Introduccin

El examen fsico del sistema nervioso requiere una metodologa dis-

tinta a la de otros sistemas7 8 si 9ien utili:a los mismos ;rocedimientos
<ins;ecci=n7 ;al;aci=n7 ;ercusi=n 8 auscultaci=n>7 los me:cla 8 com9i-
na en forma ;eculiar7 que descri9iremos a medida que estudiemos este
ti;o de examen en cada una de sus ;artes? El examen fsico se @ace con
un orden o criterio anatomofuncional 8 no ;or mAtodos o ;rocedimien-
tos de ex;loraci=n?
EBem;loC en el sistema nervioso se estudia la +acie./ la actitud 8 la
0arc1a ;or la ins;ecci=nD la 0otilidad ;or la ins;ecci=n7 la ;al;aci=n 8
las manio9ras com9inadasD el tro+i.0o ;or la ins;ecci=n 8 la ;al;aci=nD
la re+lectividad ;or la ins;ecci=n7 la ;al;aci=n7 la ;ercusi=n 8 las manio-
9ras com9inadasD etcAtera? Como se ve el mAtodo de examen es dife-
rente al utili:ado en el sistema circulatorio o en el res;iratorio en que se
estudia9anC todos los signos detecta9les ;or la ins;ecci=n7 todos los que
se o9tienen ;or ;al;aci=n7 todos los signos detecta9les ;or la ;ercu-
si=n7 8 los que son ;osi9les recoger ;or auscultaci=n?
Antes de entrar en la evaluaci=n del sistema nervioso en el examen
fsico general de la ;ersona <facies7 actitud 8 marc@a> es necesario
a9ordar diferentes as;ectos generales que de9en tenerse en cuenta en el
examen integral del suBeto desde el comien:o de la entrevista7 incluso
antes del examen fsico general 8 que constitu8en el ;rimer enfoque del
examen ;articular7 8 del registro7 del sistema nervioso?

La evaluaci=n del estado mental se @ace desde el ;rimer contacto con

el suBeto7 con la o9servaci=n del com;ortamiento 8 la evaluaci=n de
las res;uestas a las ;reguntas que usted reali:= durante la entrevista o
en su comunicaci=n con la ;ersona7 desde el comien:o del examen
fsico? Solo tiene que tener en cuenta que cuando usted ;regunta7 ;or
eBem;lo7 el nom9re7 la edad7 la direcci=n7 u ordena al suBeto o;tar
determinada ;osici=n7 estI tam9iAn evaluando el estado mental del
suBeto? Si la comunicaci=n 8 las res;uestas son adecuadas7 no tiene
necesidad de re;etir cada una de las ;reguntas o tAcnicas de ex;lora-
ci=n del estado mental7 cuando estA reali:ando el examen ;articular
del sistema nervioso? Pero si en estos ;rimeros momentos usted de-

