.Tell the patient to
37、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 bone conduction is the same or greater than the air conduction,there is a conductive hearing impairment on tha
38、t 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 运动神经l 胸锁乳突肌l 斜方肌上部 定位诊断：体征是重点+结合神经解剖知识CoordinationJackson征、下肢轻瘫试验视空间技能和执行功能Lumbar PunctureThe Sensory System E
39、xaminationLocalizationTell the patient to say now when they can no longer hear the vibration.Localization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internuclear ophthalmoplegia(INO).Ocular bobbing is the rhythmical conjugate deviation of the eyes downward.Rapidly Alte
40、rnating Movement Evaluation颅内感染：脑膜炎、脑炎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。头眼反射（oculocephalic reflex）Stereognosia常规：性状、细胞数、潘迪试验Ocular bobbing is the rhythmical conjugate deviation of the eyes downward.常规：性状、细胞数、潘迪试验This finding is important in the diagnosis of transcortical aphasias.共济失调式呼吸
41、：延髓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 肌张力障碍运动系统检查共济运动 l 指
42、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 to shin coor
43、dination 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l起步情况l步幅l速度G
44、ait 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阵挛lHoffmann征l
45、Rossolimo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 nerve root.
46、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,test clonus 反射
47、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 排尿障碍的尿道动力学检查 Lumb
48、ar 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：低颅压 出血：损伤 感
49、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l语态：节奏l构音Pag
50、e 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
