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1 > Proforma History I. Name, Age, Sex, Occupation, Right or Left handed, Consanguinity II. Motor symptoms A. Power: 1. Upperlimbs: a) Proximal: Lifting the arm above the head, eating. b) Distal: Sewing, writing, buttoning, turning a key in a lock, etc. 2. B. C. D. Lower limbs: a) Proximal: Climbing stair up and down, squatting and getting up from squatting position. b) Distal: Slippers falling from foot c) Running, walking with or without suppo r t , standing witho ut support, moving limbs in the bed or complete paralysis. Truncal : turning in bed. Nutrition: Wasting of muscles (proximal or distal), atrophy, hypertrophy. Coordination: 1. Unsteadiness (For cerebellar ataxia). 2. Difficulty in feeling the ground and unsteadiness increasing in the dark. (For sensory ataxia). 3. Difficulty in reaching the target. Involuntary movements: Chorea, athetosis, tremors, dystonia, hemi- ballismus, flexor spasms, fasciculations., titubation. III. Sensory symptoms A. Tingling, numbness, root pains B. Feeling hot and cold water during a bath C. Feeling the ground well or ground feels like cotton wool. IV. Sphincter disturbances A. Bladder: 1. Feeling the sensation of bladder fullness 2. Initiation ofmicturition immediately when desired 3. Controlofmicturition, once the desire to micturate has occurred 4. Complete evacuation of the bladder or a feeling of residual urine 5. Inability to pass urine at all 6. History of catheterization B. Bowel: Constipation / Loose Stools C. Impotency: In males Cranial nerves V. A. Sensation of smell - 1st CN B. Vision - acuity and color - 2nd CN C. Diplopia, squint - 3rd, 4th, 6th CN D. Sensations (Tingling, numbness over the face, and difficulty in chewing) - 5th CN E. Facial asymmetry, dribbling of saliva from the angle of the mouth, stasis offood in the mouth- 7th CN F. Vertigo, tinnitus, deafness - 8th CN G. Hoarse voice, nasal twang, nasalregurgitatiotl dysphagia - 10th + 9th CN H. Dysarthria - 12th CN < 6 ) Central Nervous System VI. Higher functions A. Mental symptoms B. Speech disturbances C. Sym ptoms of raised intracranial tension: headache, projectile vomiting, blurred vision, altered sensorium, photophobia, diplopia D. Unconsciousness E. Convulsions: Inquire for aura, tonic and clonic convulsions deviation of eyes, incontinence of urine and stools, tongue bite, fall and injuries. Post convulsion drowsiness or unconscious�ness. Sleep attacks. VII. For Etiology A. Hypertension, diabetes, heart disease B. Tuberculosis, syphilis, HIV infection B. Trauma and fever C. Vaccinations, drugs or sera administered D. Alcohol, smoking, tobacco chewing, gutka, recreational drugs E. Similar episode in the past, in the family or in the surrounding General Examination I. Build, nutrition II. Nails and conjunctiva: Pallor, clubbing, cyanosis, icterus III. Lymphadenopathy, edema of feet, JVP IV: TPR, BP - look for postural drop V: Spine: For kyphoscoliosis VI. Skin: For hypopigmentedareas, hyperpigmented areas, cafe-au•lait spots, nodules, etc. VIL Thickened nerves Central Nervous System Examination I. Higher functions A. Consciousness B. Behavior C. Intelligence D. Memory - past and present E. Orientation in time, place and person F. II. Hallucinations, delusions G. Speech Cranial nerves A. ICN: Sense of smell in each nostril B. lICN: Acuity ofvision, field ofvision, color vision and fundus examination Ill, IV, VI CNs: l. External ocular movements on follow and command 2. Pupils: position, shape, size, equality, reaction to light and accommodation and ciliospinal reflex 3. Nystagmus 4. Ptosis (IIIrd) D. VCN: l. Sensations over the face 2. Masseters, pterygoids and temporalis muscles 3. Corneal and conjunctiva( reflexes and jaw jerk E. VIICN: l. Eye closure, frowning, raising the eyebrows 2. Blowing, whistling and showing the teeth 3. Nasolabial fold, Platysma VIJICN: F. l. Hearing tick of the watch. 