nervous system exam

The nervous system examination is to determine the location and extent of damage and damage to the nervous system, that is, to resolve the "positioning" diagnosis of the lesion. The examination should be carried out in a certain order and with the general physical examination. The cranial nerves are usually first examined, including their movements, sensations, reflexes, and autonomic functions; the motor and reflexes of the upper and lower limbs are then examined in turn, and the sensory and autonomic nervous systems are finally examined. The examination should also be based on medical history and preliminary observations, with a particular focus, especially when critically ill patients are examined. In addition, cerebral cortical dysfunction such as consciousness, aphasia, misuse, and misrecognition also belong to the category of neurological examination. Basic Information Specialist classification: neurological examination classification: neuroelectrophysiology Applicable gender: whether men and women apply fasting: not fasting Reminder: Try to relax as much as possible during the examination. Don't be too nervous and affect the results of the examination. At the same time, actively cooperate with the doctor's work. Normal value 1, normal people are conscious, no sleepiness, lethargy, coma and other conditions. 2, normal vision, single eye field of view about 90 ° side, nose and upper and lower is about 50-70 °. 3. The retina of the fundus is orange-red. The optic nerve head is located in the lateral direction of the retina. It has a round shape, a clear edge, a reddish color, and a physiological depression with a light color in the center. 4, the size of the nipple, normal shape, neat edges, no uplift, the central physiological depression did not expand. Clinical significance Abnormal result First, the visual pathway 1. Visual acuity and visual field change. 2, papilledema caused by increased intracranial pressure caused by venous return to the wall. Early nipples were congested, reddened, blurred at the edges, and the physiological depression disappeared. Then the nipple is uplifted, the vein is filled, and the beat disappears. Severe venous engorgement, distortion, flaming bleeding and exudation in the vicinity of the nipple. 3, optic atrophy, the nipple is white, accompanied by vision loss or disappearance, the visual field is narrowed, the pupil is dilated, and the light reflection is weakened or disappeared. The primary person has a clear nipple edge. If it is one side, the multiple optic nerve is directly compressed. Secondary patients have blurred papillary edges and are caused by papilledema or optic neuritis. 4, retinal arteriosclerosis early arterial thinning, thickening of the wall, enhanced reflection, like copper wire; severe arteries are silver-like, arteriovenous junction vein compression and thinning to the infix. Second, the extraocular muscles and pupils 1, eye movement nerve paralysis. 2, the same direction of movement paralysis found in the ocular nerve nucleus and abduction of the nucleus above the direction of the same direction of motion and its pathological lesions, the performance of the eyes can not be sideways at the same time, or can not be simultaneously or (and) lower vision. Symptoms of irritations may cause both eyes to be deflected or both eyes to be seen. See the chapter on location diagnosis for details. 3, pupil abnormalities One or both sides of the pupil abnormally enlarged or reduced, slow response to light or disappeared, etc., can be caused by oculomotor, optic nerve or sympathetic neuropathy, respectively. The latter is found in the brain stem following the sensory nerve path damage, in addition to the ipsilateral pupil shrinkage, and there are eyeball invagination, small eye cracks, conjunctival hyperemia, no sweat on the face, called Horner syndrome. Third, facial sensation and movement 1, facial sensation diminished and trigeminal neuralgia. 2, central facial paralysis and peripheral facial paralysis; facial nerve nucleus or (and) facial nerve damage, causing the ipsilateral upper and lower facial muscles are uniform, called peripheral facial paralysis. Damage to the facial nerve nucleus, that is, the lesion of one side of the anterior central gyrus or the cortical brainstem bundle, only causes the contralateral hemifacial spasm, which is called "central facial paralysis". 3, facial muscle twitching and spasm is a paroxysmal twitch of a lateral muscle, or continuous contraction of the facial muscles. The former is the facial nerve stimulation symptoms, found in the cerebellar cerebral horn lesions; the latter is mostly the symptoms of facial nerve nephritis recovery. 