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Neurological Examinationin the Emergency Room
急診神經學檢查
Tintinalli‘s Emergency Medicine: A Comprehensive Study Guide, 7EChapter e158.1 The Neurologic Examination in the Emergency Setting
Neurological Examination急診神經學檢查General Considerations Always consider
left to right symmetry
比較左右對稱 Consider
central vs. peripheral deficits
區分中樞或週邊缺損
Overview
Organize your thinking into six categories: 1. Mental Status 意識狀態2. Cranial Nerves 顱神經檢查3. Motor Exam 運動功能檢查4. Reflexes 反射5. Coordination and Gait 協調性及步態6. Sensory Exam 感覺功能檢查
Awareness Patient Examine for Cortical Deficits
1. Orientation: time, place, person and situation)
2. Digital span: 7 numbers foreward and 5 numbers backward
3. Confusion of right and left4. Calculation: 100 - 7 - 7…or 20 - 3 -
3…5. Recent memory: recall 3 objects after 5-
minutes interval
Brainstem Anatomy
I – Olfactory 嗅神經
Not Normally Tested
II – Optic 視神經
Examine the Optic Fundi Test Visual Acuity Screen Visual Fields by
Confrontation Test Pupillary Reactions to Light Test Pupillary Reactions to
Accommodation
III – Oculomotor 動眼神經IV – Trochlear 滑車神經VI – Abducens 外展神經 Observe for Ptosis (CN III) Test Extraocular Movements (EOM) Test Pupillary Reactions to Light (CN III)
CN6
CN4
V – Trigeminal 三叉神經
Test Temporal and Masseter Muscle Strength Test the Three Divisions for Pain Sensation Test the Corneal Reflex
VII – Facial 顏面神經
Observe for Any Facial Droop or Asymmetry Test the Corneal Reflex
VIII – Acoustic 聽神經
Screen Hearing Test for Lateralization (Weber) Compare Air and Bone Conduction (Rinne)
IX – Glossopharyngeal 舌咽神經X – Vagus 迷走神經 Listen to the patient's voice, is it hoarse
or nasal? Ask Patient to Swallow Ask Patient to Say "Ah" Test Gag Reflex
(Unconscious/Uncooperative Patient)
XI – Accessory 副神經
From behind, look for atrophy or assymetry of the trapezius muscles.
Ask patient to shrug shoulders against resistance.
Ask patient to turn their head against resistance. Watch and palpate the sternomastoid muscle on the opposite side.
XII – Hypoglossal 舌下神經
Listen to the articulation of the patient's words.
Observe the tongue as it lies in the mouth
Cranial Nerves
Observation Ptosis (III) Facial Droop or Asymmetry (VII) Hoarse Voice (X) Articulation of Words (V, VII, X, XII) Abnormal Eye Position (III, IV, VI) Abnormal or Asymmetrical Pupils (II, III)
Cerebellar Test
Coordination and Gait Rapid Alternating Movements 快速翻轉運
動 Point-to-Point Movements 點對點運
• finger-to-nose test• heel-to-shin test
Romberging test Gait 步態協調
Rapid Alternating Movements
Point-to-Point Movements
Motor Power
Pronator Drift
Muscle System
Strength Muscle Groups
0/5: no contraction
1/5: flicker
2/5: movement when gravity eliminated
3/5: movement against gravity
4/5: movement against resistance
5/5: normal strength
Reflexes 反射
Deep Tendon Reflexes 0: absent reflex 1+: trace, or seen only with reinforcement 2+: normal 3+: brisk 4+: nonsustained clonus
(i.e., repetitive vibratory movements) 5+: sustained clonus
Jendrassik's maneuver (locking the finger tips together and pulling)
Anal reflex: rectal sphincter tone, spinal cord injury
Signs of Upper Motor Neuron (UMN) & Lower Motor Neuron (LMN) Lesions
Sign UMN Lesions LMN Lesions
Weakness yes yes
Atrophy no yes
Fasciculations no yes
Reflexes ▲ ▼
Tone ▲ ▼
Babinski’s sign ▲ ▼
S1, S2
L3, L4
C5, C6
C7, C8
Plantar Response (Babinski)
Sensory 感覺
General 一般感覺 Vibration 震動 Subjective Light Touch 輕觸 Position Sense 位置感
Dermatomal Testing 皮層測驗
Pain 疼痛 Temperature 溫度 Light Touch 輕觸 Discrimination 兩點分辨
加油,還剩六分鐘!好好學,護一生喔!
C6
C7
C8
Brudzinski’s and Kernig’s SignsBoth Signs of Meningeal Irritation
Kernig’s sign:Resistance to extension of the leg while the hip is flexed
Brudzinski’s sign:Flexion of the hips and knees in response to neck flexion
Lumbar Puncture (CSF Exam):Meningitis or Subarachnoid Hemorrhage (SAH)
Neurological Examination急診神經學檢查General Considerations Always consider
left to right symmetry
比較左右對稱 Consider
central vs. peripheral deficits
區分中樞或週邊缺損