UTOYO SUNARYO

Assessment

History Physical Examination

Vital Signs Heigher functions Level of Consciousness Meningens Cranial Nerves Motor Functions Sensory Functions Reflexes Cerebellum signs and coordination Gait and speech. Involuntary movements

Diagnostic Tests Imaging Procedures CT Scan MRI PET Lumbar Puncture Contrast Studies Electroencephalogram Brain Scan Electromyography Nerve Conduction Studies Echoencephalography

Tools requiredTools required Stethoscope, gloves, tongue depressorsStethoscope, gloves, tongue depressors an ophthalmoscope,an ophthalmoscope, a reflex hammer, anda reflex hammer, and a tuning fork.a tuning fork. a pina pin

PEMERIKSAAN FUNGSI LUHUR

Higher functionsHigher functions

Mental statusMental status

MINI MENTAL STATUS EXAMINATIONMINI MENTAL STATUS EXAMINATION( MMSE)( MMSE)

Mental StatusMental Status Level of Alertness, attention and cooperation :Level of Alertness, attention and cooperation :spelling, digit span, name of the months, forwardspelling, digit span, name of the months, forwardand backwardand backward

Orientation : full name, date (d/m/y), locationOrientation : full name, date (d/m/y), location Memory : repeat 3 words after 3Memory : repeat 3 words after 3 --5 minutes5 minutes Language : spontaneous speech, comprehension,Language : spontaneous speech, comprehension,naming, repetition, reading and writingnaming, repetition, reading and writing

ComprehensionComprehension

Mental StatusMental Status Calculation, RCalculation, R--L confusion, Finger agnosia,L confusion, Finger agnosia,agraphiaagraphia

ApraxiaApraxia Neglect and ConstructionNeglect and Construction Sequencing tasks and Frontal release signsSequencing tasks and Frontal release signs

ApraxiaApraxia

NeglectNeglect andand ConstructionsConstructions

Constructions

Mental StatusMental Status Logic and abstractionLogic and abstraction

Apa persamaan apel dengan pisang ?Apa persamaan apel dengan pisang ? Apa persamaan mobil dengan perahu ?Apa persamaan mobil dengan perahu ? Bila Jane lebih tinggi dibandingkan Marry, danBila Jane lebih tinggi dibandingkan Marry, danMary lebih tinggi dibandingkan Anne. SiapakahMary lebih tinggi dibandingkan Anne. Siapakahyang tertinggi diantara mereka ?yang tertinggi diantara mereka ?

Delusions and hallucinationsDelusions and hallucinations MoodMood

Mental statusMental status MemoryMemory OrientationOrientation time, place, and persontime, place, and person IntelligenceIntelligence Vocabulary, fund of knowledge, calculations (Vocabulary, fund of knowledge, calculations ( egeg,,

serialserial--7 calculations), abstraction (7 calculations), abstraction ( egeg, use of proverbs), and judgment, use of proverbs), and judgment((egeg, what to do with a found wallet), what to do with a found wallet)

Psychological disturbancesPsychological disturbances thought process (thought process (egeg,,circumstantialitycircumstantiality ); of perception (); of perception (egeg, illusions and hallucination); or of, illusions and hallucination); or ofthought content (thought content (egeg, grandeur)., grandeur).

VITAL SIGN

GLASGOW COMA SCALE

MENINGEAL SIGNS

MeningealMeningeal signssigns NuchalNuchal rigidityrigidity TheThe BrudzinskiBrudzinski signsign

BrudzinskiBrudzinski II BrudzinskiBrudzinski IIII

TheThe KernigKernig signsign

PEMERIKSAAN SARAF KRANIALIS

Cranial NervesCranial Nerves Olfactory nerveOlfactory nerve -- CN ICN I

N. IN. I

N. IIN. II Optic nerveOptic nerve -- CN IICN II

Acuity, by using theAcuity, by using the SnellenSnellen chart (near andchart (near anddistant vision)distant vision)

Visual fields, by means of confrontation orVisual fields, by means of confrontation orperimetryperimetry if indicatedif indicated

Color, with use of an Ishihara chart or by usingColor, with use of an Ishihara chart or by usingcommon objectscommon objects

FunduscopyFunduscopy

Visual AcuityVisual Acuity

TestTest LapanganLapangan PandangPandang ((TesTesKonfrontasiKonfrontasi))

Anatomy of Visual PathwayAnatomy of Visual Pathway1.1. Optic nerveOptic nerve2.2. Optic chiasmaOptic chiasma3.3. Optic tractOptic tract4.4. Lateral geniculate bodyLateral geniculate body5.5. Optic radiationOptic radiation6.6. Visual cortexVisual cortex7.7. Superior colliculus of the midbrainSuperior colliculus of the midbrain8.8. PutamenPutamen9.9. Long association bundleLong association bundle -- inferiorinferior

occipitofrontal fasciculusoccipitofrontal fasciculus10.10. Pulvinar of the thalamusPulvinar of the thalamus11.11. Calcarine fissureCalcarine fissure12.12. Posteroinferior horn of the lateralPosteroinferior horn of the lateral

ventricleventricle

FunduscopyFunduscopy

CN IIICN III -- CN IVCN IV -- CN VICN VI OculomotorOculomotor nervenerve -- CN IIICN III

pupillarypupillary constrictors;constrictors; thethe levatorlevator palpebraepalpebrae superiorissuperioris;; the superior, inferior, and medialthe superior, inferior, and medial rectirecti; and; and the inferior oblique muscles.the inferior oblique muscles.

