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Neurological Examinationin the Emergency Room 急診神經學檢查 Tintinalli‘s Emergency Medicine: A Comprehensive Study Guide, 7E Chapter 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:  Mental Status 	意識狀態 Cranial Nerves 	顱神經檢查 Motor Exam 	運動功能檢查 Reflexes 		反射 Coordination and Gait 協調性及步態 Sensory Exam 	感覺功能檢查
Awareness Patient Examine for Cortical Deficits Orientation: time, place, person and situation)  Digital span: 7 numbers foreward and 5 numbers backward Confusion of right and left Calculation: 100-7-7…or 20-3-3… 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+:	nonsustainedclonus 	(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
C5, C6 C7, C8 L3, L4 S1, S2
Plantar Response (Babinski)
Sensory	感覺 General				一般感覺 Vibration			震動 Subjective Light Touch	輕觸 Position Sense		位置感
DermatomalTesting	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! C7 C8 C6
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)

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