The Neurological

Examination
The goals of the neurological
examination are several

Anwar Wardy

a2w@..FK.UMJ 2007

Independent learning
Case

discussion during weekly didactics

Student presentations on a topic
Consider some online material to
supplement didactics or case discussions
Group-study meeting
? PDA use to track experiences

Anwar Wardy

a2w@..FK.UMJ 2007

Major Diagnoses for clerkship

(Kuasai Sebelum Masuk RS)

*Psychosis
Schizophrenia
Substance induced
In context of delirium
*Mood disorders
Depression
Bipolar disorder
Anxiety
*Substance abuse and dependence
*Delirium
*Dementia
Neurosurgery
Head and spinal cord injury
Radiculopathy and myelopathy
Brief survey of neuro-oncology

Anwar Wardy

Pain
*Stroke
SAH
Hemorrhage
Ischemic
*Headache
*Movement Disorders
Parkinsons ,Essential tremor,
Huntingtons
Neuromuscular
Myasthenia & ALS
*Dementia
*Epilepsy
Multiple Sclerosis
Pediatric
Well child neurology examination
Static and progressive
encephalopathies
Pediatric epilepsy

a2w@..FK.UMJ 2007

Didactic Topics
(Umumnya di Indonesia)

Emergency psychiatry
Schizophrenia
Mood Disorders
Psychopharmacology
Confusion or memory problems
(Dementia and delirium)
Child psychiatry
Personality development
Substance dependence (alcohol
and others)
Neuroscience review
Eating disorders
Personality disorders
Psychotherapy
Anxiety disorders
Systems of practice in psychiatry
Anwar Wardy

Weakness Neuromuscular
problems
Numbness sensory changes
Neurological exam and what it
means
Pediatric neurology exam
Loss of consciousness differential
(seizure, syncope, coma)
Epilepsy- Adult and pediatric
Sleep disorders
Pain and headache
Stroke
Shaking-Movement disorders
Disorders of intracranial pressure
Head and spinal cord injury
Neuro-oncology

a2w@..FK.UMJ 2007

Integrated Longitudinal
Curriculum

Disease prevention and health promotion issues related to stroke and

prevention and health
Stroke prevention, endarterectomy, migraine headache treatment,
dementia
End of life care mgmt after stroke, ALS, Huntingtons, and neurodiagnoses diagonses for quality of life
Ethics cases on informed consent
Nutrition- childhood developmental disorders
Pain mgmt-Headache, back pain, neuropathy and neuropathic pain
Path and lab -?
Patient safety head injury, topics of suicide risk prevention,
involuntary commitments, informed consent, drug interactions, driving
and epilepsy
Professional communication working as a consultant and roles
Radiology neuroradiology, interventional neurology
System based practice-systems of care in psychiatry
Anwar Wardy

a2w@..FK.UMJ 2007

For patients presenting with symptoms

suggestive of a neurological problem, the
examination should

Determine, on the basis of an organized and thorough

examination, whether in fact neurological dysfunction
exists.
Identify which component(s) of the neurological system
are affected (e.g. motor, sensory, cranial nerves, or
possibly several systems simultaneously).
If possible, determine the precise location of the
problem (e.g. peripheral v central nervous system;
region and side of the brain affected etc.).
On the basis of these findings, generate a list of
possible etiologies. Unlikely diagnoses can be excluded
and appropriate testing (e.g. brain and spinal cord
imaging) then applied in an orderly and logical fashion.

Anwar Wardy

a2w@..FK.UMJ 2007

Screening for the presence of discrete abnormalities in

patients at risk for the development of neurological
disorders. This is appropriate for individuals who
have
no
particular
subjective
symptoms
suggestive of a neurological problem, yet have
systemic illnesses that might put them at risk for
subtle dysfunction. Diabetic patients, for example
(particularly those with long standing poor
control),
may
develop
peripheral
nerve
dysfunction. This may only be detected through
careful sensory testing (see Sensory Testing),
which would have important clinical implications.
Anwar Wardy

a2w@..FK.UMJ 2007

1.