2. Rinne's test 3. Weber's test G. JX,XCNS: 1. Uvula on saying 'ah' - central or deviated to one side 2. Gag reflex H. XIICN: I. Tongue movements 2. W a s ting, fasc iculations a n d fibrillations III. Motor system A. Nutrition: Wasting or hypertrophy B. Tone: Normal, hypertonia or hypotonia C. Power: Graded from O to V C. 265 PRACTICAL MEDICINE Coordination: By finger-nose test, knee heel test, rapid alternate movements at the wrist. E. Involuntary movements. Sensory system A. Superficialsensations: Touch, temperature, pain B. Deep sensations: Position, joint and vibration C. Cortical sensations: Tactile localization, tactile discrimination, tactile extinction and astereognosis D. Calf tenderness or anesthesia of the calves Reflexes D. IV. V. Ill. RS A. B. C. D. E. 2 I. Graded:Absent(-·),depressed(+), normal(++), brisk (+++) and brisk with clonus (++++).e.g. TJ SJ Right +++ +++ + Left ++ +++ +++ Kl N ++++ ++ BJ: Biceps Jerk; TJ: Triceps Jerk; SJ: Supinator Jerk; KJ: Knee Jerk; AJ : Ankle Jerk VI. Miscellaneous A. Signs of meningeal irritation: Neck stiffness, Kernig's sign, Brudzinski's sign. B. S.L.R. and Lasegue's sign C. Skull and spine D. Gait including Romberg's sign Relevant Examination of other Systems I. II. CVS A. Valvular heart disease: Heart sounds, murmur B. Blood pressure in supine and standing position : For hypertension, postural hypotension. C. Peripheral pulsations including carotid pulsations D. Bruits: Over carotids or eyeballs AS A. B. 266 Hepatosplenomegaly Ascites > Examination A: Higher Functions Consciousness Consciousness is a state of awareness of one's self and one's environment. Sleep: Sleep is a state of physical and mental inactivity from which the patient can be aroused to normal consciousness. Catatonia: Catatonia is a state during which rigid plastic postures of limbs for long hour s are assumed. The person is unresponsive, mute and immobile. It may occur in psychosis or with frontal lobe and hypothalamic lesions. Akinetic mutism: Akinetic mutism is a state during which the patient remains immobile, making no sound, follows movements slowly with his eyes and allows himself to be fed and nursed. This is seen with lesions ofdiencephalon and brainstem. Drowsiness: This is a pathological state that resembles normal sleep. Patient can be aroused with an external stimulus, but reverts back to his drowsy state on withdrawal of the stimulus. Semicoma: Semicoma is a pathological state, which requires stronger stimulation to arouse the patient, though his reflexes are normal. Stupor: Stupor is often considered synonymous to semicoma, whereas some doctors regard it as a state between drowsiness and semicoma. Coma: Thisisthedeepestlevelofunconsciousness. Patient is immobile, all the reflexes are absent and plantar response is extensor (See Ch. 7 & pg. 290). A: Superficial, B: Deep, C: Primitive. BJ Chest expansion Dullness or hyperresonant note Breath sounds Foreign sounds Vocal resonance II. Delirium Delirium is the acute state of confusion with excitement and hyperactivity. ( 6 > Central Nervous System Causes 1. Infective: Septicemia, typhoid, cerebral malaria 2. Withdrawal state: Alcohol 3. Toxic: Overdose of aspirin, amphetamine, atropine, etc 4. Deficiency of thiamine and nicotinic acid 5. Metabolic: Renal failure, porphyria Ill. Delusions Delusions are false beliefs, which cannot be corrected in spite of evidence to the contrary. Delusions have to be distinguished from superstitions, which are a part of the cultural traditions in certain societies. Causes I. Holistic: Delusions of disordered or diseased body, e.g. the body is riddled with cancer or his sex is changing. This is seen in schizophrenia or depressive illnesses. 2. Delusions of guilt: Patient may blame himself excessively for some trivial lapse and expect to be imprisoned or hanged for the same. This is seen in depressive states. 3. Delusions of grandeur: e.g. A patient who is a beggar may say that he is the richest man in the world, and is about to marry the Premier's daughter. This is seen in GP! mania and paranoid schizophrenia. Significance: False beliefs on a background of a clear consciousness are of more grave significance than those occurring when consciousness is clouded. IV. Hallucinations This is false perception of sensations in the absence of any sensory stimulus e.g. humming in the ears when there is no sound or seeing somebody who does not exist. This has to be distinguished from illusion, which is altered perception to sensory stimulus, e.g. mirage in the desert. V. Thought Content I. Sudden onset of fear or depression before 2. 