1、Symptomatology of the Neurological Disease Section 1 Consciousness Concept Concept Consciousness Consciousness is awareness of the body to self-state and the environment.Quantitative changes of Quantitative changes of consciousnessconsciousness mean reduced alertness:SomnolenceSoporComasomnolence In
2、 the early stage In the state of continued sleeping Can be awaked Talk correctly and can complete the examination after awaking Fall in sleep after stopping stimulussopor In the state of continued sleeping Can be awaked only by severe pain and heavy sound Talk simply and uncompletely after awaked,fe
3、w spontaneous speech Fall in deep-sleep after stopping stimuluscoma Is the most serious unconsciousness Complete loss of consciousness No reaction to all kinds of strong stimuli No active movement and cant open his eyes spontaneouslyClassification of coma Superficial coma Middle coma Deep comaSuperf
4、icial comaSuperficial coma 1.loss of consciousness(no response and awaked)2.reactive to stimulus(pressing orbit)3.spontaneous action 4.have corneal reflex,pupil reaction,tendon reflex 5.no change in life signs(BP,P,R,T)Middle coma:between superficial coma and deep comaDeep coma 1.loss of consciousne
5、ss(no response and awaked)2.no reactive to stimulus(pressing orbit)pletely loss of spontaneous action 4.loss of reflex,pupil reaction,tendon reflex 5.having change in life signs Locked-in syndrome is a rare neurological disorder characterized by complete paralysis of voluntary muscles in all parts o
6、f the body(except for those that control eye movement).The lesion site is in the base of the pons.It may result from traumatic brain injury,vascular diseases,demyelinating diseases,or medication overdose.Individuals with locked-in syndrome are conscious and have cognitive function,but are unable to
7、speak or move.The disorder leaves the patient completely mute and paralyzed.Communication may be possible with blinking eye movements.Section 2 Section 2 Aphasia,Apraxia and Aphasia,Apraxia and AgnosiaAgnosia Broca aphasia:Broca aphasia:is also called motive aphasia or expressive aphasia.The lesion
8、is in Broca area.It is characterized by oral expresssing dysfunction.The ability of repeat,named,read and write has been injuried on different degrees.Wernicke aphasia:Wernicke aphasia:is also called is also called auditory aphasia or sensory auditory aphasia or sensory aphasia.aphasia.The lesion is
9、 in Wernicke area.It is characterized by severe comprehension dysfunction.The ability of repeat,named,read and write has been injuried on different degrees.Complete aphasia Is also called mixed aphasia.It is the most serious type of aphasia.It is characterized by the loss of all of the language func
10、tion in clinic.Gerstmann syndrome:Gerstmann syndrome:lesion of the left angle gyrus(loss the ability to:count,write,recognize a particular finger,distinguish the left side and right side,sometimes readSection 3 Seizure&SyncopeThe differential point of seizure and syncopeClinical features seizuresync
11、opeomenNo or short(several s)long)relationship to positionnoUsually when stand Lasting timeDay and night,more in sleepMore in daySkin colorGreen purple or normalpaleLimb convulsionmorerarelyConfusion after attackoftenNone or rarelyNeurological signhavenoCardiac dysfunction nooftenEEG abnormaloftenra
12、relySection 5 NystagmusClassified into:jumping nystagmus clock-like nystagmusClassified into:horizontal nystagmus vertical nystagmus rotate nystagmusSection 6 ParalysisDifferential diagnosisfeaturesSpastic paralysisFlaccid paralysisdistributionwide,the whole limbLocal(muscle group)Muscle tensionincr
13、easeddecreasedreflexTendon reflex increased,superficial reflex disappearTe n d o n f e f l e x d e c r e a s e d o r disappearsuperficial reflex disappearPathological reflex(+)(-)Muscle atrophynohaveM u s c l e fasciculationnohaveSkin nutritiondysfunctionnoOften haveEMGNerve conduction velocity is n