4, masseter muscle atrophy and paralysis. The former is seen in the trigeminal nerve movement to destroy the bad lesions, in addition to the masticatory muscle atrophy, there is still chewing weakness, open mouth difficulty; if one side is involved, the jaw is biased to the disease side. The latter has a closed jaw. 5, corneal reflex disappeared the first branch of the trigeminal nerve, facial nerve or brain stem lesions can be caused. However, the cornea feels disappeared in the former, and the corneal sensation exists in facial neuropathy. Fourth, hearing test 1. Neurological (sensory) deafness is caused by damage to the inner ear or auditory nerve. Incomplete damage, the gas guide and bone conduction of the tuning fork test were shortened, but the ratio was unchanged, and the Rinne test was short-positive; the Weber test was biased to the healthy side. When the ear is completely neurological, the sound wave is transmitted from the skull to the contralateral ear, causing the bone conduction > air conduction illusion, and should pay attention; however, the Weber test is still biased to the healthy side, and the air conduction disappears, which can be identified. 2. Conductive (transmissive) deafness is caused by middle ear lesions or obstruction of the external auditory canal. After the sound wave is transmitted from the skull to the inner ear, part of the sound wave is transmitted to the inner ear and the outer ear canal, and the sound of the ear bone is enhanced. The Rinne test shows the bone conduction> air conduction phenomenon, which is called Rinne test negative, and the Webr test is biased to the affected side. 5. Soft palate, throat movement and feeling 1. True medullary (ball) paralysis refers to the signs of suspicion of the nucleus and the pharyngeal and vagus nerves when one or both sides of the soft palsy, pharyngeal reflexes are weakened or disappeared, drinking water coughs, difficulty swallowing, and hoarseness. It is equivalent to the lower motor neuron of the limb. 2. Pseudobulbar palsy refers to the paralysis of the pharyngeal muscles after the bilateral cortical brain stem bundle is damaged, but the pharyngeal reflex exists, which may be accompanied by bilateral pyramidal tract signs. It is equivalent to the upper motor neuron of the limb. Six, tongue muscle movement The sublingual nucleus of the central tongue is only dominated by the contralateral cortical brain stem. Therefore, when the central anterior gyrus or the cortical brain stem bundle is damaged, the contralateral lingual tendon is caused, and the tongue is biased to the opposite side of the lesion. People who need to be examined: patients with reflex arc damage, nerve damage, and brain lesions. Precautions Taboo before inspection: 1. Do a good job on the first few days of the test. Don't be too tired, don't drink alcohol, don't eat spicy and other irritating substances. 2. Patients with abnormal cognition, emotion and volitional behavior should be accompanied by family members when they go to the hospital for examination. The family members should appease the patient's emotions before the examination, so as to avoid being too excited and the inspection cannot be carried out smoothly. Requirements for inspection: 1, the environment needs to be quiet, try to avoid all kinds of external stimuli, the patient should close the eyes in the examination of the sensory function, so that the patient's attention is concentrated. 2, an inspection should not be too long, otherwise the patient is fatigued, the results are not allowed. 3. Since the various receptors have different distributions in different parts of the body, the sensitivity of the same intensity is different in different parts, so attention should be paid to the comparison of the symmetrical parts. To this end, the healthy side is stimulated first, and the affected side is stimulated with the feeling as a standard. 4, the intensity of the stimulus, generally slightly more than the normal stress 阂 can not be too strong. Strive to symmetrical stimulation intensity equal. To determine the extent of sensory impairment, the affected area can be examined with different intensities. Inspection process First, the state of consciousness 1. Clear-headed state The examinee has good knowledge of himself and his surroundings, and should include correct time orientation, location orientation, and person orientation. When the patient asks questions such as name, age, place, time, etc., the examinee can make a correct answer. 2. A form of consciousness disorder in which the somnolence state is reduced in consciousness. Refers to the patient's awareness of a lesser degree of awakening, call or push the patient's limbs, the patient can be awake immediately, and can make some short and correct conversations or do some simple actions, but the stimulus disappears and falls asleep. At this time, the patient's swallowing, pupil, cornea and other reflections exist. 