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history and neurological exam symptoms signs qualitative anatomic(topographic)diagnosis diagnosis other data lab test pathologic(etiologic)diagnosis history and n1 patients trust and cooperation reliable history and accurate exam correct diagnosis 2Taking the history Purpose:primary information of the disease where,what,whyguide to the exam and Lab test Taking the history Purpose:3Taking the history Notice:good attitude while patient saying avoiding suggestionaccurate comprehension of what he/she saytaking care to negative or other systems symptomsobtaining from a relative or friend (coma,child,mental disorder)Taking the history Notice:4Structure of the historyThe complaintThe presenting historyPast historyPersonal historyFamily historyStructure of the historyThe co5The complaint What is the main problem?What was it that caused you to come here?Use the patients language.The complaint What is the main6The presenting historyInformation of onsetNature of the main symptomProcess of the diseaseAssociated symptomsPreceding treatment The presenting historyInformat7Information of onsetWhen it was first noted by the patient?Inducing factors of onset.Was the onset sudden,subacute,insidious or gradual?acute:vascular,poison,trauma,infectionchronic:tumor,metabolism,degeneration Information of onsetWhen it wa8Nature of the main symptomWhat is its distribution?unilateral,bilateral,frontal,occipital etc.What is its nature and severity?e.g.headache:throbbing,stabbing,tensingIs there anything that makes it better or worse?e.g.movement,posture,sleep,coughing How long does it take for every attack?has itNature of the main symptomWha9Process of the diseaseIs the symptom episodic or constant?Has it worsened,improved,or stayed the same since?Process of the diseaseIs the s10Associated symptomsAre there any associated symptoms?Have any other symptoms developed since?Neurological symptoms are important,not ignoring the symptoms of other systems.Associated symptomsAre there 11Preceding TreatmentHave any tests already been performed?Has any therapy ever been given?The results of treatmentPreceding TreatmentHave any t12Past historyThe following may be relevant in neurologyHP、DM、rheumatic valvular heart diseaseinfections during childhoodhead injuries and poisona systemic disorderbirth and early developmentdrug allergiesPast historyThe following may 13Personal historyhome circumstanceeducation and occupationdietsmoking history and alcohol intakePersonal historyhome circumsta14Family historyare there any family illnesses?hereditary ataxia.muscular dystrophy epilepsy.migraine(susceptible)are parents,siblings,and children alive?if not,what did they die from?Family historyare there any fa15Neurological examinationNotice:preparation of tools ophthalmoscope、hammer、tuning-forkgood attitude and gentle behaviourproceeding from the head downwardsbeginning while taking the historytreating while examining an alarming caseNeurological examinationNotice16Neurological examinationTesting categoryhigher cortical functioncranial nervesmotor functionsensory functionreflex functionautonomic nervesmeningeal irritation signs Neurological examinationTestin17higher cortical functionlevel of consciousnesscognitive functionlanguage skillsemotional statehigher cortical functionlevel18consciousnessThe level of arousal normal-full awakefulness and responsiveness somnolent-asleep but rousable when stimulated stupor-difficult in arousal and co-operation coma-unresponsive and unrousableThe content of consciousness confusion-inattentiveness and disorientation delirium-extreme agitation with hallucinationconsciousnessThe level of arou19cognitive function orientation-to person、time、place memory-immediate、recent、remote comprehension calculation-serial sevens、real-life problem cognitive function orientati20Language skillsfluency:non-fluency,errors of grammar,paraphrasiacomprehension:to do following commandsrepetition:to repeat three common nounswriting:aphasia is often together with agraphianaming:difficulty in naming familiar