Aula Neurologia Pares Cranianos

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SEMIOLOGIA	
  
NEUROLÓGICA	
  
Semiologia	
  –	
  Componente	
  Curricular	
  MED	
  B16	
  
Faculdade	
  de	
  Medicina	
  da	
  Bahia	
  -­‐	
  FMB	
  
Universidade	
  Federal	
  da	
  Bahia	
  -­‐	
  UFBA	
  
Pares	
  Cranianos	
  
Lísia	
  Rabelo	
  
Anamnese	
  
Anamnese	
  
Queixa	
  Principal	
  (QP)	
  
IdenCficação	
  
História	
  da	
  Doença	
  Atual	
  (HDA)	
  
Interrogatório	
  Sistêmico	
  
Antecedentes	
  Pessoais	
  
Antecedentes	
  Familiares	
  
Hábitos	
  de	
  Vida	
  
História	
  Psicossocial	
  (HPS)	
  
1.	
  Anamnese	
  e	
  exame	
  Psico	
  geral	
  
2.	
  Exame	
  das	
  esferas	
  da	
  cognição	
  
3.	
  Exame	
  da	
  motricidade	
  
4.	
  Exame	
  da	
  sensibilidade	
  
5.	
  Exame	
  dos	
  nervos	
  cranianos	
  
Exame	
  Neurológico	
  
Coclear	
  
VesCbular	
  
VIII:	
  VesCbulococlear	
  
I:	
  Olfatório	
  
II:	
  ÓpCco	
  
IV:	
  Troclear	
  
VI:	
  Abducente	
  
III:	
  Oculomotor	
  
V:	
  Trigêmio	
  
VII:	
  Facial	
   XII:	
  Hipoglosso	
  
XI:	
  Acessório	
  
X:	
  Vago	
  
IX:	
  Glossofaríngeo	
  
VII:	
  Facial	
  
	
  :	
  fibras	
  sensiCvas	
  
	
  :	
  fibras	
  motoras	
  
Pares	
  Cranianos	
  
I	
  par:	
  Olfatório	
  	
  
Olfato	
  
II	
  par:	
  ÓpCco	
  	
  
Acuidade	
  visual	
  
Campo	
  Visual	
  
glass bowl that encircles the front of the patient’s head. Ask the patient to
look with both eyes into your eyes. While you return the patient’s gaze, place
your hands about 2 feet apart, lateral to the patient’s ears. Instruct the pa-
tient to point to your fingers as soon as they are seen. Then slowly move the
wiggling fingers of both your hands along the imaginary bowl and toward
the line of gaze until the patient identifies them. Repeat this pattern in the
upper and lower temporal quadrants.
Normally, a person sees both sets of fingers at the same time. If so, fields are
usually normal.
Further Testing. If you find a defect, try to establish its boundaries.
Test one eye at a time. If you suspect a temporal defect in the left visual field,
for example, ask the patient to cover the right eye and, with the left one, to
look into your eye directly opposite. Then slowly move your wiggling fin-
gers from the defective area toward the better vision, noting where the pa-
tient first responds. Repeat this at several levels to define the border.
A temporal defect in the visual field of one eye suggests a nasal defect in the
other eye. To test this hypothesis, examine the other eye in a similar way,
again moving from the anticipated defect toward the better vision.
Small visual field defects and enlarged blind spots require a finer stimulus.
Using a small red object such as a red-headed matchstick or the red eraser
on a pencil, test one eye at a time. As the patient looks into your eye directly
opposite, move the object about in the visual field. The normal blind spot
can be found 15° temporal to the line of gaze. (Find your own blind spots
for practice.)
TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES
146 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
When the patient’s left eye
repeatedly does not see your fingers
until they have crossed the line of
gaze, a left temporal hemianopsia is
present. It is diagrammed from the
patient’s viewpoint.
A left homonymous hemianopsia
may thus be established.
An enlarged blind spot occurs in
conditions affecting the optic nerve,
e.g., glaucoma, optic neuritis, and
papilledema.
Covered
LEFT RIGHT
LEFT RIGHT
Fundo	
  de	
  olho	
  
II	
  par:	
  ÓpCco	
  +	
  III	
  par:	
  Oculomotor	
  	
  
Tamanho	
  e	
  Forma	
  das	
  Pupilas	
   Reações	
  Pupilares	
   Resposta	
  à	
  acomodação	
  
Pupilas	
  normais	
  
Anisocoria	
  com	
  miose	
  à	
  D	
  
Isocoria	
  com	
  midríase	
  bilateral	
  
Discoria	
  à	
  E	
  
III	
  par:	
  Oculomotor	
  +	
  IV	
  par:	
  	