3. Confusion refers to the degree of patient's disturbance of consciousness is deeper than lethargy, can not clearly understand external stimuli; spatial and temporal dynamism; understanding, retardation, or error; memory blur, near memory is worse The impression of the real environment is ambiguous, often inconsistent in thinking, and slow in thinking activities. In general, when a patient has time and place disorientation, it is called confusion. 4, the state of stupor state (stuporstate) reduced consciousness is deeper than the state of consciousness blur. Shouting or pushing the limbs does not cause a reaction. When a patient is pressed with a finger to press the inside of the upper edge of the patient, the patient's facial muscles (or acupuncture of the patient's hands and feet) can cause defensive reflexes. At this time, deep reflection hyperactivity, tremor and involuntary movement, cornea, eyelash and other reflections are weakened, but the light reflection still exists. 5, superficialcoma (superficialcoma) refers to the patient's voluntary movement loss, call should not, no response to general stimulation, strong pain stimulation such as compression, pressure roots, etc., shallow reflection disappears, tendon reflex, glossopharyngeal reflex The corneal reflex and the pupil reflect the light, and there is no obvious change in the breathing and pulse. Found in severe cerebrovascular disease, encephalitis, brain abscess, brain tumor, poisoning, early shock, hepatic encephalopathy. 6. Deep coma (deepcoma) means that the patient has no response to various stimuli, and is completely in a motionless position. The corneal reflex and pupil reflexes disappear, the incontinence is incontinent, the breathing is irregular, and the blood pressure is lowered. Brain rigidity. In the later stage, the patient's muscles were slack, the eyeballs were fixed, the pupils were scattered, and they were dying. Found in hepatic encephalopathy, pulmonary encephalopathy, cerebrovascular disease, brain tumor, brain trauma, severe poisoning, late shock and so on. 7, delirium (delirium) an acute disturbance of consciousness, manifested as disorientation, illusion, hallucinations, emotional instability, behavioral disorders, etc., sometimes with fragmentary delusions. Symptoms often show fluctuations in light day and night. Patients sometimes have sleepiness during the day and noisy at night. Due to illusions or hallucinations, patients can behave like self-injury or injury. It can be caused by a variety of causes, such as poisoning, infection, trauma, severe metabolism or nutritional disorders. Second, the cranial nerve (1) Vision and fundus [anatomy physiology] Retinal optic fiber → optic papilla → optic nerve / hole into the cranial chiasm (retina only side of the retina) Lateral geniculate body→ visual radiation→ occipital visual cortex (visual path)→optic tract→middle cerebral anterior region and upper humerus→EW's nucleus→ oculomotor nerve (pupil light reflection path) Third, the visual pathway 1. Vision: First exclude the lesions of the eyeball, and check the eyes separately. Usually with an eye chart, the rough test can read the book and compare it with normal people. If the visual acuity is significantly reduced, it can be used to identify the hand index or finger sway at different distances in front of the eye, or to test whether it has a light perception by flashlight. They are represented by “blindness”, “light perception”, “finger movement”, and “distance index within XX centimeters”. 2. Field of view: The range of space outside the gaze point that can be seen when the eye is facing is called the field of view. The normal monocular field of view is about 90° on the temporal side, and the nasal side and upper and lower sides are about 50-70°. Accurate visual field examination using a perimeter, coarse measurement common control method: the patient's backlight is sitting opposite the doctor, closing the left eye, the doctor's finger gradually moves from the upper, lower, left and right peripheral parts to the center, when the patient sees the finger Say it immediately. The same method will test another eye. According to the normal field of view, the general situation of the patient's visual field defect can be compared. 