HISTORY TAKING AND PHYSICAL

EXAMINATION
IN
DIAGNOSING OF
NEUROLOGIC DISORDERS

Alya Tursina, dr. SpS

THREE IMPORTANT STEPS IN THE DIAGNOSIS OF
NEUROLOGIC DISEASE
1.   HISTORY TAKING / ANAMNESIS
2.   PHYSICAL EXAMINATION
3.   SUPPORTING MEASURES (LABORATORY, RADIOLOGY, ETC)

BEAR IN YOUR MIND !!!

CENTRAL NERVOUS SYSTEM IS LOCATED WITHIN THE
(SKULL/VERTEBRAE) BONES
 IT CAN NOT BE :
 INSPECTED
                       

 PALPATED
                       

 AUSCULTATED
                       

 NEED A CORRECT AND THOROUGH TECHNIQUE

 HIERARCHY IN NEUROLOGIC EXAMINATION
(GENERALLY WRITTEN IN RESUME
•
ANAMNESIS :
 NEUROLOGICAL STATUS :
                         CHIEF COMPLAINT
MENINGEAL IRITATION
                         HISTORY OF PRESENT ILLNESS
CRANIAL NERVES
                         PAST MEDICAL HISTORY
MOTOR SYSTEM
• PHYSICAL EXAMINATION SENSORY SYSTEM
                         GENERAL STATUS REFLEXES
                         INTERNAL STATUS COORDINATION AND GAIT
                         NEUROLOGICAL STATUS MENTAL STATUS
•                     
 THE COURSE OF ILLNESS IN
ANAMNESIS ANAMNESIS
o STATISTICAL DATA : AGE, SEX,
   

MARITAL STATUS, RESIDENCE,

TAKING OF HISTORY FROM HANDEDNESS, ETC
THE PATIENT’S OWN SELF
o CHIEF COMPLAINT AND HISTORY OF
   
(ALLO-ANAMNESIS) OR
PRESENT ILLNESS
FROM THE
RELATIVES/FAMILIES o PAST MEDICAL HISTORY
   

(HETEROANAMNESIS)
THAT AIM TO GET AND o FAMILY HISTORY (INCL. SEXUAL
   

COLLECT DATA HISTORY)

ABOUT PATIENT’S SYMPTOMS o SOCIAL HISTORY (PATIENT’S HABITS –
   

AND/OR SIGNS THE USE OF ALCOHOL, TOBACCO, AND

“RECREATIONAL” DRUGS)
o OCCUPATIONAL HISTORY
   
1. CHIEF COMPLAINT :
  

SYMPTOM THAT FORCED THE PATIENT TO SEEK

MEDICAL FACILITIES (HOSPITAL, CLINIC, OUT-PATIENT
CARE, PRIVATE PRACTICE, ETC)
     

SOME TYPICAL CHIEF COMPLAINTS :

RIGHT/LEFT LIMBS WEAKNESS
(HEMIPARESIS) IN STROKE

CONVULSION IN EPILEPSY   

UPPER/LOWER LIMBS WEAKNESS

(PAREPARESIS) IN MYELOPATHY
2. HISTORY OF PRESENT ILLNESS

ANALYSIS OF CC CONSIST OF :
ONSET OF TIME
      

SEVERITY AND THE COURSE/NATURE

      

LOCALIZATION AND DISTRIBUTION

      

RELATION TO TIME
       3. PAST MEDICAL HISTORY
CONCOMITTANT SYMPTOMS
      

CONDITIOS
       THAT WORSEN PAST EVENTS THAT RELATE TO
SYMPTOMS PRESENT ILLNESS
CURRENT MEDICATION (INCL. DOSES)
      

DEVELOPMENT :
      
HISTORY OF PREVIOUS ILLNESS,
a. RELAPSING/RECCURENCE
  
OPERATION, ALLERGIES)
b. CHRONIC DISEASE
  

EXAMPLE :
 RISK FAKTORS OF STROKE
 CNS INFLAMMATION
 EPILEPSY
 TRAUMA OF SPINE IN
MYELOPATHY
 PHYSICAL EXAMINATION

1. GENERAL STATUS  NEUROLOGICAL STATUS :

2. INTERNAL STATUS MENINGEAL IRITATION
3. NEUROLOGICAL STATUS CRANIAL NERVES
  MOTOR SYSTEM
SENSORY SYSTEM
REFLEXES
COORDINATION AND GAIT
MENTAL STATUS
GENERAL STATUS
DETERMINE