Cursory screening/documentation of baseline

function for those who are otherwise healthy. In
patients with neither signs nor risk factors for
neurological disease, its unlikely that the detailed
exam would uncover occult problems. Simply
observing the patient during the course of the usual
H&P (i.e. watching them walk, get up and down from
the exam table, etc.) may well suffice. Many
examiners incorporate some aspects of the neuro
exam into their standard evaluations. Cranial Nerve
testing, for example, can be easily blended into the
Head and Neck evaluation. Deciding what other
aspects to routinely include is based on judgment
and experience.
Anwar Wardy

a2w@..FK.UMJ 2007

The major areas of the exam, covering the

most testable components of the
neurological system, include:

Mental status testing (covered in a separate

section of this web site)
Cranial Nerves
Muscle strength, tone and bulk
Reflexes
Cerebellar Function
Sensory Function
Gait

Anwar Wardy

a2w@..FK.UMJ 2007

Real and imagined problems with

the neurological examination
The neurological examination is one of
the least popular and (perhaps) most
poorly performed aspects of the
complete physical. I suspect that this
situation exists for several reasons:

Anwar Wardy

a2w@..FK.UMJ 2007

This exam is perceived as being time and labor intensive.

Students and house staff never develop an adequate level of
confidence in their ability to perform the exam, nor in the accuracy
of their findings. This, in turn, probably translates into poor
performance later in their careers.
Exam findings are often quite subjective.Thus, particularly when the
examiner does not have confidence in their abilities (see above),
interpretation of the results can be problematic.
Understanding/Interpretation of some neurological findings requires
an in depth understanding of neuroanatomy and pathophysiology.
As many clinicians do not see a large number of patients with
neurological disorders, they likely maintain a limited working
understanding of this information.
There is an over reliance on the utility of neuro-imaging (e.g. CT,
MRI). These studies provide an evaluation of anatomy but not
function. Thus, while extremely helpful, they must be interpreted
within the context of exam findings. Careful examination may make
imaging unnecessary. Also, exam findings can make a strong case
for the presence of a pathologic process, even if it is not seen on a
particular radiological study (i.e. there are limits to what can be
seen on even the most high tech imaging).

Anwar Wardy

a2w@..FK.UMJ 2007

Cranial Nerve (CN) Testing

CN2
CN3, 4, 5
CN6
CN7
CN8
CN9, 10
CN11
CN12
Anwar Wardy

a2w@..FK.UMJ 2007

Cranial Nerve 1 (Olfactory):

Each nostril should be checked separately.

Push on the outside of the nares, occluding
the side that is not to be tested.
Have the patient close their eyes. Make sure
that the patient is able to inhale and exhale
through the open nostril.
Present a small test tube filled with
something that has a distinct, common odor
(e.g. ground coffee) to the open nostril. The
patient should be able to correctly identify
the smell.
Anwar Wardy

a2w@..FK.UMJ 2007

Alcohol Pad Sniff Test

Anwar Wardy

a2w@..FK.UMJ 2007

Cranial Nerve 2 (Optic)

Acuity:

Each eye is tested separately. If the patient uses glasses to view

distant objects, they should be permitted to wear them (referred
to as best corrected vision).
A Snellen Chart is the standard, wall mounted device used for
this assessment. Patients are asked to read the letters or
numbers on successively lower lines (each with smaller
images) until you identify the last line which can be read with
100% accuracy. Each line has a fraction written next to it. 20/20
indicates normal vision. 20/400 means that the patient's vision
20 feet from an object is equivalent to that of a normal person
viewing the same object from 400 feet. In other words, the larger
the denominator, the worse the vision.

Anwar Wardy

a2w@..FK.UMJ 2007

Snellen chart for measuring

visual acuity

Anwar Wardy

a2w@..FK.UMJ 2007

Hand held visual

acuity card
There are hand held
cards that look
like
Snellen
Charts but are
positioned
14
inches from the
patient. These are
used simply for
convenience.
Testing
and
interpretation are
as described for
the Snellen.
Anwar Wardy

a2w@..FK.UMJ 2007

If neither chart is available and the patient has

visual complaints, some attempt should be
made to objectively measure visual acuity. This
is a critically important reference point,
particularly when trying to communicate the
magnitude of a visual disturbance to a
consulting physician. Can the patient read news
print?
The headline of a newspaper?
Distinguish fingers or hand movement in front
of their face? Detect light?Failure at each level
correlates with a more severe problem.
Anwar Wardy

a2w@..FK.UMJ 2007

Visual fields can be crudely

assessed as follows

The examiner should be nose to nose with the patient,

separated by approximately 8 to 12 inches.
Each eye is checked separately. The examiner closes one eye
and the patient closes the one opposite. The open eyes should
then be staring directly at one another.
The examiner should move their hand out towards the periphery
of his/her visual field on the side where the eyes are open. The
finger should be equidistant from both persons.
The examiner should then move the wiggling finger in towards
them, along an imaginary line drawn between the two
persons.The patient and examiner should detect the finger at
more or less the same time.
The finger is then moved out to the diagonal corners of the field
and moved inwards from each of these directions. Testing is
then done starting at a point in front of the closed eyes. The
wiggling finger is moved towards the open eyes.
The other eye is then tested.
Anwar Wardy

