semiologia neurológica matheus
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aula semiologia neurologicaTRANSCRIPT
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SEMIOLOGIA DO SISTEMA NERVOSO
MATHEUS FELIPE B. LOPESMEDICINA - UNIMONTES
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REPERTÓRIO NOSOLÓGICO DO SNC
DOENÇAS: DOENÇAS:
• CONGÊNITAS• INFECCIOSAS• NEOPLÁSICAS• VASCULARES• METABÓLICAS• TÓXICAS• TRAUMA• DESMIELINIZANTES• DEGENERATIVAS
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EFEITOS DE QUALQUER LESÃO NEURAL•PERDA OU DÉFICIT DA CAPACIDADE
FUNCIONAL•LIBERAÇÃO OU DESINIBIÇÃO DE
FUNÇÃO•IRRITAÇÃO OU EXCITAÇÃO
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ANAMNESE
•IDENTIFICAÇÃO•NOME•SEXO•IDADE•PROCEDÊNCIA:
ESQUISTOSSOMOSE MENINGITES ENCEFALITES NEUROCISTICERCOSE ETC...
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ANAMNESE
QUEIXAS FREQUENTES:
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ANAMNESE•HMA: DETALHAR CADA QUEIXA/SINTOMA:• INÍCIO, LOCALIZAÇÃO, DURAÇÃO,
INTENSIDADE, TIPO, FREQUENCIA, IRRADIAÇÃO, FATORES DESENCADEANTES, AGRAVANTES, ATENUANTES
•HP: Infecções, hipóxia, trauma, transtornos psiquiátricos, meningite, internações, cirurgias
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•HF: ▫Consaguinidade▫Distrofias▫Demências▫Cefaléia▫Epilepsia▫Parkinson▫AVC, HAS, DM, etc...
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•HS: Profissão, residência, intoxicações, álcool, tabagismo, drogas.
•ISDA.
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PRINCIPAIS QUADROS DOLOROSOS EM NEUROLOGIA
• DOR NEUROPÁTICA• DO MEMBRO AMPUTADO• FANTASMA• CAUSALGIA: lesão parcial de um nervo >>>
hipersensibilidade cutânea com exacerbação simpática
• NEURALGIA DO TRIGÊMIO• NEURALGIA DO GLOSSOFARÍNGEO
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• DOR FACIAL ATÍPICA• NEURALGIA OCCIPITAL• CEFALÉIA TENSIONAL• ENXAQUECA• CEFALÉIA PÓS-TRAUMÁTICA• SÍNDROME DO TÚNEL DO CARPO• MERALGIA PARESTÉSICA• CERVICOBRAQUIALGIA• LOMBOCIATALGIA
PRINCIPAIS QUADROS DOLOROSOS EM NEUROLOGIA
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OUTRAS QUEIXAS NEUROLÓGICAS• DISTÚRBIOS VISUAIS:
– ESCOTOMAS– DIMINUIÇÃO DA ACUIDADE– DIMINUIÇÃO DO CAMPO VISUAL– DIPLOPIA– AMAUROSE FUGAZ
• DISTÚRBIOS DO MOVIMENTO:– HIPO/HIPERCINÉTICOS
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•DISTÚRBIOS AUDITIVOS:▫ZUMBIDOS▫DIMINUIÇÃO DA ACUIDADE▫ALUCINAÇÕES AUDITIVAS
•DISTÚRBIOS DE OUTROS NC:▫OLFATO, PALADAR, SIALORRÉIA,
PARALISIA FACIAL, DISARTRIA, DISFAGIA E REGURGITAÇÃO
OUTRAS QUEIXAS NEUROLÓGICAS
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•SINTOMA/SINAIS AUTONÔMICOS▫SUDORESE, VASOMOTORES,
IMPOTÊNCIA, DISTURBIOS DA MICÇÃO/DEFECAÇÃO
•DISTÚRBIOS DA LINGUAGEM:▫DA COMPREENSÃO▫DA EXPRESSÃO▫AFASIAS
OUTRAS QUEIXAS NEUROLÓGICAS
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ANAMNESE
•EXEMPLO•HOMEM DE 30ANOS É LEVADO AO PS E
A IRMÃ INFORMA QUE ELE TEVE UMA “CONVULSÃO”
•O QUE É IMPORTANTE QUESTIONAR?
