物理诊断技术 王长凯 精品课系列 NO-15 http:// jpkc.czmc.cn

任务15—脑血栓形成病人的诊查

资讯：学生自学脑血栓形成的相关知识 决策：指导学生根据具体疾病确定查体顺序 计划：学生以小组为单位，制定诊查计划 实施：学生按照诊查计划查体 检查：对照查体流程标准，回顾检查 评价：教师对学生诊查过程进行评价

问题： 你对脑血管病了解多少？

神 经 系 统 查 体

临 床 场 景 当你面对一位在街上突然晕倒的病人 他是心脏病发作还是脑卒中？ 当你面对一位感到下肢麻木无力的病人 他是脊髓疾病还是骨关节疾病？ 当你面对一位突发恶心、呕吐的病人 是应该去看消化科？ 还是应该做脑CT ? 还是应该立即脱水降颅压处理？ great clinicians could pinpoint a lesion in the nervous system with often astounding accuracy. Today, with the availability of modern imaging techniques, the neurologic exam remains a critical way in the clinical decision-making process. All these questions can quickly be answered by a carefully performed neurologic exam

本堂课的目的 讲述神经系统检查每一步应该怎么操作。 每一项检查的临床意义。 In addition, we will briefly discuss which neuroanatomic systems are tested by each part of the neurologic exam, so that its functional and practical relevance will be better appreciated.

需要的器具 叩诊锤 检眼镜 棉签 128 Hz 音叉 笔式电筒 大头针 等等

神经系统查体和全身查体的关系 全身查体 神经系统查体 The neurologic exam is part of the general physical examination. Thus, the neurologic exam should always be preceded by and interpreted in the context of a more general examination including vital signs, heart, lungs, abdomen, etc.

神经查体的格式 意识状态 颅神经 运动系统检查 感觉系统检查 反射系统检查 The neurologic examination is always performed and recorded in a sequential and uniform manner in order to avoid omissions and to facilitate the subsequent analysis of case records.

一. 意识状态检查 清醒度和注意力 定向力 记忆力 语言功能 计算力 Memory: Ask the patient to recall three items after a delay of 3 to 5 minutes Remote memory. Ask the patient about historical personal events. Calculation:subtract 7 from 100 and then subtract 7 from the product, and so on.

1. 清醒度和注意力 清醒度：对刺激的反应能力 注意力: 正数6位数 倒数4位数 (538792) 1. 清醒度和注意力 清醒度：对刺激的反应能力 注意力: 正数6位数 倒数4位数 (538792) Level of consciousness is severely impaired in damage to the brainstem reticular formation, and in bilateral lesions of the thalami or cerebral hemispheres

2. 定向力 时间、地点、人物定向力 纪录方法: 人物: “他是医生” 地点: “在医院”但不知道在那家医院 2. 定向力 时间、地点、人物定向力 纪录方法: 人物: “他是医生” 地点: “在医院”但不知道在那家医院 时间: “2004年……” 但不知几月几日

3. 记忆力 近记忆: 首先告诉患者3个东西，请其记住，3~5分钟后让他回忆（如天空、旗杆、绵羊） 远记忆: 询问他个人重大生活事件的发生时间 (如结婚时间、大儿子出生日期)

4. 语言功能 自发性语言: 注意患者语言的流利性、用词准确 理 解 力: 患者是否能理解简单的问题和命令？ 自发性语言: 注意患者语言的流利性、用词准确 性、语句的长短、速度和丰富程度。 理 解 力: 患者是否能理解简单的问题和命令？ Different kinds of language abnormalities are caused by lesions in the dominant (usually left) frontal lobe, including Broca's area; the left temporal and parietal lobes, including Wernicke's area 命名能力: 让患者叫出常见物体的名字 复述能力: 患者能否重复医生说的简单词句

失 语 症 类 型 Broca’s 失语 (运动性失语） 不能表达，可以理解 Wernicke‘s 失语 (感觉性失语) 可以表达，不能理解 混合性失语 不能表达，不能理解

神经查体的格式 意识状态 颅神经 运动系统检查 感觉系统检查 反射系统检查 The neurologic examination is always performed and recorded in a sequential and uniform manner in order to avoid omissions and to facilitate the subsequent analysis of case records.