a2w@..FK.UMJ 2007

Pupils
The pupil has afferent (sensory) nerves
that travel with CN2. These nerves carry
the impulse generated by the light back
towards the brain. They function in
concert with efferent (motor) nerves that
travel with CN 3 and cause pupillary
constriction. Seen under CN 3 for
specifics of testing.
Anwar Wardy

a2w@..FK.UMJ 2007

CN 3 (Occulomotor):
This nerve is responsible for most of the eyeballs
mobility, referred to as extra-occular movement. CN
3 function is assessed in concert with CNs 4 and 6,
the other nerves responsible for controlling eyeball
movement. CN 4 controls the Superior Oblique
muscle, which allows each eye to look down and
medially. CN 6 controls the Lateral Rectus muscle,
which allows each eye to move laterally. CN 3
controls the muscles which allow motion in all other
directions. The pneumonic S O 4 L R 6 All The
Rest 3 may help remind you which CN does what
(Superior Oblique CN 4 LateralRectus CN 6 All
The Rest of the muscles innervated by CN 3).
Anwar Wardy

a2w@..FK.UMJ 2007

Inspeksi diskus optikus papiledema, atau atrofi Nn

Optikus.
3.Nn. Optikus dan Okulomotoris, reaksi pupil
terhadap cahaya, jika hasil AbN, Uji reaksi sampai
maksimal Kebutaan, paralisis Nn.III, Sindroma
Horners
4. Nn.III, IV, VI; gerakan ekstraokuler strabismus
atau nistagmus akibat paralisis.
5.Nn.V(Trigeminal); raba, konraksi temporal dan
otot2 maseter, hilangnya sensorik atau motorik
karena lesi Nuvleus atau UMN refleks kornea
dan sentuhan ringan-nyeri pada wajah
Anwar Wardy

a2w@..FK.UMJ 2007

 Bells
Bell's

Palsy
Facial Nerve Paralysis
Causes
Infectious

Disease
Herpes Ophthalmicus
Ramsey Hunt Syndrome
Assorted Pages in
Cranial Nerve
Progressive Bulbar Para
lysis
Trigeminal
Anwar Wardy

Neuralgia
a2w@..FK.UMJ 2007

6.

7.
8.

Nn.VII. (Fasialis); angkat kedua alis

mata, cemberut, menutup mata dengan
rapat, perlihatkan gigi, tersenyum.
Nn.VIII(Akustik); jika pendengaran
menurun, uji lateralisasi (Weber / Rinne).
Nn.Glossopharungeus & Vagus
( IX, X); amati kesulitan menelan,
dengar suara serak atau hidung. Amati
naiknya langit2 lunak dengan Ah
paralisis palatum.
Uji refleks gag pada kedua sisi hilang
refleks.
Anwar Wardy

a2w@..FK.UMJ 2007

9. Nn Asesori (XI); Otot trapezius, kekuatan

angkat bahu. Mm Sternokleidomastoideus;
uji berpaling kekiri / kekanan terhadap tahan
tangan pemeriksa.
10. Nn.XII (Hypoglosal); dengarkan artikulasi
pasien, inspeksi seluruh lidah dan bila
dijulurkan apakah ada deviasi ke kiri /
kekanan ada kelemahan atau disartri, atau
fasikulasi, serta atrofi lidah.
Anwar Wardy

a2w@..FK.UMJ 2007

SISTEM MOTORIK
Posisi

: Hemiplegi / Hemiparese!
Gerakan involenter; amati letak,
kualitas, frekwensi, irama, amplitudo
tremor, fasikulasi, tiks, chorea,
atetosis, diskinesis oro-fasial.
Bulk otot; inspeksi kontur otot atrofi.
Tonus otot; amati tahanan dari
kekuatan pasif lengan atau
tungkai spastis, kekakuan atau flasid.
Anwar Wardy

a2w@..FK.UMJ 2007

Lanjutan; periksa rentang gerak

Fleksi pada pinggul dan lutut, fleksi dari tungkai yang

berlawanan mengisyaratkan deformitas pada pinggul
tersebut.
Rotasi pada pinggul, baik internal dan
eksternal, keterbatasan pada artritis.
Abduksi pada pinggul keterbatasan pada artritis.
Palpasi; sendi pinggul dan bursa ileopektinal, lateral
terhadap denyut femoralis, nyeri pada sinovitis.
Bursa trochanter mayor pada femur bursitis
Bursa iskial, nyeri pada bursitis.
Amati lutut dan kaki saat berdiri; pembengkakan popliteal
(kista Bakers,& kaki datar)