       STATE OF CONSCIOUSNESS

       BLOOD PRESSURE
       PULSE / HEART RATE
       RESPIRATORY RATE
       TEMPERATURE

  INTERNAL STATUS

LOOK FOR THE OTHER CONDITIONS

/ILLNESSES THAT RELATE TO THIS
NEUROLOGIC PROBLEM
NEUROLOGICAL STATUS

EXAMINATION OF
       MENINGEAL IRITATION
           NUCHAL RIGIDITY
           BRUDZINSKI SIGNS
           LASEAGUE SIGN
           KERNIG SIGN
CRANIAL NERVES
   CN I (OLFACTORY) - SENSE OF SMELL

   CN II (OPTIC) – VISUAL ACUITY, VISUAL FIELDS,

FUNDUSCOPY
     
CN III (OCCULOMOTOR), IV (TROCHLEAR),
AND VI (ABDUSCENS) –
EXTRAOCCULAR MOVEMENT
OTHER FUNCTION OF CN III :
LID RETRACTION, REACTION TO LIGHT,
ACCOMODATION,
PUPIL (SIZE, REGULARITY, EQUALITY)
      CN V (TRIGEMINAL)
SENSATION OF FACE, OPEN/CLOSE JAW,
MASTICATION, CORNEAL REFLEX)
CN VII (FACIAL)
FACIAL MOVEMENT AND
EXPRESSION,
TASTE OF ANTERIOR
TWO THIRD OF
TONGUE,
BLINKING REFLEX
Central 7th palsy Peripheral 7th palsy
CN VIII (VESTIBULO-COCHLEAR)
BALANCING
SENSE OF HEARING
CN IX (GLOSSOPHARYNGEAL) AND CN X
(VAGUS)

ELEVATION OF PALATE/UVULA, GAG REFLEX 

CN XI (SPINAL
ACCESSORY) –
HEAD MOVEMENT,
SHOULDER
SHRUG/ELEVATION

CN XII – TONGUE
MOVEMENT
 MOTOR SYSTEM

•MUSCLE BULK
•MUSCLE TONUS
•MUSCLE POWER/STRENGTH
•FASCICULATION
SENSORY SYSTEM

SUPERFICIAL SENSORY MODALITIES : PAIN PERCEPTION,

TEMPERATURE DISCRIMINATION, LIGHT TOUCH

DEEP SENSORY MODALITIES : VIBRATION SENSE, POSITION SENSE

CORTICAL FUNCTION : TWO-POINT DISCRIMINATION (EXTINCTION),

STEREOGNOSIS
 REFLEXES

PHYSIOLOGIC REFLEX [MUSCLE STRETCH (DEEP) REFLEX] :

BICEPS, TRICEPS, BRACHIORADIAL, KNEE JERK (KPR), ANKLE
JERK (APR)

SUPERFICIAL REFLEX : ABDOMINAL SKIN REFLEX, CRESMATERIC,

ANAL, BULBOCAVERNOUS

PATOLOGIC REFLEX : BABINSKI, CHADDOCK, HOFFMANN –

TROMMER, REGRESSION
PHYSIOLOGIS REFLEKS
• Refleks Biceps
• Refleks Triceps
• Refleks Brachioradialis
• Refleks Patella (Knee Jerk)
• Refleks Tendon Achilles
• Refleks Superfisial

“ STIMULUS – RESPONSE
TECHNIQUE “

(FROM SIMPLE TO
COMPLEX METHODS)
23
REFLEX : SEGMENTAL LEVEL

24
 REFLEKS BICEPS
• Pasien berbaring relaks
• Pemeriksa memfleksikan siku pasien dan meletakkannya di atas abdomen
• Pemeriksa meletakkan jari telunjuk pada tendon biceps pasien dan dengan
lembut mengetukkan palu pada telunjuknya
• Respon : Kontraksi otot biseps dan fleksi siku
• Bandingkan respon kedua sisi

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Reflexes physiologis FM UNISBA 2015.ppt 07/07/20 26
 REFLEKS TRICEPS

• Posisikan pasien spt refleks biseps

• Fleksikan siku pasien 90 derajat
• Siku sedikit diangkat
• Ketuk tendon triseps dengan palu
• Respon :Kontraksi otot triseps dan ekstensi siku
• Bandingkan respon kedua sisi

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 REFLEKS BRAKIORADIALIS
• Lengan pasien diletakkan di samping badan
• Pemeriksa memegang lengan bawah pasien dan mengetukkan palu pada
pergelangan tangan
• Respon : Kontraksi brakioradialis dengan gerakan fleksi siku
• Bandingkan respon kedua sisi

Reflexes physiologis FM UNISBA 2015.ppt 07/07/20 29

 REFLEKS PATELLA
• Pemeriksa memfleksikan lutut pasien
dengan meletakkan tangan di bawah lutut
menahan tungkai pasien
• Pemeriksa memukulkan palu pada tendon
patella di lutut
• Respon : ekstensi tungkai bawah
• Bandingkan respon kedua sisi