  Troclear	
  +	
  VI	
  par:	
  Abducente	
  	
  
Movimentos	
  Extra	
  oculares	
  
Movimentos	
  conjugados	
  
Convergência	
  dos	
  olhos	
  	
  
Nistagmo	
  
Ptose	
  
V	
  par:	
  Trigêmio	
  
Motor	
  
SensiCvo	
  
Sensibilidade	
  da	
  face	
  
Reflexo	
  corneano	
  
Contração	
  dos	
  músculos	
  temporal	
  e	
  masseter	
  
VII	
  par:	
  Facial	
  
Movimentos	
  faciais	
  
Sensibilidade	
  gustaCva	
  dos	
  dois	
  terços	
  
anteriores	
  da	
  língua	
  	
  
VIII	
  par:	
  VesCbulococlear	
  
Ramo	
  VesCbular:	
  equilíbrio	
  
Ramo	
  Coclear:	
  audição	
  
TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES
158 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
a tuning fork, preferably of 512 Hz
or possibly 1024 Hz. These frequen-
cies fall within the range of human
speech (300 Hz to 3000 Hz)—func-
tionally the most important range.
Forks with lower pitches may lead to
overestimating bone conduction and
can also be felt as vibration.
Set the fork into light vibration by
briskly stroking it between thumb
and index finger or by tapping
it on your knuckles.
! Test for lateralization (Weber test).
Place the base of the lightly vi-
brating tuning fork firmly on top
of the patient’s head or on the
midforehead.
Ask where the patient hears it: on one or both sides. Normally the sound
is heard in the midline or equally in both ears. If nothing is heard, try
again, pressing the fork more firmly on the head.
! Compare air conduction (AC) and bone conduction (BC) (Rinne test).
Place the base of a lightly vibrating tuning fork on the mastoid bone, be-
hind the ear and level with the canal. When the patient can no longer hear
the sound, quickly place the fork close to the ear canal and ascertain
whether the sound can be heard again. Here the “U” of the fork should
face forward, thus maximizing its sound for the patient. Normally the
sound is heard longer through air than through bone (AC > BC).
In unilateral conductive hearing
loss, sound is heard in (lateralized
to) the impaired ear. Visible expla-
nations include acute otitis media,
perforation of the eardrum, and
obstruction of the ear canal, as 
by cerumen.
In unilateral sensorineural hearing
loss, sound is heard in the good ear.
In conductive hearing loss, sound
is heard through bone as long as
or longer than it is through air 
(BC = AC or BC > AC). In sensori-
neural hearing loss, sound is heard
longer through air (AC > BC). See
Table 5-19, Patterns of Hearing Loss
(pp. 196–197).
—!
→
→
TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES
158 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
a tuning fork, preferably of 512 Hz
or possibly 1024 Hz. These frequen-
cies fall within the range of human
speech (300 Hz to 3000 Hz)—func-
tionally the most important range.
Forks with lower pitches may lead to
overestimating bone conduction and
can also be felt as vibration.
Set the fork into light vibration by
briskly stroking it between thumb
and index finger or by tapping
it on your knuckles.
! Test for lateralization (Weber test).
Place the base of the lightly vi-
brating tuning fork firmly on top
of the patient’s head or on the
midforehead.
Ask where the patient hears it: on one or both sides. Normally the sound
is heard in the midline or equally in both ears. If nothing is heard, try
again, pressing the fork more firmly on the head.
! Compare air conduction (AC) and boneconduction (BC) (Rinne test).
Place the base of a lightly vibrating tuning fork on the mastoid bone, be-
hind the ear and level with the canal. When the patient can no longer hear
the sound, quickly place the fork close to the ear canal and ascertain
whether the sound can be heard again. Here the “U” of the fork should
face forward, thus maximizing its sound for the patient. Normally the
sound is heard longer through air than through bone (AC > BC).
In unilateral conductive hearing
loss, sound is heard in (lateralized
to) the impaired ear. Visible expla-
nations include acute otitis media,
perforation of the eardrum, and
obstruction of the ear canal, as 
by cerumen.
In unilateral sensorineural hearing
loss, sound is heard in the good ear.
In conductive hearing loss, sound
is heard through bone as long as
or longer than it is through air 
(BC = AC or BC > AC). In sensori-
neural hearing loss, sound is heard
longer through air (AC > BC). See
Table 5-19, Patterns of Hearing Loss
(pp. 196–197).
—!
→
→
Teste	
  de	
  Weber	
   Teste	
  de	
  Rinne	
  
IX	
  par:	
  Glossofaríngeo	
  e	
  X	
  par:	
  Vago	
  
Sensibilidade	
  gustaCva	
  do	
  terço	
  posterior	
  da	
  língua	
  	
  
Voz	
  
DegluCção	
  
Movimento	
  do	
  palato	
  mole	
  e	
  da	
  faringe	
  –	
  pesquisar	
  desvio	
  da	
  úvula	
  
Reflexo	
  do	
  vômito	
  
XI	
  par:	
  
Músculo	
  trapézio	
  	
  
Músculo	
  
esternocleidomastoídeo	
  	
  
XII	
  par:	
  
Língua	
  	
  
https://informatics.med.nyu.edu/modules/pub/neurosurgery/
coordination.html 
https://www.youtube.com/watch?v=fgwN1P5PDaA - 3 minute neurological 
examination 
https://www.youtube.com/watch?v=4hOSkmDYAR4 - Romberg sign 
http://www.medicina.ufmg.br/neuroexame/VideoPage.php?videoLocation=/
videos/normal/Craniano%20Olfatorio/video.mp4&videoName=I%20nervo
%20craniano