Anwar Wardy

a2w@..FK.UMJ 2007

VERTEBRA (T.BELAKANG)
Inspeksi dari ventral dan dorsal;perhatikan setiap
kurvatura abnormal (perhatikan asimetris; bahu, krista
iliaka atau bokong) Kifosis, Skoliosis, Lordosis, Gibbus.
Posisi berdiri amati bentuk asimetris bahu, krista iliaka
atau bokong; pelvik mendongak
Periksa rentang gerak pada; fleksi, gerakan kelateral,
ekstensi dan rotasi
Konkavitas lumbal yang menetap dan keterbatasan gerak
karena spasme otot, penyakit diskus, atau ankilosing
spondilitis.
Palpasi terhadap nyeri tekan kelaianan diskus, spasme
otot, fraktur kompresi atau kondisi lain.

Anwar Wardy

a2w@..FK.UMJ 2007

SISTEM MOTORIK
Posisi

: Hemiplegi / Hemiparese!
Gerakan involenter; amati letak,
kualitas, frekwensi, irama, amplitudo
tremor, fasikulasi, tiks, chorea,
atetosis, diskinesis oro-fasial.
Bulk otot; inspeksi kontur otot atrofi.
Tonus otot; amati tahanan dari
kekuatan pasif lengan atau
tungkai spastis, kekakuan atau flasid.
Anwar Wardy

a2w@..FK.UMJ 2007

Kelompok Otot Besar

Fleksi siku C5, C6

Ekstensi siku C6, C7, C8.
Ekstensi pergelangan tangan C6, C7,C8 saraf radialis.
Genggaman tangan C7, C8, T1.
Abduksi jari-jari C8, T1, saraf ulnaris.
Posisi ibu jari C8, T1;saraf medianus.

Anwar Wardy

a2w@..FK.UMJ 2007

GARIS BESAR PEMERIKSAAN

GEJALA SENDI
Kepala & Leher: (Posisi Pasien Duduk)

Palpasi sendi temporomandibula ketika pasien

membuka dan menutup mulut;
Pembengkakan, Nyeri Tekan, Hambatan gerakan
pada artritis.
Inspeksi leher untuk mengetahui adanya
deformitas;
Tortikolis; immobilitas pada ankilosis spondilitis,
Palpasi Columna Vetebra Servikal dan ototnya dari
belakang pasien;
Nyeri tekan setempat.
Anwar Wardy

a2w@..FK.UMJ 2007

UJI BATAS GERAK LEHER:

FLEKSI
EKSTENSI
ROTASI
GERAKAN

& KANAN.

Anwar Wardy

KEARAH LATERAL KIRI

a2w@..FK.UMJ 2007

Dermatom

Anwar Wardy

a2w@..FK.UMJ 2007

Neuro-Ophthalmology
Eye Neurologic Exam
Oculocephalic Reflex
Nystagmus
Face Exam
Cranial Nerve Exam
Palpebral fissures equal
Facial symmetry
Tongue midline with no fasciculations
Jaw symmetric

Anwar Wardy

a2w@..FK.UMJ 2007

Cranial Nerve

Cranial Nerve I
Cranial Nerve II
Cranial Nerve III
Cranial Nerve IV
Cranial Nerve V
Cranial Nerve VI
Cranial Nerve VII
Cranial Nerve VIII
Cranial Nerve IX
Cranial Nerve X
Cranial Nerve XI
Cranial Nerve XII

Anwar Wardy

a2w@..FK.UMJ 2007

Oropharynx Exam

Gag Reflex
Swallow reflex
Regurgitation (nasal or liquid)

Larynx and Language

Voice quality
Speech Exam
Dysarthria (explosive or nasal)
Aphasia (writing)

Anwar Wardy

a2w@..FK.UMJ 2007

Sensory

Two Point Discrimination

Sharp and dull discrimination

Proprioception (finger up or down?)