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Reflexes physiologis FM UNISBA 2015.ppt 07/07/20 32
 REFLEKS TENDON ACHILLES

• Pemeriksa meletakkan salah satu tungkai pasien di atas tungkai lainnya

dan menekuk kaki pada pergelangan kakinya
• Dalam keadaan dorsofleksi, pemeriksa memukulkan palu pada tendon
Achilles
• Respon : plantar fleksi kaki

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Reflexes physiologis FM UNISBA 2015.ppt 07/07/20 34
REFLEKS SUPERFISIAL ABDOMEN

• Pasien membuka baju di daerah perut

• Pemeriksa menggores kulit dan abdomen secara lembut dengan dasar palu
dgn arah :
• Diagonal ke bawah
• Lateral ke medial (menuju garis tengah)

• Tempat goresan :
• Diatas umbilikus Kedua sisi
• Setinggi umbilikus abdomen
• Di bawah umbilikus

• Respon : kontraksi otot dinding abdomen berlawanan dengan arah

Reflexes physiologis FM UNISBA 2015.ppt 07/07/20 35
goresan
 REFLEKS ABDOMINAL

Reflexes physiologis FM UNISBA 2015.ppt 07/07/20 36

 REFLEKS SUPERFISIAL
EKSTREMITAS

EXTREMITAS ATAS EXTREMITAS BAWAH

• Refleks Palmar • Refleks Kremaster
• Refleks Scapular atau • Refleks Gluteal
Interscapular • Reflaks Plantar
• Refleks Anal
• Refleks Bulbokavernosus

07/07/20 37
PATHOLOGIC REFLEKS

BABINSKI REFLEKS
SCHAEFER REFLEKS
OPPENHEIM REFLEKS
GORDON REFLEKS
 COORDINATION
FINGER TO NOSE TEST
PRONATION-SUPINATION (RAPID ALTERNATING MOVEMENT)
HEEL TO KNEE TEST
TANDEM, AND
HEEL TO TOE
MENTATION (HIGHER CORTICAL FUNCTION)

EMOTIONAL STATE
SENSORIUM AND INTELECTUAL RESOURCES
(ORIENTATION, COMPREHENSION, INSIGHT, MEMORY,
LANGUAGE, ETC.)
CONTENT OF THOUGHT
STREAM OF MENTAL ACTIVITY
SUPPORTIVE MEASURES
LABORATORY : BLOOD AND URINE TEST
•COMPLETE BLOOD COUNT
•LIPID PROFILE
•RENALFUNCTION TES
•LIVER FUNCTION TEST, ETC

CSF EXAM (LUMBAL PUNCTURE)

NEURORADIOLOGY
INVASIVE : ANGIOGRAPHY, MYELOGRAPHY,
PNEUMO-ENCEPAHALOGRAPHY
NON-INVASIVE : SKULL/VERTEBRAE – X-RAY,
CT-SCAN, MRI, PET, SPECT
NEUROPHYSIOLOGY
EEG, EVOKED POTENTIAL STUDY, EMG,
NERVE CONDUCTION STUDY
MENTAL STATUS EXAMINATION
 MINI MENTAL STATUS
EXAMINATION (MMSE)
• Memberikan gambaran global mengenai fungsi kognisi
• Waktu pemeriksaan 10-15’
• Paling sering dipakai
• Kosistensi internal yang baik
• Test-retest reliability baik
• High validity: good sensitivity and specificity
• Dapat digunakan untuk membantu diagnosa, follow up efek
terapi
 PEMERIKSAAN STATUS MENTAL MINI (MMSE)
No Tes Bobot Skor
ORIENTASI
1 Sekarang (tahun), (musim), (bulan), (tanggal), hari apa? 5 ---
2 Kita berada dimana? (negara), (propinsi), (kota), (rumah sakit), (lantai/kamar) 5 ---
REGISTRASI
3 Sebutkan 3 buah nama benda ( Apel, Meja, Koin), tiap benda 1 detik, pasien 3 ---
disuruh mengulangi ketiga nama benda tadi.
ATENSI DAN KALKULASI
4 Kurangi 100 dengan 7. Nilai 1 untuk tiap jawaban yang benar. Hentikan 5 ---
setelah 5 jawaban. Atau disuruh mengeja terbalik kata “ WAHYU”
MENGINGAT KEMBALI (RECALL)
5 Pasien disuruh menyebut kembali 3 nama benda di atas 3 ---
BAHASA
6 Pasien disuruh menyebutkan nama benda yang ditunjukkan ( pensil, buku) 2 ---
7 Pasien disuruh mengulang kata-kata:” namun”, “ tanpa”, “ bila” 1 ---
8 Pasien disuruh melakukan perintah: “ Ambil kertas ini dengan tangan anda, 3 ---
lipatlah menjadi dua dan letakkan di lantai”.
9 Pasien disuruh membaca dan melakukan perintah “Pejamkanlah mata anda” 1 ---
10 Pasien disuruh menulis dengan spontan 1 ---
11 Pasien disuruh menggambar bentuk di bawah ini 1 ---
Total 30 ---
MMSE = MINI MENTAL
STATE EXAMINATION