14、ormalNerve conduction velocity is abnormalMuscle biopsynormalabnormalSection7Muscular AtrophySection 8 Disorders of Somatic SensationGeneral sensationv superficial sensation(pain temperature touch)come from skin mucosav deep sensation (movementposition&vibration)come from muscletendonjointv cortical
15、 sensation (complex sensation：stereognosistwo-point discriminationfigurelocate the position special sensation-visionhearingsmelltasteclassificationSection 9 AtaxiaCerebellum ataxia1.Change of posture and gait2.incoordination vdysmetriavintention tremor3.Speech disturbance4.The eyeball movement distu
16、rbance5.Decreased muscular tension 1.Frontal lobe ataxiaCerebrum ataxia2.Parietal lobe ataxia3.Temporal lobe ataxia4.Occipital lobe ataxiaDeep sensation disturbanceSensorry ataxiaDue to the lesion of posterior cord and peripheral nerveVestibule ataxiaMainly balance disturbance,vertigovomittingnystag
17、musSection 10Gait DisordersClassification and features1.Hemispasticity gait(one side)-cerebrovascular disease2.scissors-like gait-congenital spastic paraplegia3.Festinating gait-Parkinsons syndrome4.Swinging gait-progressive muscular dystrophy5.Steppage gait-paralysis of peroneus nerve6.Sensory atax
18、ia gait-MS7.Cerebellar ataxia gait-cerebellar diseaseSection 11Involuntary MovementsInvoluntary movement The consciousness is clear,but he cant control his skeletal muscle movementStop when sleep,increased when exciting-due to the disease of the basal gangliaPill-rolling action.f:46 beats/s.appear w
19、hen stillInclude:1.static tremorCharacteristic sign of Parkinsons diseaseDifferent with intention tremor2.Choreic movement3.athetosis4.Torsion spasm5.hemiballismus6.ticsspasmodic torticollisThe localizing diagnosis of CNS lesion.Cerebral hemisphere A.the frontal lobe a.single limb paralysis(destruct
20、ive lesion),Jacksons epilepsy (stimulus lesion)caused by lesion of the motor cortex-precentral gyrus b.motor aphasia-lesion of the posterior area of the inferior frontal gyrus c.Foster-Kenndey syndrome:lesion of the basal area of the frontal lobe 1)loss of the olfaction of the lesion side 2)primary
21、optic nerve atrophy of the lesion side 3)papilledema of the contralateral side d.disturbance of psychological reaction:apathy,dullness,dementia.Cerebral hemispherical B.the parietal lobe a.loss of the complex sensation,sensory type of epilepsy:lesion of the sensory cortex-postcentral gyrus b.Gerstma
22、nns syndrome:lesion of the left angle gyrus(loss the ability to:count,write,recognize a particular finger,distinguish the left side and right side,sometimes read)C.the temporal lobe:a.temporal lobe epilepsy-taste hallucination,olfactory hallucination b.sensory aphasia-lesion of the left posterior ar
23、ea of the superior temporal gyrus D.the occipital lobe:disturbance of acuity and visual field due to the lesion of the visual cortex-cortex around the calcarine fissure E.limbic system:psychological symptoms.Internal capsule Hemiplegia Hemianopia Hemianesthesia -due to cerebrovascular disease.The ba
24、sal ganglia A.hypertonia ,decrease movement,static tremor-lesion of pallidum(Parkinsons syndrome)B.hypotonia,increase movement-lesion of the caudate nucleus and putamen(Chorea).Brain stem(cross sensory and motor disturbance)A.mid-brain:Weber syndrome(cross hemiplesia of CN.)B.pons:Millard-Gubler syn
25、drome(cross hemiplesia of CN.)C.medulla oblongata:Wallenberg syndrome:a.cause:usually due to infarction of the cerebellar posterior inferior artery b.clinical manifestation:vertigo,nausea,vomiting and nystagmus dysphagia,dysarthria,loss of pharynx reflex ataxia Horners syndrome crossed sensory distu