TrochlearTrochlear nervenerve -- CN IVCN IV superior oblique musclesuperior oblique muscle

AbducensAbducens nervenerve -- CN VICN VI the lateralthe lateral rectusrectus

TesTes Ocular MotilityOcular Motility

CN VCN V Trigeminal nerveTrigeminal nerve -- CN VCN V

ophthalmic; V1ophthalmic; V1 maxillary; V2maxillary; V2 MandibularMandibular; V3; V3

SensorySensory

MotorikMotorik

CN VIICN VII MotorikMotorik otototot--otototot wajahwajah KelenjarKelenjar LakrimalisLakrimalis KelenjarKelenjar SalivaSaliva PengecapanPengecapan 2/32/3 depandepan lidahlidah N.N. StapediusStapedius -->> HyperacusisHyperacusis

MotorikMotorik N. VIIN. VII

PareseParese N. VIIN. VII periferperifer

CN VIIICN VIII Hearing and Vestibular functionsHearing and Vestibular functions Hearing Function:Hearing Function:

Weber TestWeber Test RinneRinne TestTest SchwabachSchwabach TestTest

Vestibular Function:Vestibular Function: Romberg TestRomberg Test

TesTes PendengaranPendengaran

Weber TestWeber Test

RinneRinne TestTest

C IXC IX SensorySensory innervationinnervation of the posterior third ofof the posterior third ofthe tongue and the pharynx.the tongue and the pharynx.

Loss of taste in the posterior third of theLoss of taste in the posterior third of thetongue and loss of pain and touch sensationstongue and loss of pain and touch sensationsin the same area, soft palate, and pharyngealin the same area, soft palate, and pharyngealwallswalls

Pharyngeal musculature, particularly thePharyngeal musculature, particularly thestylopharyngeusstylopharyngeus , in concert with the, in concert with the vagusvagusnerve.nerve.

CN IXCN IX CN XCN X The pharyngeal gag reflex : tongue retractionThe pharyngeal gag reflex : tongue retractionand elevation and constriction of theand elevation and constriction of thepharyngeal musculature in response topharyngeal musculature in response totouching the posterior wall of the pharynx,touching the posterior wall of the pharynx,tonsillartonsillar area, or base of the tonguearea, or base of the tongue

The palatal reflex : elevation of the soft palateThe palatal reflex : elevation of the soft palateandand ipsilateralipsilateral deviation of the uvula ondeviation of the uvula onstimulation of the soft palatestimulation of the soft palate

AnatomyAnatomy

PareseParese N.IX yangN.IX yang manamana ??

PareseParese N. IX yangN. IX yang manamana ??

CN XICN XI When the right SCM is weak, pushing to theWhen the right SCM is weak, pushing to theopposite (opposite ( ieie, left) side is impaired, and vice, left) side is impaired, and viceversa.versa.

Shrugging of the shoulder is impairedShrugging of the shoulder is impairedipsilaterallyipsilaterally when thewhen the trapeziustrapezius is weak.is weak.

N. XIN. XI

CN XIICN XII It provides motorIt provides motor innervationinnervation for all thefor all theextrinsic and intrinsic muscles of the tongueextrinsic and intrinsic muscles of the tongueexcept theexcept the palatoglossuspalatoglossus..

To test the hypoglossal nerve, have theTo test the hypoglossal nerve, have thepatient protrude the tongue; when paralyzedpatient protrude the tongue; when paralyzedon 1 side, the tongue deviates to the side ofon 1 side, the tongue deviates to the side ofparalysis on protrusionparalysis on protrusion

N. XIIN. XII

N. XIIN. XII

PareseParese N. XIIN. XII kanankanan

PEMERIKSAAN MOTORIK

Motor systemMotor system TrophicTrophic statestate ::

33 SSs: size, shape, and symmetrys: size, shape, and symmetry Muscle toneMuscle tone

HypotoniaHypotonia HypertoniaHypertonia : Clasp: Clasp--knife,knife, paratoniaparatonia ((gegenhaltengegenhalten),),cogcog--wheel, leadwheel, lead--pipepipe

Size, Shape,Size, Shape, SymetrySymetry

Size, Shape,Size, Shape, SymetrySymetry

Hemiparese, Tetraparese, ParapareseKekuatan :

0 = tidak terlihat kontraksi1 = terlihat kontraksi tetapi tidak ada

gerakan pada sendi2 = ada gerakan pada sendi, tidak dapat

melawan gaya gravitasi (bergeser)3 = bisa melawan gravitasi, tidak dapat

melawan tahanan4 = bisa bergerak melawan tahanan tetapi

berkurang kekuatannya5 = kekuatan normal

SKALA PEMERIKSAAN MOTORIK

The deltoid muscle isThe deltoid muscle isinnervated by the C5 nerve rootinnervated by the C5 nerve rootvia thevia the axillaryaxillary nervenerve

Pronator Drift, Lesi UMNPronator Drift, Lesi UMN

The biceps muscle is innervated by theThe biceps muscle is innervated by theC5 and C6 nerve roots via theC5 and C6 nerve roots via themusculocutaneousmusculocutaneous nerve.nerve.