3, fundus: with an ophthalmoscope for examination. The retina of the normal fundus is orange-red, and the optic nerve head is located in the lateral direction of the retina. It has a round shape, a clear edge, a reddish color, and a physiological depression with a light color in the center. The central retinal artery and vein pass through the center of the optic papilla, and the upper and lower branches and many small branches do not coincide with each other. The arterial color is bright red, thin and straight, the vein color is dark red, thick and curved; the ratio of the diameter of the artery and vein is about 2:3. The macula is located at a distance of about two optic nipples slightly below the temporal side of the optic papilla. The range has a papillary size, the color is darker than the retina, and there is a very bright foveal reflection point in the center. Pay attention to the observation: the color, size and shape of the nipple, whether the edge is neat, whether there is bulge, whether the central physiological depression is enlarged; the fine curvature of the arteries and veins and the reflective intensity of the wall; the vein compression at the intersection of arteries and veins; the retina and the macula Whether there is exudate, hemorrhage, pigmentation and edema in the area, whether the fovea is present. Fourth, extraocular muscles and pupils [anatomy physiology] 1, extraocular muscle: eye movement by the eye, the pulley, the abduction of the innervation. After being emitted by the respective nucleus, the brain is ventral to the ventral side of the midbrain, the dorsal side and the ventral side of the pons, passing through the cavernous sinus and splitting into the eyelid through the supraorbital sinus, reaching the superior rectus, the inferior rectus, the medial rectus, and the lower The sacral muscle, the superior oblique muscle and the lateral rectus muscle dominate the movement and eye movement. 2, pupil: (1) 瞳 瞳: Edinger-Westphall nucleus → oculomotor nerve → pupil sphincter. (2) Dilatation: nerve fibers originate from the hypothalamic sympathetic center, descending to the C8-T2 lateral angle of the spinal cord (ciliary spinal cord center) to emit sympathetic nerves, with the carotid artery into the cranium and then with the trigeminal nerve eye to the pupil dilated muscle. In addition, the sympathetic pathway also dominates the ipsilateral tarsal muscle (assisting the ipsilateral upper iliac crest), the posterior bulging muscle (slightly protruding the eyeball), the facial sweat gland (sweat), and the blood vessels (contracted blood vessels). [Inspection Method] 1, the width of the eye crack: observe the size of the two eye cracks, with or without eyelid drooping (should be excluded from the eyelid itself). Attached to check if the eyeball is protruding or sunken. 2, eye position and movement: 1 strabismus: paralyzed patients face front, observe whether there is eyeball deflection; 2 eye movement and diplopia; both eyes move with the doctor's finger in all directions, observe the side of the eye movement restricted and extent, and Ask whether there is double vision; 3 co-directional deviation and same-direction movement paralysis; eyes not simultaneously at one side (side view paralysis) or upward and downward gaze (vertical movement paralysis); 4 convergent reflexes: paralyzed patients look ahead The doctor's finger is far away to observe whether there is an obstacle in both eyes. 3, pupil: 1 shape: observe the position, size, shape of the pupil, whether the edge is neat, whether the sides are equal. The normal pupil is round, and the sides are equal, and the diameter is 2-5mm under natural light. 2 pairs of light reflection: use the flashlight to illuminate the pupil from the side, it can be seen that the pupil is reduced, called direct light reflection; the opposite pupil is also reduced, called indirect light reflection. 3 Vision reflex: When performing the radiation reflex inspection, both eyes are also closed, and the bilateral pupils are also reduced. Fifth, facial feeling and movement: [anatomy physiology] 1. Facial sensation: the head and face and the facial sensation fibers form the trigeminal ocular branch, the maxillary branch, and the mandibular branch. They are inserted into the skull through the supracondylar fissure, the garden hole, and the egg garden hole to the semilunar ganglion, and then to the corresponding nucleus of the pons The hair fiber rises and crosses to the contralateral thalamus and the central back to the lower part. 2, facial movement (1) Expression muscle movement: mainly dominated by facial nerves. In addition, the facial nerve also transmits 2/3 taste in front of the tongue. The nucleus on the facial nucleus is innervated by the bilateral cortical brain stem bundle, and the lower nucleus is only dominated by the contralateral cortical brain stem bundle. (2) Masticatory muscle movement: completed by the diaphragm and masseter muscles of the trigeminal motion branch. [Inspection Method] 1. Facial sensation: According to the distribution range of the trigeminal nerve, the pain and touch are tested with pin and brocade, respectively, and the two sides are compared with the upper, middle and lower. 