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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 13 Neurological signs
302
Examining the nervous system
If there are no symptoms at all suggestive of neurological disease, it is
customary to perform a quick examination of the nervous system, and if
this examination is normal, then the nervous system is not examined
further.
At this point, you will have had an opportunity to note the patient’s
posture and gait in the consulting room (or as the patient moves around
the bed on the ward). If the patient’s face looks normal and moves
normally during speech, then there is unlikely to be a cranial nerve
abnormality. Ask the patient to hold both arms out to assess posture,
perform a finger–nose test, tap each hand on the other in turn, show the
motion used to unscrew lightbulbs, and tap each foot on the floor (or
the examiner’s hand if in bed); then do a heel–shin test with each leg.
Finally, test the reflexes in the arms and legs. If all of these are normal
(and, as emphasized already, there are no symptoms of neurological
disorder), then there is no need to examine the nervous system further. If
there is a symptom or sign of neurological disorder, the nervous system
has to be examined carefully, perhaps beginning with the territory under
suspicion.
DISTURBED CONSCIOUSNESS1
303
Disturbed consciousness
Consciousness is assessed using the Glasgow Coma Scale (GCS), which is
based on adding scores for (a) best motor response (p. 304), (b) best
verbal response (p. 305), and (c) eye opening (p. 305).
Some differential diagnoses and typical outline evidence
Probably no
current brain
damage
Suggested by: GCS = >15 (patient complying with all
requests, oriented in time and place, opening eyes
spontaneously)
Confirmed by: neurological observation
Probable minor
brain injury
Suggested by: GCS of 13–15
Confirmed by: neurological observation or CT or MRI
scan appearance
Probable
moderate brain
injury
Suggested by: GCS of 9–12
Confirmed by: neurological observation or CT or MRI
scan appearance
Probable severe
brain injury
Suggested by: GCS of 3–8
Confirmed by: neurological observation or CT or MRI
scan appearance
Probable very
severe brain
injury
Suggested by: GCS =<3 (no response to pain, no
verbalization, and no eye opening)
Confirmed by: neurological observation or CT or MRI
scan appearance
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CHAPTER 13 Neurological signs
304
Best motor response
This is used to compute the GCS score.
Differential diagnosis
Carrying out verbal
requests: score 6
Confirmed by: doing simple things that you ask
(ignore grasp reflex)
Localizing
response
to pain: score 5
Confirmed by: purposeful movement in response
to pressure on fingernail, supraorbital ridges, and
sternum
Withdraws to pain:
score 4
Confirmed by: pulling limb away from painful
stimulus
Flexor response
to pain decorticate
posture: score 3
Confirmed by: flexion of limbs to painful
stimulus
Extensor
response to
pain decerebrate
posture: score 2
Confirmed by: pain causing adduction and internal
rotation of shoulder and pronation of forearm
No response to
pain: score 1
Confirmed by: no response to painful stimulus
EYE OPENING1
305
Best verbal response
This is used to compute the GCS score.
Differential diagnosis
Oriented:
score 5
Confirmed by: knowing own name, the place,
why there, year, season, and month
Confused
conversation:
score 4
Confirmed by: conversation but does not know
name, nor place, nor why there, nor year, season, or
month
Inappropriate
speech: score 3
Confirmed by: no conversation but random
speech or shouting
Incomprehensi-
ble speech:
score 2
Confirmed by: moaning but no words
No speech at
all: score 1
Confirmed by: silence
Eye opening
This is used to compute the GCS score.
Differential diagnosis
Spontaneous
eye opening:
score 4
Confirmed by: eyes open and fixing on objects
Eye opening
in response to
speech: score 3
Confirmed by: response to specific request or a shout
Eye opening in
response to
pain: score 2
Confirmed by: response to pain
No eye opening
at all: score 1
Confirmed by: no response to pain
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CHAPTER 13 Neurological signs
306
Speech disturbance
Inability to converse can result from a disturbance in any part of the
process such as deafness, poor attention, receptive dysphasia, motor
dysphasia, dysarthria, dysphonia, aphonia, or combinations of these factors.