Stereography
Motor Exam

Motor Strength

Tone (flaccid, rigid, or cogwheel)

Atrophy

Fasciculations

Muscle tenderness

Tremor

Anwar Wardy

a2w@..FK.UMJ 2007

Sensory Exam

Agnosia;

ketidaksanggupan
mengenali benda dan artinya
Diabetic Neuropathy Testing
Two Point Discrimination
Anwar Wardy

a2w@..FK.UMJ 2007

Motor Exam :
Movement

Disorder
Reflex Exam
Tetany
Acute Motor Weakness Causes
Hemiplegia
Left Hemiplegia
Right Hemiplegia

Anwar Wardy

a2w@..FK.UMJ 2007

Sign of UMN Lession

Weakness
Increased

tone
(spasticity)
Atrophy of disuse
only
Increased deep
tendon reflexes.
Extensor plantar
response (Babinski)
Anwar Wardy

a2w@..FK.UMJ 2007

Sign of LMN Lession

Weakness
Decreased

tone (flaccidity)

Atrophy
Fasciculations
Decreased

to absent deep
tendon reflexes

Anwar Wardy

a2w@..FK.UMJ 2007

Reflexes

Deep Tendon Reflexes

Primitive Reflexes
Babinski Reflex
Grasp Reflex
Suck Reflex
Glabellar Reflex
Hoffman Reflex

Anwar Wardy

a2w@..FK.UMJ 2007

PERGELANGAN TANGAN &

TANGAN
Instrusikan pasien membuat kepalan tangan pada

kedua tangan;
Perhatikan signifikansi fungsi dan arti diagnosis dari
keterbatasan gerakan.
-Meluruskan jari-jari;
-Fleksi dan ekstensi pergelangan tangan.
-Membalikkan tangan (dgn telapak tangan menghadap
kebawah) kearah lateral dan medial (penyimpangan lateral
dan medial)
-Inspeksi tangan dan pergelangan tangan;
Deformitas, pembengkakan atau atrofi muskular
Anwar Wardy

a2w@..FK.UMJ 2007

Lanjutan

Palpasi;
-

Sendi intrafalangeus distal dan

proksimal;
Pembengakakan pada sendi artritis
reumatoid; adanya nodulus distalis
akibat osteostrritis (nodus
Heberdens)

Anwar Wardy

a2w@..FK.UMJ 2007

Sendi metakarpofalangeal;

Pembengkakan

pada artritis reumatoid.

Sendi pergelangan tangan;

Bengkak pada artritis rematoid dan pada infeksi
-

Gonococcus dari sendi atau selaput tendon ekstensor .

Anwar Wardy

a2w@..FK.UMJ 2007

SIKU
Pasien dianjurkan menekuk dan meluruskan
siku.
Membalikkan telapak tangan keatas dan
kebawah (supinasi dan pronasi) dari lengan
bawah.
Inspeksi dan Palpasi Siku, temasuk;
-Prosessus olekranon; adanya bursitis olekranon.
-Lekukan pada sendi siku; nyeri tekan pada
artritis.
-Epikondile medial dan lateral; nyeri tekan pada
epikondilitis.
-Permukaan ekstensor dari ulna; adanya nodulus
rematoid.

Anwar Wardy

a2w@..FK.UMJ 2007

BAHU
(Perhatikan adanya Hambatan Pergerakan)

Mengangkat kedua tangan kearah vertikal keatas / bebawah.

Letakkan kedua tangan dibelakang leher dengan siku ke arah
luar (abduksi dan rotasi eksternal)
Letakkan kedua tangan dibelakang punggung atas (rotasi
internal).
Inspeksi bahu dan pangkal bahu dari depan dan belakang;
adanya Atropi muskular.
Palpasi terhadap nyeri tekan dibeberapa daerah sendi bahu;
adanya tendinitis manset rotator adalah penyebab umum dari
nyeri tekan subakromial(B); lht- gambar/ Tendinitis bisipital (A)

Anwar Wardy

a2w@..FK.UMJ 2007

PERGELANGAN KAKI DAN

TUNGKAI.
Inspeksi

sendi pergelangan
kaki; Hallus valgus, corns, calluses.
Palpasi setiap sendi nyeri pada
artritis; nyeri ligamen pada saat terkilir.
Raba sepanjang tendon
Achilles nodulus rematoid

Anwar Wardy

a2w@..FK.UMJ 2007

 Pencet

pada masing-masing kaki bagian

ventral, sehingga menekan sendi
metatarsofalangeus, kemudian palpasi setiap
sendi antara ibu jari dan telunjuk nyeri tekan
pada artritis dan kondisi lain.