PEJAMKAN MATA ANDA

 PENILAIAN MMSE

Nilai:
24 -30: Tidak ada gangguan kognitif
17 -23: Probable gangguan kognisi
0 - 16: Definite gangguan kognisi
 KETERBATASAN MMSE

• Dipengaruhi oleh tingkat pendidikan, usia dan

budaya

• Tidak dapat dipakai sebagai alat tunggal untuk

diagnosa demensia, harus dihubungkan dengan
pemeriksaan klinis
 MoCA MMSE
SENSITIFITA SPESIFISITA SENSITIFITA SPESIFISITA
S S S S
Nasreddine (2005) 90% 87% 68% 83%

Susan Folstein 1978 - 2011;

Godefroy (2011)
Marshal Folstein 1975 - Present 94% 76% 66% 97%

Larner (2012 97% 60% 62% 88%

MMSE
VS
MOCA
TERIMAKASIH
 SEMOGA PRESENTASI INI
MEMBERI MANFAAT BAGI KITA
SEMUA

TERIMAKASIH

Referat Farmakologi I/Alyatea 07/07/20 52

 NEUROLOGY : INTRODUCTION
 
TERM :
NEURO : NEURAL TISSUE
LOGOS : STUDY

THE STUDY OF NEURAL TISSUE BOTH

IN HEALTHY OR PATOLOGIC STATE.
NERVOUS SYSTEM
CONSIST OF :
CENTRAL NS
  TWO HEMIPHERES
  BRAIN STEM : MIDBRAIN, PONS, CEREBELLUM, MED.
OBLONGATA
  SPINAL CORD

PERIPHERAL NS
  CRANIAL NERVES
  NERVE ROOTS
  PERIPHERAL NERVES

AUTONOMIC NS
  SYMPATHETIC
  PARASYMPATHETIC
ETIOLOGY IN NEUROLOGIC DISORDERS :

TRAUMA : HEAD / SPINE TRAUMA

VASCULAR : STROKE
INFECTION : ENCEPHALITIS, MENINGITIS
TUMOUR
DEGENRATIVE PROCESS : PARKINSON,
DEMENTIA
IDIOPATHIC : EPILEPSY
CENTRAL NERVOUS SYSTEM

BRAIN  HEMISPHERES COVERED BY

CEREBRAL CORTEX

HIGHER CORTICAL FUNCTION

­PERCEPTION
­COGNITION
­MOTOR
DIENCEPHALON

•THALAMUS TRANSMISSION
INFORMATION
•HYPOTHALAMUS
SENSATION
•SUBTHALAMUS MOTOR
HOMEOSTASIS
•EPITHALAMUS
NERVOUS SYSTEM : FUNCTION

REGULATE VOLUNTARY OR INVOLUNTARILY

HUMAN’S BEHAVIOUR TO MAINTAIN LIFE

SENSATION : RECEIVE SENSATION FROM

ENVIRONMENT (SENSES)
VISION
HEARING
TASTE
SMELL
SOMESTETIC
BALANCE
 MOVEMENT :
­ OLUNTAIR
V
­INVOLUNTAIR

INTERNAL REGULATION
NEURAL INPUT  AUTONOM
ENDOCRINE  HORMONE

REPRODUCTION
 HORMONAL FUNCTION
 SPERM PRODUCTION (TESTIS)
OVUM PRODUCTION (OVARY)

ADAPTATION
SURVIVAL  ADAPT TO LEARNING
CONDITION
TO SOLVE PROBLEM BASED ON
PREVIOUS EXPERIENCES
NERVOUS SYSTEM

  RECEIVE SENSATION
RESPONSE TO EXTERNAL STIMULI
COORDINATE OTHE ORGANS TO MAINTAIN LIFE
STORE, ORGANIZE, RETRIEVE PRVIOUS EXPERIENCE

BASAL GANGLIA : TONE, MOVEMENT

CEREBELLUM : COORDINATION, TONE, MOVEMENT

BRAIN STEM : CRANIAL NERVE NUCLEI,

RECEIVE SENSORY INPUT FROM SKIN AND MUSCLES
IN HEAD AND NECK
  SPINAL CORD :

RECEIVE INPUT
FROM UPPER NEURON, EFECTOR

o    CERVICAL – 7 SEGMENTS

o    THORACAL – 12 SEGMENTS
o    LUMBAL – 5 SEGMENTS
o    SACRAL – 5 SEGMENTS