3. VI. an epileptic attack points to temporal lobe origin. Teichopsia preceding an attack of migraine ° represents 0ccipital visual hallucinations. Grandiose delusions are the hallmark of GPI (Neurosyphilis). Insight Lack of insight is seen in: I. Lesions of frontal lobe 2. With deteriorating intelligence VII. Emotional State Hostile, depressed or euphoric. Whether the emotions are appropriate or not. Causes oflncontinence of emotions/ Emotional lability 1. Pseudobulbar palsy 2. Cerebral arteriosclerosis, multi-infarct state 3. Organic dementia· vascular 4. Multiple sclerosis VIII. Memory Defect in registration: This is largely due to inattention. It is seen in: I. Toxic delirium 2. Manic states 3. Senile dementia 8. Defects in retention: This is seen in organic cerebral disturbances like: 1. GP! 2. Frontal lobe lesion 3. Senile dementia C. Defects in recall: This is seen in: 1. Post traumatic states 2. Epilepsy 3. Korsakoff's psychosis 4. Ganser's syndrome 5. Hysteria Dementia is an acquired deterioration of cognitive abilities. It comes in the way of performing activities of daily living. Memory is most commonly affected. A. 267 PRACTICAL MEDICINE Mini Mental State Examination (MMSE) Used for screening and progression of dementia. The total score is 30. A score of< 21 in an educated person is severe dementia. Table 6.1 : MMSE resr fer 4. 5. Multiple sclerosis Multi-infarct dementia IX. Language and Speech Language includes all modes of communication between people. The various forms oflanguage are: 1. Listening to speech which begins at about 6 months of age when the child hears some words or phrases and begins to associate them with appropriate objects or actions. 2. Speaking or Spoken language includes expression of thoughts in spoken words, phrases and sentences. It begins at about 9 months of age when the child begins to mimic the sounds he hears and begins to associate them with objects or meaning. 3. Writing implies ability to communicate by the written word. In mirror writing the letters or figures are reversed as seen in themirror. This is a normal feature in writings of children up to the age 6-7 years. Its persistence in later years is pathological and is seen in: a) Forced right-handedness. b) When a right-handed person with right hemiplegia attempts to write with his left hand. c) Developmental dyslexia: This is a 5(011!' Orientation Time, Day, Date, Month, Year Place, Floor, City, State, Country S 5 Registration Name 3 objects and ask to repeat 3 Attention and Calculation Serial subtraction: 100-7-7-7-7-7 S Recall Repeat all 3 objects named above 3 Language Name: Pencil, watch Follow 3-step command (e.g. take paper, fold in half, put on table) Copy intersecting pentagons Repeat"Satara cha matara" or "No if's and's or but's" Obey written command (e.g. 'close your eyes' writ­ ten on a piece of paper) Write a sentence (eg. Today is a sunny day) 2 3 Causes of Dementia Treatable/Reversible Drugs/Toxins: Alcohol, narcotic poisoning 1. Vitamin Deficiency: Bl, B 12, B3 (pellagra) 2. 3. Infections: Syphilis, TB 4. Neoplasm: Primary or metastatic brain tumor 5. Trauma: Chronic subdural hematoma, normal pressure hydrocephalus 6. Endocrine: Hypothyroidism, Addison's syn­ drome, Cushing's syndrome, hyp erparathyroid­ ism 7. Miscellaneous: Vasculitis, liver/renal failure Un treatable/Irreversible Degenerative Diseases: Alzheimer's, Parkinson's, 1. Huntington's disease 2. Infections: HIV, Sub acute Sclerosing Panencephalitis 3. Prion diseases: Creutzfeldt-Jacob disease Broca 's area Central sulcus Frontal pole Wemicke' area : 268 Fig 6.1 :The language areas ------- - -- - - { 6 ) Central Nervous System 4. 5. 