PRÓDROMOSFATORES PRECIPITANTESAURACOMPONENTES DA CRISEFENÔMENOS PÓS-ICTAISFREQUENCIA MEDICAMENTOS
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EXAME FÍSICO
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ESTADO MENTAL• Consciência: resposta verbal e motora ao
comando e estimulação dolorosa• Orientação: dados pessoais, tempo, espaço• Atenção: repetir palavras e números• Memória: recente e remota• Humor: observar fisionomia, atitude e reações
emocionais• Linguagem: compreensão e expressão• Praxia: execução de gestos e atos motores• Gnosia: reconhecimento de objetos, partes do
corpo e sons
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ALTERAÇÃO DO SENSÓRIO• A 24-year-old male graduate student is brought into the ER
following a two-vehicle MVA. He is on a backboard and has obvious bruises and lacerations to his head and extremities. On exam,
• he does not respond to either conversation or even shaking. He does arouse to a deep sternal chest rub and mumbles incoherently. When the stimulus ceases, he lapses back into an unresponsive state. What level of consciousness best describes his response?
• (A) Lethargic• (B) Obtunded• (C) Stuporous• (D) Comatose
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EXAME FÍSICO
•ECTOSCOPIA•EXAME GERAL•EXAME NEUROLÓGICO
▫CONSCIÊNCIA▫NERVOS CRANIANOS▫MOTRICIDADE▫COORDENAÇÃO▫SENSIBILIDADE▫MARCHA
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INSPEÇÃO
• Kayser-Fleischer ring. Wilson's disease is an autosomal recessive disorder of copper metabolism that can present with hepatic failure, psychiatric or personality disorder, or neurologic signs, including dysarthria, dystonia, rigidity, and tremor. Serum ceruloplasmin and urinary copper levels are elevated, and hepatic copper level is increased. The abnormality is the golden brown ring contrasted against the blue-gray iris bilaterally. (From Finelli [6]; with permission.)
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NEUROFIBROMATOSE
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Patient with dermatomyositis.There is evidence of ahyperememic rash on the upperchest, face and palm
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Sturge-weber Syndrome
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PELAGRA
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DISTROFIA MIOTÔNICAA patient with myotonic dystrophy who has the typical symptoms of muscle wasting, ptosis, and frontal balding. Myotonic dystrophy is a relatively common form of muscular dystrophy. It can present in children and adults and is inherited as an autosomal dominant trait. The characteristic myotonic discharges correlate with clinical myotonia. Weakness is also a feature of myotonic dystrophy and often affects distal as well as proximal muscles. Other features common in adults with myotonic dystrophy include cataracts, testicular atrophy, and an organic mental syndrome. Skeletal muscle biopsy usually shows nonspecific myopathic changes
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TCE
Battle's Sign Raccoon Eyes
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Inferior Rectus Entrapment The inferior rectus muscle is entrapped within the blowout fracture. When the patient tries to look upward, the affected eye has limited upward gaze. The patient experiences diplopia with this maneuver. (Courtesy of Lawrence B. Stack, MD.)
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MOTRICIDADE• EXAME DA FUNÇÃO
MOTORA:▫ MOTRICIDADE
VOLUNTÁRIA▫ AUTOMÁTICA▫ TÔNUS E REFLEXOS▫ COORDENAÇÃO▫ EQUILÍBRIO
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Generalized myastheniaGeneralized myastheniagravis, key features. A Ptosis B Attempted gaze to the right.Only right eye abducts incompletely. C Demonstrates proximalweakness upon attempt toraise the arms. D Holding thearms and fingers extended the extensor muscles weaken andfinger drop occurs’
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MOTRICIDADE• MOVIMENTOS
ESPONTÂNEOS OU ATIVOS
• FORÇA MUSCULAR SEGMENTAR
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CONTINUA...
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MANOBRAS DE SENSIBILIZAÇÃO OU PARA TESTAR DÉFICITS•MANOBRA DOS BRAÇOS ESTENDIDOS•MANOBRA DE MINGAZZINI•MANOBRA DE BARRÉ•MANOBRA DO PÉ: IMPORTANTE NO
PACIENTE EM COMA
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Test extension at the knee (L2, L3, L4—quadriceps).
Test flexion at the knee (L4, L5, S1, S2—hamstrings)
Test flexion at the hip (L2, L3, L4—iliopsoas)
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Test dorsiflexion (mainly L4, L5) and plantar flexion (mainly S1)
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A boy with Duchenne muscular dystrophy (DMD) demonstrating pseudohypertrophy of his calves and a positive Gower's maneuver (climbing from a sitting position because of proximal muscle weakness). DMD is the most common inherited form of muscle disease
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EXAME DOS NC
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Oculomotor nerve paresis:A Complete ptosis; B Uponlifting of the lid lateral deviationof left bulbus. Pupillary dilatation(mydriasis) signals theparasympathetic fibers for thesphincter pupillae are affected
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MOTRICIDADE: INSPEÇÃO, PALPAÇÃO, MANOBRAS•PESQUISA DE MOVIMENTOS
ANORMAIS▫BRADICINESIA▫CORÉIA▫DISTONIA▫TREMOR DE REPOUSO▫TREMOR DE MOVIMENTO
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REFLEXOS• MUSCULARES PROFUNDOS OU
MIOTÁTICOS– BOA TÉCNICA;– MÚSCULO, TENDÕES, OSSOS– VARIAÇÕES FISIOLÓGICAS.