objects(anomia)Language impairment with normal cognitive function always suggests a focal lesionLanguage skillsfluency:non-flu21emotional stateNote:anxiety or excitementdepression or apathyemotional or uninhibited behaviourslowness of movement or responsesemotional stateNote:22Cranial nerve examinationCranial nerve examin23Olfactory nerve()Test using aromatic non-irritant materialOne nostril closed while sniffing with the otherOlfactory nerve()Test using a24Optic nerve()visual acuitydeficit?mild or severe?visual fieldsgross testing by confrontationoptic fundusnote:clarity of disc edge hemorrhage arteriolosclerosis Optic nerve()visual acuity25Oculomotor(),trochlear(),abducens()nervesptosisocular movement 6 directions,diplopiaconjugate movementnystagmuspupilnote:size,shape,equality,reaction to lightOculomotor(),trochlear(),ab26Trigeminal nerve()sensation over whole face pain,temperature,light touch compare each sidecorneal reflex touch with wisp of cotton wool the most sensitive indicatormotor examination temporalis and masseter musclesTrigeminal nerve()sensation27Facial nerve()wrinkle forehead flattening of forehead fold?close eyes weakness of closure?purse lips asymmetrical elevation of one corner?show teeth flattening of nasolabial fold?Distinguish central or peripheral facial palsy!Facial nerve()wrinkle forehea28Auditory nerve()cochlear component assessing gross hearing tuning-fork test Webers test,Rinnes test differentiate conductive deafness from perceptive(nerve)deafnessvestibular component Auditory nerve()cochlear comp29Glossopharyngeal(),vague()nerveNote:voice-dysphonia swallowing-dysphagiaasymmetry of palatal movement?gag reflex compare sensitivity on each sideGlossopharyngeal(),vague()30Accessory nerve()Sternmastoid rotate head against resistanceTrapezius shrug shoulders against resistanceAccessory nerve()Sternmastoid31Hypoglossal nerve()evidence of atrophyfasciculationnote:any difficulty or deviation of protruding tongue Hypoglossal nerve()evidence o32(三)Motor systemMuscle bulkMuscle toneMuscle strengthCo-ordinationInvoluntary movementPosture and gait(三)Motor systemMuscle bulk33Muscle bulk(appearance)Note:any asymmetry or deformity muscle wasting(atrophy)muscle hypertrophycomparing sides or measuring if in doubt.Muscle fasciculation irregular,non-rhythmical contraction of groups of motor units,induced after smacking Muscle bulk(appearance)Note:34Muscle tone(tension)Tone is defined resistance of M to passive movement normal,decreased,increasedDecreased in tone lower motor neuron lesion,cerebellar disorderincreased in tone clasp-knife:upper motor neuron lesion lead-pipe:extrapyramidal lesion cog-wheel:extrapyramidal lesion Muscle tone(tension)Tone is35Muscle strength(power)The ability to contract M against force or gravitythe classic grading system scores:full strength movement against partial resistance movement against gravity only movement only if gravity eliminated little visible movement 0 no contractionslight weakness test:Barres test,pronator drift,Jackson signMuscle strength(power)36Co-ordination (cerebellar hemispheric funtion)Finger-to-nose:dysmetriaHeel-knee-shinRapid alternating movement:dysdiadochokinesiaReboundRombergs test:loss of balance(+)when eyes open or closed:cerebellar ataxia(+)only when eyes closed:sensory ataxiaCo-ordination (cerebell37Involuntary movementTremor:a rhythmic oscillatory movement static tremor:(+)at rest postural tremor:(+)during sustained posture intension tremor:(+)during movementChorea:rapid irregular M jerks hemiballismusAthetosis:slow,sinuous,writhing movementMyoclonus:sudden,rapid,twitchlike M contraction Involuntary movementTremor:a 38Posture and gaitSteppage gait(as if chicken)Cerebellar gait(as if drunk)Hemiplegic gait(circumduction)Paraplegic gait(scissoring)Swaying gait(as if duck)Parkinsonian gait(festination)Posture and gaitSteppage gait(39(四)Sensory function Notice:(5C)Co-operation Carefulness Comparison Confirmed by patient Coming again(四)Sensory function No40(四)Sensory functionSuperficial sensation pain(pin)light touch(wisp of cotton wool)temperature(cold or hot test