6. defect in learning to read. Hence here mirror writing is secondary to mirror reading. Reading is the ability to communicate through the written word. Sign language is ability to communicate by gestures. Touch language is communication by the written word employed by the blind in reading. Disorders of Language & Speech The disorders of language and speech occur with le­ sions of the dominant hemisphere. About 90% of the population have left cerebral dominance i.e. they are right handed and 10% have right cerebral dominance i.e. they are left-handed. But among left handed people 60% have left cerebral dominance. Dysphasia/ Aphasia Definition: Dysphasia is difficulty with language func­ tion. It occurs due to lesions in the language areas of the dominant cerebral hemisphere. Pathways: The main language areas are shown below: Broca's Area (Inferior frontal region) (Area 44): This is concerned with generation of motor programs for the production of words or parts of word. Damage to this area causes reduced number of words, poorly articulated, non-fluent speech and grammatical errors. The speech has a tele grammatic quality. Wernicke's Area (Posterior temporal lobe and adjoin­ ing parietal region) (Area 22): This is concerned with comprehension of language and selection of words to convey meaning. In lesions of this area, spontaneous speech is normal, fluent and articulation is normal. However the speech may contain incorrect words ( ver­ bal paraphasias), incorrect letters (literal paraphasias) and nonsense words (neologisms). Occipitotemporal (lingual) gyrus is the visuopsychicarea. The posterior part of the superior temporal gyrus is the auditory (auditopsychic) cortex. The final sensory pathway leads to the inferior part of the post central gyrus for coordination of the meaning of the information and the organization of any response that may be required. If any motor response is expected, then a relay of information goes to the precentral gyrus (the motor coordinating centre and from there, to the motor speech area if verbal response is expected. Types of Dysphasia/ Aphasia: Sensory (Wernicke's) dysphasia: Auditory: The patient is unable to carry out simple verbal commands in absence of loss of hearing. The lesion is in the posterior part of the superior temporal gyrus (word deafness). Visual: Inability to read in absence of loss of vision (word blindness). The lesion is in the medial occipi­ totemporal gyrus. It is associated with inability to write (dysgraphia). Nominal: Inability to name objects. The lesion is in the left temporoparietal region. Table 6.2 : Aphasias BROCA's (Non Fluent Apha· sia) Flul!Ncy Comprehension Repetition Naming Reading Writing Lost"Telegraphic" Present Lost Lost Lost Lost Lost Lost Lost Lost Lost Present Present Lost Lost Present Present Present Present Present Present Present Lost Lost Lost Lost WERNICKE's (Fluent Aphasia) Present verbal paraphasias Neologism CONDUCTION ANOMIA TRANSCORTICAL MOTOR Word finding pauses TRANSCORTICAL SENSORY Present GLOBAL APHASIA ISOLATION OF SPEECH AREA Lost Echolalia ++ Present Lost Lost Impaired Present Present Lost Lost Present Present (No purposeful speech) Present 269 PRACTICAL MEDICINE Motor (Broca's) dysphasia: The lesion is in Broca's area. The patient is unable to express himself. There may be difficulty in forming phrases and sentences. The emotional outbursts may be retained. Central Dysphasia: This results from a disorder ofthe central organization of written or spoken speech. The patient is unable to comprehend spoken or written language and even his own speech. This is usually associated with motor or expressive defects. The lesion is in the left temporo­ parietal region (Arcuate fibers). Conduction Aphasia : Speech output is fluent but paraphasic. Repitition is impaired, naming and writing are also impaired. Reading aloud is impaired but com­ prehension of read material is present, comprehension of spoken language is intact. Lesion is in perisylvian area with damage to fibres of Arcuate faciculus. Transcortical Motor Aphasia features are similar to Broca's aphasia but repetition is intact. The lesion is anterior superior to Broaca's area. Transcortical Sensory Aphasia features are similar to Wernicke's aphasia but repetition is intact. The lesion is posterior