Evaluasi batas pergerakan sendi biasanya

nyeri (artritis), dan bertambah sakit bila
ligamen diregangkan

Anwar Wardy

a2w@..FK.UMJ 2007

Lanjutan; kaji batas gerak

Dorsofleksi

dan plantarflexi kaki terhadap

pergelangan kaki (sendi tibiotalar)
Stabilkan pergelengan kaki dengan satu tangan dan
putar ke dalam dan keluar tumit (sendi subtalar)
sendi sering sakit bila digerakkan segala arah;
terkilir sakit > hebat jika ligamen diregangkan.

Anwar Wardy

a2w@..FK.UMJ 2007

 Eversi

dan Inversi; stabilkan tumit

dan putar kedalam maupun keluar
telapak kaki depan (sendi tarsal
transversal)

Fleksikan

jari2 kaki terhadap sendi

metatarsofalangeus.

Anwar Wardy

a2w@..FK.UMJ 2007

LUTUT DAN PINGGUL

Inspeksi

dan Palpasi masing-masing

lutut, termasuk area kantung suprapatelar
dan dlm sendi lutut.
Rongga pada masing-masing sisi patella;
pembangkakan dan berisi cairan, atau
bursitis pada prepatelar.

Anwar Wardy

a2w@..FK.UMJ 2007

 Evaluasi

gerakan patella terhadap

femur nyeri dan krepitasi pada kedua
manuver ini, sesuai dengan keluhan
patelo femolar.

Tekan

kearah distal; dengan posisi

fleksi 90 derajat, palpasi
tibiofemolar nyeri krn cedera bantalan
lemak prepatelar/miniskus

Anwar Wardy

a2w@..FK.UMJ 2007

Lanjutan; periksa rentang gerak

Fleksi pada pinggul dan lutut, fleksi dari tungkai yang

berlawanan mengisyaratkan deformitas pada pinggul
tersebut.
Rotasi pada pinggul, baik internal dan
eksternal, keterbatasan pada artritis.
Abduksi pada pinggul keterbatasan pada artritis.
Palpasi; sendi pinggul dan bursa ileopektinal, lateral
terhadap denyut femoralis, nyeri pada sinovitis.
Bursa trochanter mayor pada femur bursitis
Bursa iskial, nyeri pada bursitis.
Amati lutut dan kaki saat berdiri; pembengkakan popliteal
(kista Bakers,& kaki datar)

Anwar Wardy

a2w@..FK.UMJ 2007

VERTEBRA (T.BELAKANG)
Inspeksi dari ventral dan dorsal;perhatikan setiap
kurvatura abnormal (perhatikan asimetris; bahu, krista
iliaka atau bokong) Kifosis, Skoliosis, Lordosis, Gibbus.
Posisi berdiri amati bentuk asimetris bahu, krista iliaka
atau bokong; pelvik mendongak
Periksa rentang gerak pada; fleksi, gerakan kelateral,
ekstensi dan rotasi
Konkavitas lumbal yang menetap dan keterbatasan gerak
karena spasme otot, penyakit diskus, atau ankilosing
spondilitis.
Palpasi terhadap nyeri tekan kelaianan diskus, spasme
otot, fraktur kompresi atau kondisi lain.

Anwar Wardy

a2w@..FK.UMJ 2007

Pemeriksaan Khusus

Angkat tungkai lurus, kemudian dorsofleksi kaki bila

nyeri ada kompresi radiks post. Dengan dorsofleksi
tambah nyeri.
Uji Phalens untuk synd.Tunnel-Carpal;
tahan pergelangan tangan pasien dalam fleksi akut dari
kedua tangan bersamaan membentuk sudut, selama 60
detik baal dan kesemutan pada Nn.medianus adanya
tanda positif.

Anwar Wardy

a2w@..FK.UMJ 2007

 Tanda

Lanjutan:

Tinels untuk Sindrom Tunnel

Carpal; Lakukan perkusi ringan diatas saraf
median pada pergelangan tangan rasa
semutan atau pada Nn Medianus adalah
positif.

Anwar Wardy

a2w@..FK.UMJ 2007

Tanda benjolan Cairan Sendi Lutut; gerakkan

lutut/patella untuk mendorong cairan keatas, takan
lateral patella dan perhatikan kembalinya cairan
positif adanya efusi ringan.
Tanda Balon; memegang kedua sisi patella dan
terasa cairan lat. efusi yang banyak.