145
PROPEDUTICA CLNICA Y SEMIOLOGA MDICA SECCIN I
tecta alguna alteraci=n que ;ueda interferir con el 9uen
desenvolvimiento del examen fsico7 es recomenda9le
evaluar ;rimero el estado mental7 e incluso todo el exa-
men del sistema nervioso7 ;ara ;oder conocer c=mo
enfocar el resto del examen fsico 8 sus limitaciones en
cuanto a las tAcnicas que necesiten de la comunicaci=n
adecuada con el suBeto?
Si 9ien es cierto que las tAcnicas de la evaluaci=n
mental se reali:an detalladamente en los suBetos que se
sos;ec@a o 8a tienen alteraciones neurol=gicas7 es ne-
cesario conocerlas desde a@ora7 ;ara ;oder concluir que
el examen del estado mental es normal7 ;ara ;oder lle-
varlo @asta el final7 si se detecta alguna anormalidad 8
;ara ;oder evaluar adecuadamente el estado mental de
individuos con alteraciones ;siconeurofisiol=gicas7 ;ero
;or lo demIs7 orgInicamente sanos7 como sucede en
los ancianos?
El examen del estado mental es el ;roceso de evalua-
ci=n de las funciones que son controladas ;or la corte:a
cere9ral7 como la @a9ilidad de ;ensar7 entender e
interactuar con el medio?
Los signos indicativos del estado mental ;ueden
revelarse ;or la a;ariencia 8 la conducta de las ;ersonas7
as como ;or las res;uestas a ciertas ;reguntas o ins-
trucciones?
Una forma de evidenciar tales signos es reali:ar el exa-
men del estado mental de una forma ordenada que com-
;rende lo siguienteC
$ Nivel de conciencia?
$ Orientaci=n <en tiem;o7 es;acio 8 ;ersona>?
$ Xa9ilidades ;ara la comunicaci=n?
$ Memoria?
$ LenguaBe?
La conciencia se refiere al nivel de vigilia 8 de res-
;uesta 8 estI regulada ;or el sistema reticular activador
ascendente <SRAA> en el tallo cere9ral <vAase YSndro-
me comatosoZ en el Ca;tulo [\7 en el Tomo \>?
De9e tenerse claro que en el sentido estricto7 la concien-
cia no es lo mismo que orientaci=n? Una ;ersona ;uede
estar consciente7 ;ero desorientada en tiem;o 8 es;acio?
El nivel de conciencia se eval]a o9servando el desen-
volvimiento de la ;ersona7 la @a9ilidad de @a9lar 8 cum-
;lir =rdenes ver9ales7 8 las @a9ilidades motoras?
De forma ;rimaria7 se clasifica 8 descri9e en relaci=n
con la intensidad de los estmulos sensoriales requeridos
;ara des;ertar a una ;ersona?
Los tArminos que ;ueden utili:arse ;ara descri9ir el
nivel de conciencia sonC
$ Alerta?
$ Consciente7 vigil o totalmente des;ierto?
146
$ O9nu9ilado?
$ Estu;oroso?
$ Comatoso?
Aunque estos tArminos estIn estandari:ados 8 re;re-
sentan o9servaciones es;ecficas7 algunos suBetos no ;ue-
den incluirse exactamente en una de estas categoras? En
estos casos7 el nivel de conciencia ;uede documentarse
con una descri;ci=n detallada del ti;o de estmulo que se
a;lic= ;ara @acerlo reaccionar 8 las res;uestas ver9ales
o motoras de este?
Alerta o vigilante. Es el nivel de conciencia mIs alto7
caracteri:ado ;or la ca;acidad de res;onder a todos los
ti;os de estmulos sensoriales de intensidad mnima7 cuan-
do las condiciones externas necesitan que el individuo
reaccione lo mIs rI;ido ;osi9le7 8 se manifiesta incluso
en modificaciones electroencefalogrIficas? Este nivel mIs
alto que el de la conciencia normal o vigil7 ;uede ser
incluso ;atol=gico?
8otal0ente de.9ierto/ con.ciente o vigil. Nivel de con-
ciencia en el cual el individuo estI com;letamente des-
;ierto 8 orientado en tiem;o7 lugar 8 ;ersona? AdemIs7
la ;ersona es ca;a: de res;onder a las =rdenes ver9ales?
Sin em9argo7 insistimos7 un individuo ;uede estar com-
;letamente consciente7 ;ero continuar desorientado?
:;nu;ilado. El suBeto se muestra somnoliento7 o dormi-
do la ma8or ;arte del tiem;o7 ;ero es ca;a: de reali:ar
movimientos es;ontIneos? Es ;osi9le des;ertarlo7 ;ero
@a9itualmente se requiere una suave ;almada o sacudida
adicional7 ;ara que diga su nom9re? Un suBeto o9nu9ilado
tiende a volver a dormirse fIcilmente 8 ;uede estar deso-
rientado?
<.tu9oro.o. El suBeto duerme casi todo el tiem;o 8 reali-
:a ;ocos movimientos cor;orales es;ontIneos? Se nece-
sitan estmulos mIs vigorosos como gritarle o sacudirlo
;ara ;oder des;ertarlo? l es aun ca;a: de res;onder
ver9almente a estos estmulos7 aunque lo @ace err=nea-
mente 8 ;or ;oco tiem;o7 ;ero estI menos a;to o es
inca;a: de cum;lir =rdenes 87 si ;retende @acerlo7 sus
res;uestas son equivocadas? Un suBeto estu;oroso rara-
mente se orienta o se des;ierta com;letamente7 incluso
cuando el examinador le estA reali:ando ;rue9as de res-
;uesta a estimulaciones sensoriales?
=o0ato.o. El suBeto estI inconsciente la ma8or ;arte del
tiem;o 8 no muestra actividad motora es;ontInea? Se
necesitan estmulos nocivos fuertes como el dolor7 ;ara
;rovocar una res;uesta motora7 que @a9itualmente es un
intento dirigido a quitar el estmulo? Las res;uestas ver-
9ales estIn limitadas a alg]n monosla9o o ausentes? Si
no ocurre res;uesta refleBa7 el individuo estI en coma
;rofundo?
 CAPTULO 13
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172
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D= V D7S6 <P:8=@D8I?DM>=8C M@?>D JD7O D10 V D11S
V <P:8=@D8I?DM>=8C >=#@E>DE JD11 V D1RS.
4$ Reflejo cremasteriano ; reflejo <om/logo en la mujer.
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9P B8E:@ 9PB@E>DEO D <DMBE>M>@=?D C8 M898 ?@ CD9
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?@C DIC><PD M8VDE JE@#C@UD ?@ G@>$@CS.
+entros reflex/genos: L1 V LR.
5$ Reflejo cutaneoplantar. L8 @A<>:8<>F= <D= C8 V@M8 ?@C
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