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PEMERIKSAAN KLINIS NEUROLOGIS

dr. Ahmad Muzayyin, Sp.S., M.Kes.

KESADARAN
Kuantitatif ------GCS Kualitatif : Tingkah laku: hipo, normo, hiperaktif aktif Perasaan hati: euforia, hipertimik, dll Orientasi : OWTS Jalan pikiran: logorhea,remming, flight, dll Kecerdasan : normal, RM Daya ingat kejadian : baik, amnesia

Penurunan kesadaran - GCS


Membuka Mata (Eye opening) Spontan Jika dipanggil Harus dengan rangsang sakit (dicubit) Tidak ada respon Respon verbal (Verbal response) Orientasi penuh Bicaranya setengah sadar Kata-kata sulit dimengerti Suara tidak jelas Tidak ada sama sekali Respon motorik (Motor response) Mengikuti perintah Dengan rangsang nyeri setempat Fleksi normal (Withdrawl) Fleksi abnormal (decorticate) Ekstensi (decerebrate) Tidak ada 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1

Fungsi Sensorik
Sensasi taktil Sensasi nyeri : superfisial/dalam Sensasi suhu Sensasi gerak & posisi Sensasi getar/fibrasi Sensasi tekan Sensasi diskriminasi : diskriminasi 2 titik, stereognosis, gramestesia

Pemeriksaan sensibilitas kulit :


waktu yang lama kesabaran dan ketelitian yang tinggi kerja sama yang baik dengan pasien sangat subyektif dan sulit dipertanggung jawabkan.

Pemeriksaan sensibilitas yang ideal :


obyektif sederhana mudah dikerjakan repeatable konsisten murah biayanya dapat dipertanggung-jawabkan hasilnya belum ada yang memenuhi semua sifat tsb

Ada macam-macam cara pemeriksaan sensibilitas sulit diperbandingkan hasilnya membingungkan perbedaan pendapat dalam menilai hasilnya. diperlukan yang bersifat lebih obyektif

Pemeriksaan sensibilitas rutin:


kapas rambut kuda jarum pentul

--->- sangat kasar dan subyektif - sulit dipertanggung jawabkan - test penyaring saja curiga ada gangguan : test lebih teliti

SARAF KRANIAL

Classification of cranial nerves


Sensory cranial nerves: contain only afferent (sensory) fibers
Olfactory nerve Optic nerve Vestibulocochlear nerve

Motor cranial nerves: contain only efferent (motor) fibers



Oculomotor nerve Trochlear nerve Abducent nerve Accessory nerve Hypoglossal nerve
Trigeminal nerve, Facial nerve, Glossopharyngeal nerve Vagus nerve

Mixed nerves: contain both sensory and motor fibers---

Nervus I (Olfactorius)
Fungsi pembauan/penciuman

Nervus II (Opticus)
Daya penglihatan Medan penglihatan Pengenalan warna Fundus okuli : papil retina arteri /vena perdarahan

Nervus II (Opticus)

Nervus II (Opticus)

Nervus III (Oculomotorius)


Ptosis Gerak mata (atas, bawah, medial) Reflek cahaya langsung & konsensuil Reflek akomodatif Ukuran pupil Strabismus divergen Diplopia Bentuk pupil

Nervus IV (Trochlearis)
Gerak mata ke lateral bawah Strabismus konvergen Diplopia

Nervus V (Trigeminus)
Menggigit Membuka mulut Trismus Reflek : kornea, bersin, maseter, zigomatikus Sensibilitas muka (tengah, atas, bawah)

Nervus V (Trigeminus)

Nervus VI (Abducens)
Gerak mata ke lateral Strabismus konvergen Diplopia

Nervus VI (Abducens)

Nervus VII (Facialis)


Mengerutkan dahi & kerutan kulit dahi Menutup mata & kedipan mata Meringis, lipatan naso-labial, sudut mulut Mengembungkan pipi, bersiul Tiks fasial Lakrimasi

Nervus VII (Facialis)


Daya kecap lidah 2/3 depan Reflek : visuo-palpebral, glabella, aurikulopalpebral Tanda Myerson Tanda Chovstek

Nervus VII (Facialis)

Nervus VIII (Acusticus)


Mendengar suara berbisik Mendengar detik arloji Tes Rinne Tes Schwabach Tes Weber

Nervus IX (Glosopharingeus)
Arkus farings sengau Daya kecap lidah 1/3 belakang Reflek muntah - tersedak

Nervus X (Vagus)
Arkus farings Menelan Bersuara Nadi

Nervus X (Vagus)

Nervus XI (Acesorius)
Memalingkan kepala Mengangkat bahu Sikap bahu Trofi otot bahu

Nervus XII (Hipoglosus)


Sikap lidah Menjulurkan lidah Kekuatan lidah Artikulasi Trofi otot lidah Tremor lidah Fasikulasi lidah

Variabel Kekuatan
Gerakan Trofi Tonus Klonus Refleks Fisiologis Refleks Patologis

UMN/SPASTIC 0
Terbatas 0 Normal Normal Hiper (+) (-) (+) hiper (+)

LMN/FLACCID 0
Terbatas 0 Hipo atrofi Hipo (-) Hipo (-) (-)