• Obs: assimetria é patológica.– GRADUAÇÃO:
• 0: ABOLIÇÃO 1-3: RESPOSTA CRESCENTE, CLÔNUS TRANSITÓRIO, 5: CLÔNUS PERMANENTE
– MANOBRAS DE FACILITAÇÃO (DISTRAÇÃO)– Jendrasik, cálculo, etc.
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REFLEXOS DE NERVOS CRANIANOS•Fotomotor direto e consensual (II e III
parass)•Orbicular pálpebras: glabelar e
supraorbitário (V-VII)•Corneano ou córneo-palpebral (V-VII)•Orbicular dos lábios ou focinho (V-VII)•Palmo-mentoniano•Massetérico ou mandibular (V)•Faríngeo ou do vômito (IX-X)
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REFLEXOS DE IMPORTÂNCIA CLÍNICA
• BICIPITAL (C5-6) N. MUSCULO-CUTÂNEO
• TRICIPITAL (C7) N. RADIAL
• BRAQUIORADIAL, ESTILORADIAL OU SUPINADOR (C5-6) N. RADIAL
• REFLEXO DOS PRONADORES, CUBITO-PRONADOR OU RADIO-PRONADOR (C7-C8) N. ULNAR
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• FLEXORES DOS DEDOS (C8-T1) N. MEDIANO E ULNAR
• REFLEXO DOS FLEXORES DA MÃO (C8-T1): N. MEDIANO E ULNAR
• REFLEXOS MUSCULAR ABDOMINAL OU ABDOMINAL PROFUNDO: PERCUSSÃO DO R.C OU SINFISE PÚBICA > DESLOCA UMBIGO (T6-12)
• R. DOS ADUTORES (L4) N. OBTURADOR• PATELAR (L2-L4) N. FEMORAL• AQUILEU (S1) N. CIÁTICO E TIBIAL
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REFLEXOS CUTÂNEOS SUPERFICIAIS•REFLEXO CUTÂNEO-PLANTAR (S1) N.
CIÁTICO E TIBIAL
A Babinski response may also beseen in unconscious states due todrug or alcohol intoxication or inthe postictal period following aseizure.
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SUCEDÂNEOS DO BABINSKI
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REFLEXOS SUPERFICIAIS
•CUTÂNEO ABDOMINAL (T6-12)•REFLEXO ANAL (S3-5)•REFLEXO CREMASTÉRICO (L1-L2)•REFLEXO DE GEIGEL (L1-L2): contração
do grande oblíquo e leve retração do grande lábio ipsilateral
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REFLEXOS PRIMITIVOS
•ORBICULAR DOS OLHOS OU GLABELAR•ORBICULAR DOS LÁBIOS: Percussão do
lábio superior leva à anteriorização labial•SUCÇÃO•PALMO-MENTONIANO•PREENSÃO (GRASPING)
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LESÕES DA VIA MOTORA
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AVALIAÇÃO DA COORDENAÇÃO
• PROVAS:• ÍNDEX-NARIZ• ÍNDEX-NARIZ-ÍNDEX• CALCANHAR-JOELHO-CRISTA DA TÍBIA• PROVA DOS MOVIMENTOS
ALTERNADOS (MARIONETES)• PROVA DE STEWART-HOLMES
(RECHAÇO)• MARCHA
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SÍNDROME CEREBELAR
DismetriaDecomposição dos movimentosDisdiadococinesiaTremor durante realização de movimentosMarcha atáxicaHipotonia
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EQUILÍBRIO
•SINAL DE ROMBERG;•MARCHA USUAL, EM LINHA RETA,
PONTA DOS PÉS E CALCANHAR;•PROVA DO ÍNDEX•NISTAGMO
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SÍNDROME VESTIBULAR PERIFÉRICA• ALARGAMENTO DO POLÍGONO DE SUSTENTAÇÃO• DESVIO LATERAL DA CABEÇA E DO CORPO PARA O
LADO DA LESÃO• NISTAGMO COM COMPONENTE LENTO DIRIGIDO PARA
O LADO LESADO• SINAL DE ROMBERG COM TENDÊNCIA À QUEDA PARA
O LADO LESADO• TENDÊNCIA DURANTE A MARCHA DE DESVIO PARA O
LADO DA LESÃO
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SÍNDROME VESTIBULAR CENTRAL• MAL SISTEMATIZADAS, INCOMPLETAS, NÃO
HARMÔNICAS• DESVIO DO CORPO• DESVIO DO ÍNDEX NA PROVA DOS BRAÇOS
ESTENDIDOS• NISTAGMO GIRATÓRIO OU VERTICAL
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SENSIBILIDADE • PROFUNDA OU PROPRIOCEPTIVA