Anwar Wardy

a2w@..FK.UMJ 2007

Lanjutan:
Mengukur

panjang tungkai; tungkai

lurus simetris, dengan meter/plester
dari spina iliaka sup/anterior ke
maleolus medialia melalui lutut dibagian
medial bila tdk sama adanya
skoliosis.
Mengukur rentang gerak; tangan fleksi
dan ektensi; 0 45- 90 dan 160 derajat.
Anwar Wardy

a2w@..FK.UMJ 2007

Cara Berjalan
Berjalan

hemiparesis spastik; lengan

tertahan rapat pada sisi tubuh dengan
persendian fleksi. Tungkai ekstensi dan kaki
fleksi plantar. Saat berjalan, jari-jari kaki
mencengkram dan tungkai circumduksi.
Berjalan
seperti gunting (paresis
spastik bilateral);cara berjalan yang kaku,
paha menyilang ke depan satu sama lain
setiap kali melangkah. Langkahnya pendek.
Anwar Wardy

a2w@..FK.UMJ 2007

 Berjalan

Timplang (Gangguan saraf

Perifer); karena foot drop, tampak
menyeret kaki atau mengangkatnya tinggitinggi dan menghentakkan kebawah.
Ataksia sensoris; tidak tegap cara
berjalan dengan ancang yang melebar,
secara sepihak dapat diperbaiki dengan
memperhatikan lantai. Kaki diajunkan
kedepan dan keluar dan dijatuhkan pada
tumid dan kemudian jari-jari kaki. Dengan
test Romberg positif.
Anwar Wardy

a2w@..FK.UMJ 2007

 Berjalan

Atasia
Serebral;
tidak
mantap saat berjalan dengan ancang lebar
dan mengalami kesulitan bila berbalik
arah.Saat test Romberg, tidak tegap
dengan mata terbuka atau terpejam. Tanda
lain serebral berkaitan.
Jalan
Parkinsonisme;
postur
membungkuk
dengan
siku
dan
pergelengan tangan fleksi. Cara berjalan
lambat, melayang dengan langkah pendek
dan kaku saat berbalik.
Anwar Wardy

a2w@..FK.UMJ 2007

Daerah Pinggul
Fleksi

pinggul L2, L3, L4

Adduksi pinggul L2,L3,L4
Abduksi pinggul L2, L5, S1
Ekstensi pinggul S1.
Ekstensi lutut L2,L3,L4
Fleksi lutut L4,L5, S1,S2.
Dorsofleksi pergelangan kaki L4, L5.
Plantar pergelangan kaki S1.
Anwar Wardy

a2w@..FK.UMJ 2007

Skala Kekuatan Otot.

0;

Tidak terdapat konraksi otot yang

terlihat.
1; Kontraksi dapat terlihat.
2.Gerakan aktif penghilangan gravitasi.
3.Gerakan aktif terhadap gravitasi.
4.Gerakan aktif dengan tahanan.
5.Gerakan aktif terhadap tahanan
penuh.
Anwar Wardy

a2w@..FK.UMJ 2007

Koordinasi.

Cara berdiri: Uji Romberg, pasien berdiri mata terbuka kaki rapat,
kemudian pejamkan mata selama 20-30 detik.Sedikit terjadi
goyangan perhatikan pada saat tangan direntangkan dgn mata
tertutup selama 20-30 detik, terjadi penyimpangan pronasi dan fleksi
kearah bawah; hemiparese.

Cara berjalan:
1. Berjalan menjauh, berputar dan kembali.
2. Berjalan jinjit atau berjungkit (bergantian)
3. Melompat ditempat dengan ke.2 kaki
4. Lakukan gerakan dengan melipat 1 tungkai.
Bergantian berdiri dari kursi dan berjinjit, melompat dan jongkok sesuai
kebutuhan. Kelemahan motorik, ataksia serebral, parkinson dan
hilangnya keseimbangan posisi
dapat2007mempengaruhi semua performa.
a2w@..FK.UMJ

Anwar Wardy

Lanjutan:
Kelemahan

koordinasi,
inkoordinasi pada
buruknya indra-posisi
(propioseptif) dapat
terjadi bila pasien
diminta untuk menahan
tangannya keatas, dan
kita menepuk tangan
tersebut kearah bawah.
Bila kembali keposisi
semua secara perlahan;
Normal
Anwar Wardy

a2w@..FK.UMJ 2007

Types of Paralysis

Flaccid paralysis occurs with damage to ventral root

or anterior horn, resulting in no stimulation of
voluntary and involuntary movement.
Spastic paralysis from damage of upper motor
neurons of primary motor cortex, causes loss of
voluntary movements, but spinal reflex activity still
occurs.
Paraplegia is a term used to indicate loss of lower
limb control due to damage to cord in thoracic region.
Quadraplegia refers to damage at cervical region,
which affects all limbs.