二. 颅 神 经

I – 嗅神经 让患者用每一个鼻孔闻不同气味并辨别. 禁用刺激性气味，因为它可能刺激鼻孔内三叉神经痛觉纤维 除非怀疑颅前凹病变，否则临床上一般不检查此神经

II – 视神经 视力 视野 眼底检查 .

III – 动眼神经 观察是否有上睑下垂 眼球各向运动 瞳孔光反射 (直接、间接光反射) 瞳孔调节反射、辐凑反射 瞳孔光反射 (直接、间接光反射) 瞳孔调节反射、辐凑反射 Test Extraocular Movements Stand or sit 3 to 6 feet in front of the patient. Ask the patient to follow your finger with their eyes without moving their head. Check gaze in the six cardinal directions using a cross or "H" pattern. Pause during upward and lateral gaze to check for nystagmus. [6] Check convergence by moving your finger toward the bridge of the patient's nose. Test Pupillary Reactions to Light Dim the room lights as necessary. Ask the patient to look into the distance. Shine a bright light obliquely into each pupil in turn. Look for both the direct (same eye) and consensual (other eye) reactions. Record pupil size in mm and any asymmetry or irregularity

IV – 滑车神经 检查眼外肌活 (向内下运动 ) VI – 外展神经 检查眼外肌活动 (向外运动)

V – 三叉神经 检查颞肌和咀嚼肌力量 检查三个分支区域的痛觉 检查角膜 反射 Test Temporal and Masseter Muscle Strength Ask patient to both open their mouth and clench their teeth. Palpate the temporal and massetter muscles as they do this Test the Three Divisions for Pain Sensation Explain what you intend to do. Use a suitable sharp object to test the forehead, cheeks, and jaw on both sides. [7] Substitute a blunt object occasionally and ask the patient to report "sharp" or "dull Test the Corneal Reflex ++ Ask the patient to look up and away. From the other side, touch the cornea lightly with a fine wisp of cotton. Look for the normal blink reaction of both eyes. Repeat on the other side.

VII – 面神经 观察是否存在口角歪斜 叫病人做下列动作: 皱眉、皱额 抵抗阻力闭眼 鼓腮 示齿

闭眼动作是关键的鉴别点之一 睑裂以上的面部表情肌由双侧上运动神经元支配 因此诸如脑卒中等上运动神经元损害时引起对侧睑裂以下表情肌麻痹，而睑裂以上的肌肉不受影响。 而诸如面神经炎等下运动神经元损害时引起整个对侧表情肌麻痹。 闭眼动作是关键的鉴别点之一

VIII – 听神经 听力检查 Weber 试验 Rinne 试验 Screen Hearing [9] Face the patient and hold out your arms with your fingers near each ear. Rub your fingers together on one side while moving the fingers noiselessly on the other. Ask the patient to tell you when and on which side they hear the rubbing. Increase intensity as needed and note any assymetry. If abnormal, proceed with the Weber and Rinne tests Test for Lateralization (Weber) ++ Use a 512 Hz or 1024 Hz tuning fork. Start the fork vibrating by tapping it on your opposite hand. Place the base of the tuning fork firmly on top of the patient's head. Ask the patient where the sound appears to be coming from (normally in the midline). Compare Air and Bone Conduction (Rinne) ++ Place the base of the tuning fork against the mastoid bone behind the ear. When the patient no longer hears the sound, hold the end of the fork near the patient's ear (air conduction is normally greater than bone conduction)

IX – 舌咽神经 X – 迷走神经 患者声音是否有鼻音或声音嘶哑？ 让患者作吞咽动作 让患者发“啊”的音，并观察软颚上抬度。 测咽反射

XI – 副神经 抵抗阻力耸肩 抵抗阻力转头 Watch and palpate the sternomastoid muscle on the opposite side

XII – 舌下神经 观察患者是否有构音障碍 让患者伸出舌头，观察是否有偏斜

神经查体的格式 意识状态 颅神经 运动系统检查 感觉系统检查 反射系统检查 The neurologic examination is always performed and recorded in a sequential and uniform manner in order to avoid omissions and to facilitate the subsequent analysis of case records.

