《神经系统体格检查.doc》由会员分享，可在线阅读，更多相关《神经系统体格检查.doc（4页珍藏版）》请在三一文库上搜索。
1、 Nervous SystemCranial nerve: I Olfactory nerve: left not measured, right not measured II Optic nerve:leftrighteyesightnormalnormalVisual fieldNo defectNo defectfundusnormalnormal III, IV, VI Oculomotornerve, trochlearnerve, abducens nerve palpebralfissure: left: normal right: normal Eyelid: left: n
2、o ptosis right:no ptosis Diplopia: no accommodation reflex: exist Nystagmus: left: no right: no Eye movement: left:normal right: normalPupils: left: round, diameter 3.0mm, direct light reflex sensitive, indirect light reflex sensitive right: round, diameter 3.0mm, direct light reflex sensitive, indi
3、rect light reflex sensitiveV Trigeminal nerve:Facial sensory： Left facial pain：normal；Temperature： normal；Touch： normal. Right facial pain：normal；Temperature： normal；Touch： normal.Movement: Left temporalis, masseter shrink: no. Mastication: powerful. Right temporalis,masseter shrink: no. Mastication
4、: powerful. The jaw : no deviation. Left Right Direct corneal reflection: Existence ExistenceIndirect corneal reflection: Existence Existence Jaw reflex: (-) facial nerve：LeftRightWrinkles in the forehNot shallowNot shallowPalpebral fissureNormalNormalNasolabial grooveNot shallow Not shallowClose ey
5、esThewyThewyFrownThewyThewyCheek bulgingThewyThewyWhistleNormalNormalKnit ones brownsNormalNormalTaste in the anterior 2/3 tongueNo checkNo checkCorner of the mouth： no askew.Show teeth： no askew of corner of the mouth. Auditory Nerve: Auditon: Left: Normal Right: Normal、 Glossopharyngeal Nerve、Vagu
6、s Nerve:Pronunciation: No rhinolalia, dysarthria, dysphagia, cough when drinking, or hoarseness.Uvula: on the middle line.LeftRightSoft Palate LiftingPowerfullyPowerfullyPharyngeal ReflexNormalNormalTaste on the posterior 1/3 of tongueUnexaminedUnexamined Accessory Nerve: LeftRightSternocleidomastoi
7、dNo atropyNo atropyTrapeziusNo atropyNo atropyShoulderdropNoNoTorticollisNoNoNeck RotationPowerfullyPowerfullyShrugPowerfullyPowerfullyXII Hypoglossal nerve Tongue： in the middle Lingualis：no atrophy Lingualis fibrillation: noneLocomotor system:muscle forceUpper limbLower limbNear-endFar-endNear-end
8、Far-endleftLevel 5Level 5Level 5Level 5rightLevel 5Level 5Level 5Level 5 muscular tension Left upper limbRight upper limbLeft lower limbRight lower limbnormalnormalnormalnormal muscular atrophy: no fasciculation: no coordination motorleftrightfinger-to-nose testnormalnormaldiadochokinetic testnormal
9、normalheel-knee-tibia testnormalnormalmuscle rebound phenomenonnegativenegative Romberg sign: eyes open:(-) eyes close:(-) posture & gait: normalSensory systemSuperficial sensation: algesia of trunk and all fours exists symmetrically, temperature sensation exists symmetrically, tactile sensation exi
10、sts symmetrically.Deep sensation: topesthesia exists symmetrically, cinesthesia exists symmetrically, seismesthesia exists symmetrically.Complex sensation: skin topethesia exists symmetrically, two points discrimination exists symmetrically, weight sensation exists symmetrically, stereognosis exists
11、 symmetrically, graphics sensation exists symmetrically.Reflex system:Deep reflex: left rightBiceps reflex: normal normalTriceps reflex: normal normalRadial reflex: normal normalKnee reflex: normal normalAnkle reflex: normal normalRossolimo sign: negative negativeHoffmann sign: negative negativeClon
12、usleftrightpatella-ankle-Superficial reflexAbdominal reflexsuperiormediumunderneathleftnormalnormalnormalrightnormalnormalnormalPlantar reflexLeft normal Right normalAnal reflexnormalPathological signLeft - Right Autonomic nerve system: Normal skin, normal perspiration, normal hair, normal nails and
13、 toenails. No edema, ulcer and decubitus. No abnormality of urination and defecation. Autonomic nerve reflex: Oculocardiac reflex: Unknown Diaphoretic test: UnknownPilomotor test: Unknown dermatographism test: UnknownRecumbent-upright test: UnknownMeningeal irritation sign：Neck flexion sign： negativeKernigs sign：left：negative right：negativeBrudzinskis sign：negative