26、rbance.Cerebellum(ataxia)Central lesion(vermis)-ataxia of trunk Hemispheric lesion-ataxia of limb of the same side.Spinal cord A.upper cervical cord(C1-4)a.UMN palsy of the four limbs b.loss of all sensation below the lesion level c.dysfunction of the sphincter d.root pain occasionally.Spinal cord B
27、.cervical intumescentia(C5-T2)a.LMN palsy of the upper limbs b.UMN palsy of the lower limbs c.loss of all sensation below the lesion level d.dysfunction of sphincter e.radical pain f.Horners syndrome due to the lesion of the lateral cells of C8-T1.Spinal cord C.Thoracic cord:a.paraplegia of low limb
28、s b.loss of the all the sensation below the lesion level c.dysfunction of sphincter.Spinal cord D.lumber intumescentia(L1S2)a.LMN paralysis of the lower limbs b.loss of all the sensation of the lower limb and perineum c.dysfunction of the sphincter d.root pain occasionally.Spinal cord E.conus(S3S5):
29、a.loss of the sensation in the anus and perineum b.dysfunction of sphincter(true urine incontinence).Spinal cord F.cauda equina:a.obvious root(radical)pain b.sensory disturbance of perineum c.unobvious dysfunction of the sphincter The cranial nerves Classification Sensory nerve Olfactory nerve Optic
30、 nerve Vestibulocochlear nerveMotive nerve Oculomotor nerve Trochlear nerve Abducent nerve Accessory nerve Hypoglossal nerveMixed nerve Trigeminal nerve Facial nerve Glossopharyngeal nerve Vagus nerveThe position of the cranial nerve nucleus in brain stem mid-brain：、pons：、medulla oblongata：、.olfacto
31、ry NFoster-Kenndey syndrome:lesion of the basal area of the frontal lobe 1)loss of the olfaction of the lesion side 2)primary optic nerve atrophy of the lesion side 3)papilledema of the contralateral side.Optical N A.anatomy and physiology Gangliocytes of retina optical N optic chiasmoptic tract lat
32、eral ganiculate body optic radiation occipital lobeB.Clinical features lesion of the visual pathway:1.abnormal acuity 2.defect of visual fielddefect of visual fielda.Optic N 1.uniocular blindness 2.loss of the direct pupillary radiation to light b.Optic chiasm 1.central lesion-bitemporal hemianopia
33、eg.pituitary tumor 2.lateral lesion-unilateral nasal hemianopiaoptic tract binocular equilateral hemianopia(contralateral)defect of visual fieldd.optic radiation:1.upper lesion-binocular equilateral,lower quadrant anopia 2.lower lesion-binocular equilateral,upper quadrant anopia 3plete lesion-binocu
34、lar equilateral hemianopiae.Visual cortex:cortical blindnessIII.Oculomotor N B.clinical features:Lesion of oculomotor N result in:1.ptosis 2.disturbance of eyeball movement 3.diplopia 4.dilated pupil and showing no reaction to light causes:multiple sclerosis,vascular disease,tumor etc Pathway of pup
35、ils reaction to light Light retina optic n midbrain E-W nucleus(parasympatic)oculomotor N ciliary ganglia postganglia fibres sphincter of pupil so any damage of the pathway so any damage of the pathway may result in the dilated may result in the dilated pupil,wich show no reaction to pupil,wich show
36、 no reaction to lightlightIV.Trochlear NVI.Abducent NOphthalmoplegia Peripheral ophthalmoplegia palsy of oculomotor nerve palsy of trochlear nerve：rare palsy of abducent nerve Nuclear ophthalmoplegia Internuclear ophthalmoplegia One and a half syndrome supranuclear ophthalmoplegiaV.Trigeminal NTrige
37、minal N is mixed nerve,composed of sensory part and motor partB.Leison of Trigeminal N Clinical features:1.sensory loss of the face and mucosa of mouth and nose:onion like sensory loss;2.loss of the corneal reflex 3.Paralysis of mastication m.Corneal reflex arch:Corneal ophthalmic N the main sensory
38、 nucleus bilateral facial N nucleus facial N Orbicularis Oculi m.Facial N A.Anotomy:is mixed nerve,composed of sensory root and motor root motor root:innervate the facial expression m.(the main function of facial N)sensory root:supply the anterior 2/3 taste bulb on the tongue Parasympathetic fiber:g
