Status Examination Neurology Anamnesis
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Usually taking Anamnesis follows two General Patterns, namely :
Taking a good Anamnesis Combine the two ways mentioned above.Interviews with patients usually begins by asking the name, age, occupation, address. Then ask the main complaint, that complaint which encourages patients come to see the doctor. In each complaint or abnormality worth exploring :
- Since when starting
- The nature and severity of
- Location and Spread.
- Relation to time (morning, noon, night, sleeping, time period, after eating, etc.)
- Another complaint that has to do with the complaint
- Previous treatment and how the results
- Factors that make a complaint heavier or lighter
- Travel complaints, whether sedentary, gain weight, grow light, comes in the form of attack, and so forth.
1. Headache : Do you suffer from headaches? How nature, in the form of an attack or is it constant? Where is it located? Are progressive, more and more severe or more frequent? Is to interfere with daily activities?
2. Vomiting : Is accompanied by nausea or not? Is this sudden vomiting, suddenly, as if the stomach contents dumped out (Projectile)?
3. Vertigo : Have you ever felt as if you are moving around, spinning or you feel yourself moving or spinning? Is it something to do with the sense of a change in attitude? Is accompanied by nausea or vomiting? Is accompanied by tinnitus (Ringing in the ears, Hhissing)?
4. Perception Disorders (Visual Acuity) : Is your visual acuity decreased in one or both eyes? Do you see the double (Diplopia)?
5. Hearing : Are there any changes in your hearing? Is there tinnitus (ringing noise / hiss in the ear)?
6. Nerves Brain : Is there interference smell, taste, salivation (saliva expenses), lacrimation (tear expenses), and the feeling in the face? Is there a weakness in the facial muscles? Is the speech so slurred and pelo? Did you change your voice so hoarse, or bindeng (dysphonia), or so shrink / disappear (afonia)? Is the speech so slurred and pelo (dysarthria)? Is it hard to swallow (dysphagia)?
7. Noble Function : What about memory? Are you so forgetful? Are you content to be difficult to express your thoughts (dysphasia, motor aphasia) or to understand the speech of others (dysphasia, sensory aphasia)? How about the ability to read (aleksia)? Would be difficult to read, and understand what you read? How about the ability to write, is the ability to write changes, writing changed?
8. Awareness : Have you ever suddenly lost consciousness, not knowing what is going on around you? Have you ever felt weak and like mendada like fainting (syncope)?
9. Motor : Is there any part of your body becomes weak, or lame (hands, arms, feet, legs)? How nature, relapsing-remitting, settled or reduced?
10. Do you become deft movement? Is there any movement on the part of the body or limb loss abnormal and you can not control (khorea, tremor, tick)?
11. Sensibility : Is there any change or disturbance in the sense of the body or limb? Is there a sense of numbness, tingling, stabbing, like burnt? Where is it? Is there a sense of the spread?
12. The autonomic nervous : How urination (micturition), bowel movement (defecation) and sexual desire (libido) you? Are there any retained or inkontinesia urine or alvi?
Physical Examination
• General Examination- Sensorium (awareness)
The level of consciousness is divided into a number of which are :• Normal: compost mentis
• somnolence: The state of drowsiness. Awareness can be fully recovered when stimulated. Somnolence also called lethargy. The level of consciousness is characterized by easy dibangungkan patient, able to give a verbal answer and deflect pain stimuli.• Sopor (stupor): Sleepiness deep. Patients can still be woken up by strong stimuli, but the realization soon dropped again.
He was still able to follow the messenger that is short and still look spontaneous movement. With the patient's pain stimuli can not be woken up perfectly. Reactions to command inconsistent and vague. Can not be obtained from the patient's verbal response. Motion motor to fend off pain stimuli still good.• Coma - light (semi-coma): In this situation there is no response to verbal stimuli. Reflexes (cornea, pupil, etc.) is still good. The movement arose primarily as a response to pain stimuli. Patients can not be woken.Comma (in or complete): No spontaneous movement. There is no answer at all to stimuli howsoever pain.
• Glasgow Coma ScaleTo keep track of the level of consciousness can be used the Glasgow coma scale attention responses (response) patients to stimuli and provide value to the response. Response / patient responses to note are:
Opening Eyes• Spontaneous 4• Against talktime of 3• With two pain stimuli• No reaks 1
Verbal response (speech)• Good and no disorientation 5• Disorderly ("confused") 4• Not exactly 3• Moaning 2• No answer 1
Motor response (movement)• Obeying 6• Knowing the location of pain 5• Reaction dodge 4• flexion reflex (decortication) 3• extension reflex (deserebrasi) 2• No reaction 1o Blood Pressureo Frequency pulseo Frequency of breatho Temperature
Neurological Examination
Head and Neck- Shape : symmetrical or asymmetrical- Fontanella : closed or not- Transillumination
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Artikel Status Examination Neurology Anamnesis diposting oleh Blog-Health Tuesday, June 26, 2012. Terima kasih atas kunjungannya. Mohon Di Share Melalui Widget dibawah ini :