inferior to Wernicke's area. Global Aphasia speech is nonfluent and comprehen · sion is severely impaired. Naming, repetition, reading and writing are impaired. Lesion is usually large in middle cerebral artery territory or left internal carotid artery or a large hemorrhage or major trauma. Isolation of Speech Area : This is a rare syndrome in which comprehension is severly impaired & no purposeful speech output. He may repeat like a parrot parts of heard conversation - "echolalia". It is seen in complete watershed zone infarctions. Anomic Aphasia: There is minimal dysfunction only naming, word finding and spelling are impaired. Most common language disturbance seen (Refer to Table 6.2). Dysarthria Definition: Dysarthria is indistinct speech due to weakness or impaired coordination of the orolingual muscles concerned with the production of consonants. However, the grammar is norrqal and comprehension of spoken and written language is retained. 270 Dysarthria commonly occurs due to mechanical fac­ tors such as ill-fitting dentures. Types of Dysarthria: I. Spastic: This results from bilateral upper motor neuron lesion. The tongue is small and spastic. There is difficulty in pronouncing 'b' 'p' and 't'. Monotonous: This results from extrapyramidal 2. lesions. The speech is slow, monotonous and lacking accents. Ataxic: This results from cerebellar lesions. The 3. speech is slurred and irregular in rhythm, tone and volume due to incoordination of muscles of respiration, larynx, pharynx and lips (scanning speech). This is called scanning speech when speech has explosive character and shining of consonants it is called staccats speech. Lower motor neurone: This results from 4. paralysis of the soft palate giving rise to nasal speech. There is failure to produce sounds like "b" and "g" correctly. e.g. "Egg" is pronounced as "eng". In myasthenia gravis, the force and volume of the words diminish as the patient speaks and may return to normal after some rest. X. Other Higher Function Disorders A. Apraxia Inability to carry out learned voluntary movement in the presence of normal motor, sensory and cerebellar functions Types I. ldeomotor Apraxia : Inability to plan or complete motor actions. There is inability to pretend to use a tool e.g. pretend to brush ones hair when given a comb. The ability to spontaneously use tools is retianed e.g. brush one's hair in morning. 2. IdeationalApraxia / Conceptual Apraxia: Inability to conceptualizea task or complete a multistep task e.g. patient puts on shoes before socks, if given a screwdriver, the patient may try to write like it is a pen. 3. Limb- Kinetic Apraxia: Inability to make precise movements with an arm or leg. 4. Dressing Apraxia : Inability to dress or undress oneself. ( 6 ) Central Nervous System 5. Constructional Apraxia: Inability to draw or construct simple shapes e.g. intersecting pent,gorn 6. Orofadal Apraxia : Inability to carry out movements of the face on demand e.g. lick lips, whistle. Table 6.3 : Hemispheric Functions Left Hemisphere : Verbal, Linguistic description, Mathe matical, sequential, Analytical, linked to consciousness level Right Hemisphere: Musical, geometrical, spatial, temporal synthesis, doubtful link to consciousness B. Agnosias ls anability to recognise objects in the presence of normal sensory, motor cerebellar functionals. I. Visual: Patient is unable to name or describe use of objects shown. 2. Tactile : Able to describe the object but unable to give name or use even on seeing it. 3. Auditory: Unable to recognise sounds but can recognise them on sight or touch. Details ofLobar Functions and Dysfunctions are given in Table 6.3 and 6.4. Table 6.4 : Lobar Functions and Dysfunctions Lobe Frontal Prefrontal lesions Function Personality, emotional response, social behav­ iour Dysfunction • Dominant: Apraxias: ideational, ideomotor, limbkinetic, difficult in performing similia r motor tasks. Contralatera I hemiplegia • Nondominant: motor speech disorder with agraphia, loss of verbal fluency. Abulia, akinetic mutism, lack of ability to solve problems, lack of attention, rigidity of thinking, bland