tubes)Deep sensation joint position sensation vibration sensation(tuning fork)Compound sensation tow point discrimination stereognosis graphesthesia(四)Sensory functionSuperficial41(五)Reflex functionDeep tendon reflexesSuperficial cutaneous reflexesBabinskis sign and its equivalent signsFrontal release signs (particular if asymmetric)(五)Reflex functionDeep tendon42Deep tendon reflexes the reaction of M to being passively stretched by percussion on the tendon.graded on a scale:clonus(),brisk(),normal(),minimal(),absent(-)upper limb:Biceps,triceps,radial reflexlower limb:patellar,ankle reflexHoffmanns sign,Rossolimos sign hyperactive or the signs(+):lesion of UMN hypoactive:lesion of LMN Deep tendon reflexes the re43Superficial cutaneous reflexesAbdominal reflex upper(T7-8),middle(T9-10),lower(T11-12)Cremasteric reflex(L1)Anal reflex(S4-5)hypoactive or absent:lesion of segmental spinal cordSuperficial cutaneous reflexes44Babinskis sign and its equivalent signsplantar flexion of the toes:(-)extension upward of the great toe:(+)a sensitive but nonspecific sign of CNS diseasepathologic reflexBabinskis sign and its equiva45Frontal release signs primitive reflexes which disappear as brain matures.diffuse neuronal dysfunction,especially frontal lobe damage,release them from inhibitiongrasp signglabellar sign snout signsuck signFrontal release signs primitiv46(六)Autonomic nervesgeneral observation:nutriture of skin and hair,hidrosissphincter function incontinence,retention autonomic nerve reflex skin-striated test(六)Autonomic nervesgeneral obs47(七)meningeal irritation signsneck stiffnessKernigs sign stretching nerve roots by extending the knee cause painBrudzinskis sign(七)meningeal irritation signsn48Approach to comaemergency managementhistory and examinationdifferential diagnosisApproach to comaemergency mana49emergency managementA:ensure patency of the Airway Intubation,tracheostomyB:adequacy of BreathingC:adequacy of CirculationD:administration of Drugsemergency managementA:ensure p50history and examinationobtain a history from a relative or friend.the most crucial aspect is the time which coma developsgeneral physical examination Signs of trauma,T,BP,P,Rneurologic examination consciousness pupils(asymmetric)optic fundi(papilledema)extraocular movement(oculocephalic reflex)motor response to pain meningeal irritationLab examinationhistory and examinationobtain 51differential diagnosisIntracranial diseases infection,tumour,CVD,injuryMetabolic DM,liver failure,renal failureToxic drug intoxication,alcohol excess,CO2differential diagnosisIntracra52InfectionTumorInjuryStroke(CVD)CO,CO2Opiate(drug)Metabolic diseasesAlcohol IT IS COMA!Infection53Conditions that mimic comapsychogenic unresponsiveness catatonia,malingering,mutismlocked-in syndrome ARAS lying above the level of the midponspersistent vegetative state spontaneous eye opening,sleep-wake cyclesConditions that mimic comapsyc54Speech dysfunctionphonation:dysphonia lesion of recurrent laryngeal N,respiratory M weaknessarticulation:dysarthria cerebellar,extrapyramidal,(pseudo)bulbarlanguage production:dysphasia lesion of the dominant hemisphere expressive(Brocas),receptive(Wernickes)Speech dysfunctionphonation:dy55Assistant investigationsimaging of NS computerized tomography(CT)scanning magnetic resonance imaging(MRI)angiography digital subtractive angiography(DSA),CTA,MRAtranscranial doppler(TCD)electrophysiology EEG,EMG,EPcerebrospinal fluidAssistant investigationsimagin56CSF investigationIndication:infection of CNSCVDspinal disordersGuillain-Barre syndromemyelographytherapeuticsCSF investigationIndication:57CSF investigationContraindication:intracranial hyperpressure with prominent occupationfocal infection of puncturing severe casesleakage of CSFCSF investigationContraindicat58CSF investigationConsequent syndromes:headachecerebral hernialumbar painfocal infectionCSF investigationConsequent sy59CSF investigationContent:Pressure and Queckenstebt test routine of CSFbiochemistry of CSFetiology of CSFCSF investigationContent:60
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