Anwar Wardy

a2w@..FK.UMJ 2007

Sistem Sensorik

Bandingkan area simetris pada

kedua sisi tubuh amati defisit
homeosensoris.
Bandingkan area distal dan
proksimal dari lengan dan
tungkai terhadap nyeri,
temperatur, dan sensasi
sentuhan. parasthesi sarung
tangan/stocking karena
neuropati.
Bisa dilakukan dengan goresan
yang cukup.

Anwar Wardy

a2w@..FK.UMJ 2007

Lanjutan:
Periksa

jari tangan dan kaki kearah distal

terhadap vibrasi dan indra posisi
(propioseptif); jika respons abnormal periksa
kearah proksimal hilangnya rasa vibrasi
dan propioseptif terjadi pada kelainan tulang
belakang buat mapping pada respons abN.
(pasien diperiksa dgn mata tertutup)

Anwar Wardy

a2w@..FK.UMJ 2007

Nyeri; gunakan ujung runcing peniti/jarum dan

ujung lainya tumpul sebagai
pembanding analgesia, hipalgesia, hiperalgesia.
Temperatur;(jika ada indikasi) gunakan uji tabung
dgn air panas dan dingin dgn temp.yang sesuai(+/20 derajat tbh).
Sentuhan ringan dengan ujung kapas.
Vibrasi; garpu-tala 128 Hz 256 Hz letakkan pada
tonjolan tulang Vibrasi dan posisi keduanya
melalui cornu posterior C.Vertebra, sering
berhubungan satu dengan lainnya.

Anwar Wardy

a2w@..FK.UMJ 2007

 Posisi;

gerakan ibu jari kaki kearah

lateral, atas / bawah; tahan bebera saat.

Anwar Wardy

a2w@..FK.UMJ 2007

Sensasi diskriminasi

Stereognosis; minta pasien mengindentifikasi

benda-benda umum yang diletakkan diatas
tangannya.
Identifikasi angka; goreskan dengan ujung pensil
tumpul ketangan angka atau gambar lain dan pasien
mengidentifikasinya;
Hilangnya / berkurang sensasi ini mungkin
kelainan pada pada columna postrior atau korteks
sensoris.

Anwar Wardy

a2w@..FK.UMJ 2007

 Diskriminasi

15 mm.

2 titik dengan jarum; jarak <

Lokalisasi

titik; dengan mata tertutup

sentuh dengan cepat kemudian pasien
mengidentifikasi letaknya lesi dikorteks
sensori kontralateral.
Ekstinksi; sentuh dua titik bergantian
berlawanan pada bagian tubuh yang sama;
kemuadian identifikasi kedua titik tsb.
Anwar Wardy

a2w@..FK.UMJ 2007

REFLEKS-REFLEKS
Biceps

(C5, C6)
Triceps (C6, C7)
Supinator( brachioradialis; C5, C6).
Abdominal; gores kearah umbilikus dengan
pensil tumpul.
Refleks hiperaktif, Abdominal Reflek (-),
Babinsky + adalah lesi UMN.
Anwar Wardy

a2w@..FK.UMJ 2007

Anggota bawah:
Refleks

Lutut (L 2, L3, L4); ketok

tendo patella inferior.
Pergelangan kaki (S1); ketok tendo
Achiles.
Plantar (L5, S1)-fleksor; gores dari
lateral kemedial Refleks Babinski
bila positif; Periksa klonus otot kaki.

Anwar Wardy

a2w@..FK.UMJ 2007

Skala Peringkat Refleks:

+

4 hiperaktif dengan klonus AbN.

+ 3 Lebih cepat dari biasanya; jangan
cepat mengambil kesimpulan AbN.
+ 2 rata-rata Normal.
+ 1 Penurunan normal rendah.
0 Tak ada respons.

Anwar Wardy

a2w@..FK.UMJ 2007

Buku bacaan wajib:

Medical Neurology, Gylroy/Meyer 2005.
2. Handbook of Neurophysiology, Stalberg 2005.
3. Principles of Neurology, Edisi 8, Adam and
Victors, 2005.
4. Gambar; erossyah
(Buku diatas ada pada Penulis)
Tidak semua pointer (85) diberikan pada
Mahasiswa; diwajibkan kembangkan dari buku
teks dan online.
1.

Anwar Wardy

a2w@..FK.UMJ 2007

Jakarta, 12 Desember 2007

FKK-UMJ

WassalamuAlaikum Wr,
Wbr.

Anwar Wardy

a2w@..FK.UMJ 2007