affect, labile mood, sphincter incontinence. Release of primitive reflexes, utilization behaviours Parietal Calculation, Language, Planning, Stereognosis Temporal • Dominant Dominant: Auditory, speech, language, Homonymous superior quadrantanopian Wernicke's Aphasia, amusia, dreaminess memory and olfactlonal with uncinate seizures Non-dominant: Music • Nondominant tone appreciation Non verbal memory loss, Behavioural changes, Bilateral affection Non Verbal memory Causes: Karsakoff's amnesia, Kluver Bucy Syndrome Occipital Vision • ldiomotor, limb kinetic apraxias • Dominant - Gerstman's syndrome (ataxia, acalculia, finger agnosia and left-right confusion} Cortical sensory loss & sensory extinction - Homonymous inferiorquadrantanopia - lpsilateral opto kinetic nystagmus abolished - Graphesthesia Asterog nos is - Tactile agnosia , Non dominant - Visuospatial disorders - Geographical disorientation - Anosognosia - Dressing apraxia Constructional apraxia , Homonymous hemianopia (sparing macula) • Dominant: Splenium of corpus callosum: alexia without agraphia, colour anomia. • Non dominant: Visual illusions, hallucinations , Bilateral involvement: Cortical Blindness, Anton's syndrome, Loss of perception of color, Prosopagnosia. Ballint's syndrome, failure to grasp/ touch object under vision. Inability to scan peripheral fields. 271 PRACTICAL MEDICINE C. B: Cranial Nerves For Upper limbs: Measure the circum. ference (10 ems) above and below the olecranon (elbow}. Refer Pg. 298 ,. C: Motor System For Lower limbs: Measure the circum. ference 16 ems above patella and 10 ems below the tibial tuberosity (knees). A difference in the circumferences gives objective evidence of wasting. Nutrition A. B. Measurements: Hypertrophy of Muscles: Some patients of muscular dystrophy may develop large muscles especially calves, buttocks and infraspinati. These muscles are weak in spite of their size. Hence they are called pseudohyp ertrophy. Causes I. Parietal Lobe Lesions II. Vertebral Lesions Wasting of Muscles: Wasting of muscles may occur in several diseases as mentioned below. The wasted muscles are flabby, smaller and softer than normal. When there is associated fibrosis, the muscles feel hard, inelastic and shortened (contracture). A. Craniovertebral anomalies B. Vertebral metastasis To muscles or masllCation , 272 -:,_; ,· � '/,·..::�t r·gofs'.":la J·•·1...s: ��o•r g1�n..:::1CCOTq:1c r -2d :o:...c: e-.: s r �.r;.-;. � - r-,,_r,� , rig 6 l P:;r;:,m dcltrccts { 6 > Central Nervous System III. Spinal Cord Lesions A. Motor neuron disease B. Syringomyelia IV. Anterior Horn Cell Lesions A. Poliomyelitis B. Peroneal muscular atrophy C. Progressive muscular atrophy D. Spinomuscular atrophy V. Root Lesions (Radiculopathy) A. Cervical spondylitis B. Cervical cord tumor C. Cervical hypertrophic pachymening­ itis D. Neuralgic amyotrophy VI. Peripheral Nerve Lesions (Neuropathies) A. Leprosy B. Carpal tunnel syndrome C. Lead paralysis D. Diphtheria VII. Myoneural Junction Eaton Lambert syndrome VIII. Muscle Diseases A. Muscular dystrophy B. Polymyositis C. Myotonia IX. Disuse Atrophy A. Therapeutic immobilization: Fracture B. Arthritic: Rheumatoid arthritis X. II. C. Post paralytic Systemic Wasting A. Tuberculosis B. Malignancy C. Thyrotoxicosis D. HIV infection or AIDS E. Addison's disease Tone Tone is the resistance offered by normal muscles to passive movements. It is greatest in those muscles that maintain the body in position. These are the antigravity muscles, principally the flexors in the upper limbs and extensors in the lower limbs. A. Hypotonia (Flaccidity) Definition: It is characterized by flabby muscles, which offer less resistance to passive movements, leading toan increased range of passive movements and the limb is unable to maintain posture. Causes 1. Lowermotorneuronedisease:Poliomyelitis, peripheral neuritis, tabes dorsalis etc. 2. Neuronal shock in upper motor neurone disease 3. Cerebellar disease 4. Rheumatic chorea B. Hypertonia Definition: Hypertonia is increased resistance to passive movements, a heightened salience of the muscles and increased firmness on palpation. 273