KEKUATAN
0 1 2 3 4

ARTI KLINIS
Tidak ada kontraksi, tidak ada gerakan Ada kontraksi, tidak ada gerakan Ada kontraksi, ada gerakan tanpa melawan gravitasi (geser) Ada gerakan melawan gravitasi tanpa beban/tahanan Ada gerakan melawan gravitasi dengan beban atau tahanan terbatas

Normal

ATROFI: Hilangnya atau mengecilnya bentuk otot disebabkan musnahnya serabut otot
ATROFI: Neurogenic : lemah mengecil Miogenic : mengecil lemah Inaktifitas : (disuse atrofi) hilangnya Sarcoplasma

TONUS : Tahanan otot sehat, normal pada waktu sehat Syarat : Pasien tenang, periksa dengan tenang, tangan tidak dingin 1. Tes kepala jatuh 2. Tes lenggang lengan 3. Tes goyang tangan 4. Tes lengan jatuh 5. Tes goyang tungkai 6. Tes tungkai jatuh

REFLEKS : JAWABAN SPONTAN TERHADAP SUATU RANGSANGAN TEKNIK PENGETUKAN: Gerakan tangan bukan lengan Tepat pada tendon, direct-indirect Simetris Intensitas Santai tidak tegang

Refleks Superfisial adalah gerakan reflektorik yang timbul sebagai respon atas stimulasi terhadap kulit atau mukosa. Berbeda dengan refleks dalam, refleks superfisial tidak saja mempunyai busur refleks yang segmental melainkan mempunyai komponen supraspinal juga.

REFLEKS PATOLOGIS :

Refleks-refleks yang tidak dapat dibangkitkan pada orang sehat kecuali bayi

Bentuk vertebra

Bentuk vertebra

Bentuk vertebra

Test Provokasi Nyeri


Valsava test Naffziger test Lhermittes test Laseque test OConnel test Patrick test Kontra Patrick test Gaenselen test

Test Meningeal sign


Kernig sign Brudzinski I Brudzinski II Brudzinski III Brudzinski IV

Bell Palsy

Background
Bell's palsy is a unilateral, peripheral facial paresis or paralysis that has an abrupt onset & no detectable cause. One of the most common neurologic disorders affecting the cranial nerves First described in 1821, by the Scottish anatomist & surgeon Sir Charles Bell, much controversy still surrounds its etiology & management.

Pathophysiology
Actual pathophysiology is unknown; this is an area of interminable debate. A popular theory champions inflammation of the facial nerve. During this process, the nerve increases in diameter and becomes compressed as it courses through the temporal bone.

Anatomy
The facial nerve (seventh cranial nerve) has 2 components. The larger portion comprises efferent fibers that stimulate the muscles of facial expression. The smaller afferent portion contains taste fibers to the anterior two thirds of the tongue, secretomotor fibers to the lacrimal and salivary glands, and some pain fibers.

Anatomy

Anatomy

Anatomy

Causes
Remains unclear, although vascular, infectious, genetic, & immunologic causes have all been proposed. Patients with other diseases or conditions sometimes develop a peripheral facial nerve palsy, but these are not classified as Bell palsy.

Causes
Viral infections: Herpes simplex :HSV-1; HSV-2; Human herpes virus (HHV); varicella zoster virus (VZV); Mycoplasma pneumoniae; Borrelia burgdorferi; influenza B; adenovirus; coxsackievirus; Ebstein-Barr virus; hepatitis A, B, and C; cytomegalovirus (CMV); and rubella virus.

Causes
Pregnancy: Bell palsy is uncommon in pregnancy; however, the prognosis is significantly worse in pregnant women with Bell palsy than among nonpregnant women with palsy. Genetics: Recurrence rates (4.5-15%) and familial incidence (4.1%) have been addressed in various studies. Genetics may have a role in Bell palsy, but which factors are inherited is unclear.

Lab Studies
No specific laboratory tests exist. Complete blood count, Erythrocyte sedimentation rate, Thyroid function, glucose level, Rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test, Human immunodeficiency virus (HIV), CSF analysis, IgM, IgG, IgA titers for CMV, rubella, HSV, hepatitis A, hepatitis B, hepatitis C, Dll

Imaging Studies
Bell palsy remains a clinical diagnosis. Imaging studies are not indicated in the ED. Excluding other causes of facial palsy may require one of the following imaging studies depending on clinical setting.

Other Tests
Electrodiagnosis of the facial nerve: These studies assess the function of the facial nerve. These tests are rarely performed on an emergent basis. Electromyography (EMG) Electroneurography (ENoG) compares evoked potentials on the paretic side versus the healthy side.

Treatment
Steroids : remains controversial. Numerous research articles have been written on the benefit or uselessness of steroids to treat patients with Bell palsy. Antiviral agents: Although there is insufficient research evaluating the efficacy of antiviral medicines in Bell palsy, most experts believe in a viral etiology. Eye care

Treatment

Treatment

Prognosis
Group 1 regains complete recovery of facial motor function without sequelae. Group 2 experiences incomplete recovery of facial motor function, but no cosmetic defects are apparent to the untrained eye. Group 3 experiences permanent neurologic sequelae that are cosmetically and clinically apparent.

Prognosis
Most patients develop an incomplete facial paralysis during the acute phase. This group has an excellent prognosis for full recovery. Patients demonstrating complete paralysis are at higher risk for severe sequelae. Of patients with Bell palsy, 85% achieve complete recovery. Ten percent are bothered by some asymmetry of facial muscles, while 5% experience severe sequelae.