39、landsB.Clinic features Facial paralysis:a.peripheral type:b.central type:a.Peripheral typeCaused by the injury of lower motor neuron CM:Disappearance of the forhead wrinkles Inability to close the eye Loss of the nasolabial furrow Causes:virus infection,eg Bell palsy b.Central typecaused by the inju
40、ry of upper motor neuron CM:1.loss of the nasolabial furrow only of contralateral side 2.the function of the upper facial m.preserved Cause:cerebrovascular disease.Auditory N Auditory N composed of Cochlear N and Vestibular N1.Cochlear N Clinical features:lesion of cochlear N.will appear:deafness an
41、d tinnitus2.Vestibular N Clinical features:leison of vestibular N will appear :vertigo,disturbance of equilibrium,nystagmus.Glossopharyngeal N andvagus N A.anatomy:B.CM:Lesion of two nerves:1.Bulbar palsy:Difficulty in swallowing Hoarseness of the voice Drinking water choke Dysarthria(构音障碍)Weakness
42、of the palate Absent gag reflex Caused by lesion of the one side of the bulb2.pseudobulbar palsy:caused by lesion of bilateral corticobulbar tracts(more common seen in clinic than bulbar palsy)Cause:cerebrovascular disease CM:Difficulty in swallowing Hoarseness of the voice Drinking water choke Dysa
43、rthria (difference with bulbar palsy:compulsivecrying and laughing,dementia,apperance of primitive reflex).Accessory N A.anotomy:is simple motor N.Innervate:sternocleidomastoid m.trapezius m.B.clinical features:paralysis-weakness in sbrug and turning head.Hypoglossal N A.anatomy:is simple motor N.In
44、nervate:glossal m.B.clinical features:Paralysis peripheral type:1.the tongue deviated to the lesion side 2.atrophy and fasciculation of the tongue Central type:1.the tongue deviated to the normal side 2.no atrophy and fasciculation of the tongueThe Clinical Methods of NeurologySection 2 neurological
45、 examinationForm of neurological examinationconsciousness12 cranial nervesexamination of motor systemexamination of sensory systemreflexBrocas aphasia can understand,but cant expressWernickes aphasia can express,but cant understandMixed aphasia cant express and understandtype of aphasiaI olfactory n
46、erveforbid stimulant substanceII optic nervevisual acuityvisual fieldsbase of the eyeIII oculomotor nerveptosis,invasion of the eyeballEvery direction movement of eyeballLight reflex of pupil(direct、indirect light reflex)Regulating reflex of pupilIV trochlear nerveIV trochlear nerve examine the move
47、ment of extraocular muscle VI abducens nerveVI abducens nerve examine the movement of extraocular muscle V trigeminal nerve mixed nerveV trigeminal nerve mixed nerveExamine pain sensation in the region of three branchesExamine the force of temporal and masticatory muscles corneal reflex (direct,indi
48、rect)VII facial nervemixed nerveVII facial nervemixed nerveDeviation of the mouthAsk the patient to do a series of actionIf the paralysis below and above the eye fissure peripheral facial palSy eg.idiopathic facial palsy If the paralysis below the eye fissure central facial palSy eg.cerebral vascula
49、r diseaseVIIIVIIIauditory nerveauditory nerveAbility of hearing Weber test Rinne testIX glossopharyngeal nerveIX glossopharyngeal nerve X vagus nerve X vagus nerveAsk the patient say“a”,and observe two soft palatesTaste of posterior 1/3 of the tonguegag reflexXI accessory nerveXI accessory nerveAsk
50、the patient turn his head against the resistanceAsk the patient shrug his shoulders against the resistance XII hypoglossal nerveXII hypoglossal nerveask the patient to extension his tongue，observe whether has deviation、muscle atrophy and muscle fibrillation三三.Examination of motor.Examination of moto