Some differential diagnoses and typical outline evidence
Deafness due
to ear disease
or eighth cranial
nerve lesions
Suggested by: no reaction to speech or noises
(e.g., startling)
Confirmed by: features of ear disease
Inattention due
to dementia,
depression, etc.
Suggested by: normal reaction (e.g., startling) to
noise or speech but no interest in source of noise
or speech
Confirmed by: features of causal condition, e.g.,
dementia or depression
Sensory
dysphasia due
to lesions in
Wernicke’s
area
Suggested by: inability to understand or comprehend
speech (as if a foreign language is being spoken to
patient). Worse for vocabulary or language acquired
later in life
Confirmed by: CT or MRI scan showing lesion in
Wernicke
’s area in dominant temporal lobe
Motor dysphasia
(or aphasia) due
to lesion in
dominant
frontal-parietal
lobe
Suggested by: inability to find words or names of
things (nominal dysphasia)
Confirmed by: CT or MRI scan showing lesion in
Broca
’s area in frontal lobe
Dysarthria (or
anarthria) due to
cerebellar
connections,
upper or lower
motor neuron
lesion
Suggested by: inability to coordinate speech, with
slurring, mumbling, and failure to initiate or sustain
speech
Confirmed by: associated features of weakness or in
coordination of oral muscles
Dysphonia
(or aphonia)
due to
vocal cord
dysfunction
Suggested by: hoarseness, voice loss or weakness,
inability to cough properly
Confirmed by: indirect laryngoscopy (using mirror)
to show vocal cord dysfunction or paresis
DYSARTHRIA1
307
Dysarthria
This is difficulty with articulation, and incoordination of speech muscles.
Some differential diagnoses and typical outline evidence
Cortical
cerebral lesion
(due to bleed,
infarction, or
tumor)
Suggested by: slow, stiff speech (and dysphasia if
extensive lesion in dominant hemisphere, i.e., most
dextrous hand is also affected) and other cortical
signs
Confirmed by: CT or MRI scan of brain
Internal capsule
cerebral lesion
(due to bleed,
infarction, or
tumor)
Suggested by: slow, stiff speech and other internal
capsule signs (e.g., spastic hemiparesis)
Confirmed by: CT or MRI scan of brain
Upper motor
neuron
brain stem
(pseudobulbar
palsy due to
ischemia, motor
neuron disease,
multiple
sclerosis [MS])
Suggested by: slow, stiff speech, nasal quality, slurring,
other brain stem signs (e.g., spastic hemiparesis,
dysphagia)
Confirmed by: MRI scan of brain stem
Lower motor
neuron brain
stem (bulbar)
palsy
(due to ischemia,
motor neuron
disease, polio
syringobulbia, MS)
(e.g., spastic hemiparesis, dysphagia)
Confirmed by: MRI scan of brain stem
Extrapyramidal
dysarthria
(due to
Parkinson’s
disease)
Suggested by: difficulty in initiating speech, which is
slow with other signs of Parkinsonian syndrome
Confirmed by: response to dopaminergic drugs
Cerebellar
lesion
(due to MS,
ischemia, tumor,
hereditary ataxias)
Suggested by: staccato, undulating speech, broken
flow, slurring, and other cerebellar signs (e.g., ataxia)
Confirmed by: MRI scan of cerebellum
Drug effect
(e.g., alcohol,
sedatives)
Suggested by: dysarthria (slurred speech) and other
drug effects
Confirmed by: response to removal of drug
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CHAPTER 13 Neurological signs
308
Anosmia (absent sense of smell)
This is not tested routinely, but ask the patient if there is anything
abnormal about his or her sense of smell or taste. This is tested using
bottles with familiar scents.