The triceps muscle is innervated byThe triceps muscle is innervated bythe C6 and C7 nerve roots via thethe C6 and C7 nerve roots via theradial nerve.radial nerve.

The wrist extensors are innervatedThe wrist extensors are innervatedby C6 and C7 nerve roots via theby C6 and C7 nerve roots via theradial nerveradial nerve

Finger flexion is innervated byFinger flexion is innervated bythe C8 nerve root via thethe C8 nerve root via themedian nerve.median nerve.

Finger abduction or "fanning" isFinger abduction or "fanning" isinnervated by the T1 nerve root viainnervated by the T1 nerve root viathethe ulnarulnar nervenerve

Thumb opposition is innervated byThumb opposition is innervated bythe C8 and T1 nerve roots via thethe C8 and T1 nerve roots via themedian nervemedian nerve

PEMERIKSAAN SENSORIK

Sensory systemSensory system NoncorticalNoncortical sensory systemsensory system

Light touch,Light touch, pain,pain, heat, cold, andheat, cold, and vibration sensationsvibration sensations

Cortical sensory systemCortical sensory system Position sensationPosition sensation StereognosisStereognosis -- AStereognosisAStereognosis GraphesthesiaGraphesthesia -- AGraphesthesiaAGraphesthesia

Pain, Light touchPain, Light touch

PropioceptionPropioception

VibrationVibration

MonofilamentMonofilament

PEMERIKSAAN REFLEKS

ReflexesReflexes Primitive reflexesPrimitive reflexes

glabellarglabellar tap,tap, snout,snout, sucking, andsucking, and palmomentalpalmomental reflexesreflexes

Superficial reflexesSuperficial reflexes corneal,corneal, conjunctivalconjunctival ,, abdominal,abdominal, cremastericcremasteric,, anal wink, andanal wink, and plantar (plantar (BabinskiBabinski) reflexes.) reflexes.

Deep tendon reflexesDeep tendon reflexes

PEMERIKSAAN CEREBELLUM DANKOORDINASI

CerebellarCerebellar signssigns Ataxia,Ataxia, Intention tremorIntention tremor DyssynergiaDyssynergia ((incoordinationincoordination)) DysmetriaDysmetria DysrhythmiaDysrhythmia DysdiadochokinesisDysdiadochokinesis DysarthriaDysarthria (staccato or scanning speech)(staccato or scanning speech)

CoordinationCoordination Finger to NoseFinger to Nose Heel to KneeHeel to Knee Rapid alternating movementRapid alternating movement Fine motorFine motor RombergRombergs signs sign

PEMERIKSAAN CARA BERJALAN DANBICARA

GaitGait HemipareticHemiparetic gaitgait Ataxic gaitAtaxic gait Shuffling gait /Shuffling gait / parkinsonparkinson gaitgait SteppageSteppage gaitgait Spastic or scissor gaitSpastic or scissor gait AntalgicAntalgic gaitgait Waddling gaitWaddling gait

SpeechSpeech DysphoniaDysphonia oror aphoniaaphonia DysarthriaDysarthria oror anarthriaanarthria Dysphasia or aphasiaDysphasia or aphasia

PEMERIKSAAN GERAKAN INVOLUNTER

Involuntary movementsInvoluntary movements Fibrillations are not visible to the naked eyeFibrillations are not visible to the naked eyeexcept possibly those in the tongue.except possibly those in the tongue.

FasciculationsFasciculations may be seen under the skin asmay be seen under the skin asquivering of the musclequivering of the muscle

AsterixisAsterixis TicsTics MyoclonusMyoclonus is a muscle jerk; it is a brief (

DystoniasDystonias are muscle contractions that areare muscle contractions that aremore prolonged thanmore prolonged than myoclonusmyoclonus and result inand result inspasms (spasms (blepharospasmblepharospasm, spasmodic, spasmodictorticollistorticollis,, oromandibularoromandibular dystoniadystonia,,spasmodicspasmodic dysphoniadysphonia, and writer's cramp)., and writer's cramp).

ChoreaChorea--AthetosisAthetosis BallismusBallismus

DIAGNOSTIC TEST

Spike, generalized. Note the high amplitude, and the aftergoing backgroundsuppression and slow wave.

LUMBAL PUNGSI

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