▫ CINÉTICO POSTURAL▫ VIBRATÓRIA
• SUPERFICIAL▫ TÉRMICA▫ TÁTIL▫ DOLOROSA
• DE INTEGRAÇÃO CORTICAL▫ GRAFESTESIA▫ ESTEREOGNOSIA▫ DISCRIMINAÇÃO DE DOIS PONTOS▫ DUPLO ESTÍMULO
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SINAIS DE IRRITAÇÃO MENÍNGEA•RIGIDEZ DE NUCA•KÉRNIG
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ALTERAÇÕES DA SENSIBILIDADE•DOR•PARESTESIAS•HIPO/ANESTESIA•HIPERESTESIA•ALODÍNIA
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SÍNDROME DO TÚNEL DO CARPO
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SÍNDROME DO TÚNEL DO TARSO
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NEUROPATIA PERIFÉRICA
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NEUROPATIAS POR METAIS PESADOS
Fig. 15. Meese lines at the nailbed,in case of arsenic poisoningand polyneuropathy (courtesyDr. Freymueller, Hermagor,Austri
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LESÃO DO NERVO ULNAR
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LESÃO DO NERVO RADIAL
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Fig. 32. Ilioinguinal nerve lesionafter gynecologic surgery.The sensory loss (marked with aball pen) reached almost the labia
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MARCHA: • A 55-year-old retired woman comes to your office complaining of
worsening problems with walking accompanied by falling down. She states that she has to watch the ground while she is walking or she will often misstep and fall. She has a 20-year history of type-2 diabetes and has had a history of diabetic foot ulcers in the past. She denies any smoking, drug, or alcohol use. On exam, you note that she has decreased feeling on the planter surfaces of her feet. She cannot remain steady with her feet together and her eyes closed; she remains steady with her eyes open. While watching her walk, you also note that she has a wide gait with slapping motion with her feet on the floor. What abnormalities of gait best describe her symptoms and signs?
• (A) Sensory ataxia• (B) Cerebellar ataxia• (C) Parkinsonian gait
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CASO CLINICO• HMA: E.F.S, MASCULINO, 60 ANOS, CHEGA AO PS 11/3/10, COM QUADRO DE
“DESEQUILÍBRIO” HÁ UMA SEMANA, PROGRESSIVO, COM QUADROS TRANSITÓRIOS DE CONFUSÃO MENTAL INFORMADO PELA FILHA. NEGA TCE, FEBRE, PLEGIAS OU ALTERAÇÕES VISUAIS. QUEDA NO INÍCIO DO QUADRO COM QUEIXA ASSOCIADA DE DOR LOMBAR.
• HP: DESCONHECE COMORBIDADES. ETILISTA E TABAGISTA.• HS: MORADOR DE ZONA RURAL.• • AO EXAME: PA:140/90, FC 70 BPM, • ECTOSCOPIA: CONSCIENTE, ORIENTADO, EUPNÉICO, POSTURA ATIVA;• EX. NEUROLÓGICO: GLASGOW 15, PUPILAS ISOCÓRICAS E FOTORREATIVAS,
DISCRETA ASSIMETRIA DA COMISSURA LABIAL COM DESVIO PARA DIREITA, SEM PTOSE.
• MOTRICIDADE: MARCHA NECESSITANDO DE APOIO PARA SE SUSTENTAR, PARESIA LEVE DE MIE E QUESTIONÁVEL DE MSE. REFLEXOS DE MMII EXACERBADOS. BABINSKI POSITIVO BILATERALMENTE.
• ROMBERG: NEGATIVO, • ÍNDEX-NARIZ: TREMOR À ESQ.
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REFERÊNCIAS BIBLIOGRÁFICAS
•PRINCIPLES OF NEUROLOGY. ADAMS E VICTOR. 2005
•SEMIOLOGIA MÉDICA. MÁRIO LOPES. 2005
•EXAME NEUROLÓGICO. SEBASTIÃO N. GUSMÃO
•PROPEDÊUTICA MÉDICA. BARBARA BATES
•A NEUROLOGIA QUE TODO MÉDICO DEVERIA SABER. RICARDO NITRINI.
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