Some differential diagnoses and typical outline evidence
Coryza
(common cold)
Suggested by: running nose, fever, headache, sporadic
perhaps with contact history
Confirmed by: history and nasal speculum examination
Nasal allergy Suggested by: running nose, fever, headache, recurrent
and recognizable precipitant
Confirmed by: history and nasal speculum examination
Skull fracture Suggested by: history of facial or head injury
Confirmed by: history or skull X-ray in acute phase
Frontal lobe
tumor
Suggested by: personality change, features of dementia,
recent epilepsy
Confirmed by: CT or MRI scan of brain
Kallman’s
syndrome
(anosmia and
hypogonadism)
Suggested by: delayed puberty or poor secondary
sexual characteristics and libido, infertility. Primary
amenorrhea in women
Confirmed by: low estrogen or testosterone and low
FSH and LH
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CHAPTER 13 Neurological signs
310
Abnormal ophthalmoscopy
Start with high positive (+) numbers for the eye surface and use the
lowest light level possible. Look for the red reflex and zoom in to the
eye until the red reflex fills the field of view.
Examine the retina by rotating down to negative (–) numbers. Start with
the disc, found by looking toward the patient’s midline, and then follow
the four main arteries out and back.
Examine the macula by asking the patient to look at the light.
Some differential diagnoses and typical outline evidence
Corneal opacity
in quiet eye
(old ulcer due to
past trauma,
trachoma—
tropical
countries)
Suggested by: gray opacity in the clear cornea without
dilated blood vessels, gradual loss of vision
Confirmed by: absence of staining with fluorescine
Cataract
(due to aging
[75%], diabetes,
trauma, steroids,
radiation, intra-
uterine rubella
or toxoplasmosis,
or rubella, hypo-
calcemia, etc.)
Suggested by: history of gradual onset of visual blurring
and lens opacity visible during the red reflex examina-
tion with the ophthalmoscope. Usually >65 years of
age or history of underlying condition (often already
known and cataract develops later)
Confirmed by: ophthalmoscopic appearance
Optic nerve
swelling or
(eventually)
atrophy
(due to papillitis
from MS, or
papilledema or
optic nerve i
nfarction in
temporal arteritis
and retinal artery
occlusion)
Suggested by: raised pink optic disc with blurred
margins 9 distended capillaries, and adjacent streak
hemorrhages progressing to pale white disc with pale
margins. Gradual loss of vision after initial disturbance
Confirmed by: visual field mapping. Ophthalmoscopic
appearance
Peripheral
retinal damage
(laser therapy
for diabetic
retinopathy)
Suggested by: irregular pale patches of depigmenta
t
ion
with central black areas of pigment clumping
Confirmed by: ophthalmoscopic appearance and
history
ABNORMAL OPHTHALMOSCOPY1
311
Age-related
macular
degeneration
(usually senile)
Suggested by: gradual loss of central vision, large,
central, yellowish white scar or hemorrhage when
patient looks at ophthalmoscope light
Confirmed by: ophthalmoscopic appearance
Retinal vein
occlusion
Suggested by: sudden vision loss often in upper or
lower half only
Confirmed by: extensive superficial retinal hemor-
rhages following the nerve fiber layer which may
be in only the upper or lower half of the retina
Retinal artery
occlusion
Suggested by: sudden loss of vision. May be total or
partial upper or lower field
Confirmed by: in the first few days, retinal pallor.
Later, a white, thready, thin artery
Primary optic
atrophy
(prior inflammation
not seen—due to
MS or optic nerve
infarction)
Suggested by: gradual visual loss in a quiet eye and
pale disc with sharp margins
Confirmed by: ophthalmoscopic appearance of pale
white, featureless disc and may have thin, thready
vessels
Glaucoma Suggested by: gradual loss of vision, deeply
cupped disc
Confirmed by: ophthalmoscopic appearance of
deep cupping with visible cribriform plate and nasal
displacement of vessels. Loss of peripheral field.
Raised intraocular pressure
Retinitis
pigmentosa
Suggested by: loss of peripheral and night vision
Confirmed by: visual-field mapping. Pale disc, thin,
thready blood vessels, and fine, star-shaped pigment
without patches of depigmentation. Visual-field
mapping
Choroidoretinitis Suggested by: gradual loss of vision or blurring
(in acute phases), and patchy visual loss—scotoma
Confirmed by: visual-field mapping showing irregular,
patchy areas of visual loss. Corresponding areas in
the eye of irregular depigmentation with dense
areas of pigment in the center.
Tests results for underlying cause: CXR, serology,
sputum, lung biopsy
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