三. 运动系统检查 观察 不自主运动 患者的姿势 是否有肌肉萎缩 步态

2. 肌张力 嘱患者放松 伸、屈患者的腕、肘、肩关节 伸、屈患者的膝、踝关节. 正常被动活动关节时，一直存在适当的阻力，为正常肌张力。

观察是否存在阻力增高（肌张力高）、阻力降低（肌张力低）。

肌张力增高 类型 病灶定位 折刀样 --- 上运动神经元(锥体束系统) 铅管样 --- 基 底 节(锥体外系统)

肌 力 嘱患者抵抗阻力活 动肌肉，检查肌力。 检查时需双侧对比。 肌力分级从0~5级。

肌 力 分 级 分级 描述 0/5 1/5 2/5 3/5 4/5 5/5 无肌纤维活动 有肌肉活动，无关节运动 肌 力 分 级 分级 描述 0/5 无肌纤维活动 1/5 有肌肉活动，无关节运动 2/5 有关节运动， 但不能抵抗重力 3/5 可以抵抗重力，但不能抵抗阻力 4/5 可以抵抗阻力，但较正常差 5/5 正常肌力

上运动神经元和下运动神经元损害的鉴别 表现 上运动神经元 下运动神经元 肌无力 是 肌萎缩 否 肌束震颤 腱反射 亢进 减弱 肌张力 增高 下降 瘫痪 痉挛性 驰缓性

4. 共济运动 快速轮替运动 指鼻试验 跟膝胫试验

昂 伯 氏 征 Rapid Alternating Movements Ask the patient to strike one hand on the thigh, raise the hand, turn it over, and then strike it back down as fast as possible. Ask the patient to tap the distal thumb with the tip of the index finger as fast as possible. Ask the patient to tap your hand with the ball of each foot as fast as possible. Point-to-Point Movements Ask the patient to touch your index finger and their nose alternately several times. Move your finger about as the patient performs this task. Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patient to move their arm and return to your finger with their eyes closed. Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the patient's eyes closed. Romberg Be prepared to catch the patient if they are unstable. Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without support. The test is said to be positive if the patient becomes unstable (indicating a vestibular or proprioceptive problem).

共济失调类型 定位 肢体共济失调 小脑半球及其 (指鼻试验、轮替运动) 联系通路 躯干共济失调 小脑蚓部及其 (昂伯氏征) 联系通路

神经查体的格式 意识状态 颅神经 运动系统检查 感觉系统检查 反射系统检查 The neurologic examination is always performed and recorded in a sequential and uniform manner in order to avoid omissions and to facilitate the subsequent analysis of case records.

四. 感觉系统检查 检查原则 每一步检查前向病人解释检查目的和方法 检查过程中始终要求患者闭上眼睛 左右对比 肢体近端和远端对比 检查感觉障碍时，尽量勾勒出感觉障碍范围

1. 浅感觉 痛觉 温度觉 轻触觉 Pain Use a suitable sharp object to test "sharp" or "dull" sensation. [7] Test the following areas: Shoulders (C4) Inner and outer aspects of the forearms (C6 and T1) Thumbs and little fingers (C6 and C8) Front of both thighs (L2) Medial and lateral aspect of both calves (L4 and L5) Little toes (S1) Temperature Often omitted if pain sensation is normal. ++ Use a tuning fork heated or cooled by water and ask the patient to identify "hot" or "cold." Light Touch Use a fine whisp of cotton or your fingers to touch the skin lightly. Ask the patient to respond whenever a touch is felt.