2, facial muscle movement: When investigating the facial muscles, pay attention to whether the eye cracks become larger or larger, and use the lifting, frowning and eye-closing movements to see if the frontal lines disappear, become shallow, and the eyes are weak or unable. When investigating the facial muscles, pay attention to whether the nasolabial folds are shallow or not; when showing teeth and smiling movements, there is no angular deviation; there is no air leakage or whistling when blowing whistle and drumsticks. 3, chewing exercise: observe the diaphragm muscle, masseter muscle with or without atrophy; test whether the muscle strength on both sides of chewing exercise is equal; observe the jaw when the jaw is skewed. 4, corneal reflex: 嘱 gaze to one side, with cotton silk from the other side light touch the cornea, causing the eyelids to close agile. The ipsilateral reaction is called direct reflection and the opposite side is indirect reflection. Sixth, hearing test: [anatomy physiology] 1. Hearing is transmitted by the cochlear nerves in the auditory nerve. The other nerve in the auditory nerve is the vestibular nerve, which is balanced. One side of the cochlear nucleus is associated with the bilateral temporal lobe cortical center, so one side of the cortical or brain stem damage generally does not produce unilateral hearing impairment. 2, vestibular nerve Vestibular fiber → vestibule of vestibular ganglion In addition, the vestibular nerves are associated with balance-related self-perception, movement, reflexes, and autonomic responses through association with the cerebral vestibule representative region, cerebellum, spinal cord, and vagus nerve. [Inspection Method] 1. Hearing: Commonly used (256HZ) tuning fork test. (1) Rinne test: compare the air conduction and bone conduction time of one ear. The vibrating fork handle was placed on the posterior mastoid to measure the conduction time of the skull. When the sound was not heard, it was immediately moved to 1 cm from the external auditory canal to measure the air conduction time. The normal air conduction is longer than the bone conduction time for more than 15 seconds, and the ratio of conduction time is about 2:1, which is called Rinne test positive. (2) Weber test: compare the bone conduction time of both ears. Place the vibrating tuning fork handle in the center of the forehead, and the sound waves pass through the bone to reach the inner ear. The sound heard by both ears is equal, so the Weber test is centered. 2, eye tremor: The patient's head does not move, and the eyes of the doctor who are moving up, down, left, and right with both eyes (do not exceed 45 degrees when moving in the lateral direction), observe whether there is nystagmus and its type, amplitude, and speed. Clinically, vestibular nystagmus with fast phase (fast phase is the direction of the eye) is most common, which can be horizontal, vertical, rotational or mixed, indicating that the vestibular system has irritative lesions. When the nystagmus is negative and there is a suspected vestibular system lesion, the method of rapid replacement of the position can be used to observe whether there is nystagmus at each position, which is called a positional nystagmus test. Seven, soft palate, throat movement and feeling: [anatomy physiology] In addition, the glossopharyngeal nerve also transmits the taste of the posterior part of the tongue; the vagus nerve transmits the visceral sensation of the chest and abdomen, and the fibers are derived from the upper part. [Inspection Method] 1, pharyngeal movement: understand and observe whether there is difficulty swallowing, drinking water cough or reflux, pronunciation hoarseness or nasal sound, to observe whether the uvula is centered, soft sputum with or without sagging. The paralyzed patient made an "ah" sound and observed whether the soft palate could be lifted and whether the sides were equal. Vocal cord motion can be observed with an indirect laryngoscope. 2, pharyngeal wall reflex: observe and compare the nausea and sputum reaction caused by tapping the left and right pharyngeal posterior wall with tongue depressor, and understand the agility of feeling. Eight, tongue muscle movement: open mouth, observe the position of the tongue in the mouth: then stretch the tongue to see if it is skewed and the tongue muscles are atrophy or muscle fibrillation. Not suitable for the crowd Inappropriate people: Patients with spontaneous pain in their bodies. Adverse reactions and risks Nothing.