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