2. 位置觉 握住病人大脚趾的两侧，并上下活动. 分别演示上、下的位置 嘱病人闭眼，再次上下活动其大脚趾，让其判断上或下。

3. 振动觉 将振动的音叉头放在病人中指或大脚趾的关节处。 让病人判断是否有振动感。

如果出现感觉突然变化的 感觉平面 时特别注意,因为这往往提示脊髓的损害， 可能需要紧急处理。

感觉平面

神经查体的格式 意识状态 颅神经 运动系统检查 感觉系统检查 反射系统检查 The neurologic examination is always performed and recorded in a sequential and uniform manner in order to avoid omissions and to facilitate the subsequent analysis of case records.

五. 反射系统检查 检查原则 检查前病人必须保持放松，肢体自然放置。 腱反射的强度和敲击的力量有关，因此敲击力量要适中。 病人紧张影响腱反射的检查时可以嘱其同时用力收缩其他肌肉以转移注意力，有利于顺利引出腱反射。 纪录时用0~4个 + 描述反射强度。

腱反射敲击手法

1. 深腱反射 腱反射分级标准 分级 描述 消失 1+ or + 反射减弱 2+ or ++ 正常 3+ or +++ 反射增强，无阵挛 1. 深腱反射 腱反射分级标准 分级 描述 消失 1+ or + 反射减弱 2+ or ++ 正常 3+ or +++ 反射增强，无阵挛 4+ or ++++ 反射增强，有阵挛

深腱反射的定位 反射 涉及的神经根 肱二头肌 颈5,颈6 桡骨膜 颈6 肱三头肌 颈7 膝反射 腰4 踝反射 骶1 Biceps (C5, C6) The patient's arm should be partially flexed at the elbow with the palm down. Place your thumb or finger firmly on the biceps tendon. Strike your finger with the reflex hammer. You should feel the response even if you can't see it. Triceps (C6, C7) Support the upper arm and let the patient's forearm hang free. Strike the triceps tendon above the elbow with the broad side of the hammer. If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close to the chest. Brachioradialis (C5, C6) Have the patient rest the forearm on the abdomen or lap. Strike the radius about 1-2 inches above the wrist. Watch for flexion and supination of the forearm. Abdominal (T8, T9, T10, T11, T12) Use a blunt object such as a key or tongue blade. Stroke the abdomen lightly on each side in an inward and downward direction above (T8, T9, T10) and below the umbilicus (T10, T11, T12). Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus. Knee (L2, L3, L4) Have the patient sit or lie down with the knee flexed. Strike the patellar tendon just below the patella. Note contraction of the quadraceps and extension of the knee. Ankle (S1, S2) Dorsiflex the foot at the ankle. Strike the Achilles tendon. Watch and feel for plantar flexion at the ankle

深 腱 反 射

肱二头肌反射

肱三头肌反射

桡 反 射

膝 反 射

跟腱反射

跖反射 用棉签从后向前轻划足底外侧缘 注意大脚趾的运动，正常向足底屈曲 异常时大脚趾背屈，伴其他四指的散开（ 巴彬斯基征 Babinski sign)

霍夫曼征 (Hoffmann‘s sign) 握住病人的中指，向下弹击中指指甲，如果出现其余四指的屈曲，大拇指的内收，即为阳性。

巴彬斯基征 提示上运动神经元损害，锥体束损害 霍夫曼征 提示上运动神经元损害，累及上肢

2. 浅反射 腹壁反射：用棉签轻划一侧腹壁，引起同侧腹肌收缩。 提睾反射：用棉签轻划大腿内侧缘，引起同侧睾丸上提。

3. 病 理 反 射 Oppenheim Babinski Gordon

4. 脑膜刺激征 颈项强直 Kernig Sign Brudzinski Sign

锥体束病变不应出现： A．Babinski征 B．Oppenheim征 C．Gordon征 D．Chaddock征　 E．Kernig征 答案：E

17．深反射不包括： A. 肱二头肌反射 B．肱三头肌反射 C．膝反射 D．桡骨骨膜反射 E．跖反射 答案：E

作业： 1.神经反射包括哪些内容？ 2.角膜反射的反射弧组成？ 3.课下分组练习神经反射的检查方法。 4.类风湿性关节炎病人的诊查