Basics of CNS examinationBY:

Dr, WALAA SALAH MANAA SPECIALEST OF PEDIATRIC &

FEVER مـستشفى حمـيات كـفر الشـيخ

1-mental status.2-speech

3-cranial nerves.Sign of meningeal irritation.-4

5-motor system- posture.

- gait.- muscle(status-tone –power).

- Involuntary movement-coordination .6-sensory system.

7-reflexes- superficial.

- deep- others

NEUROLOGICAL EXAM

1-consciousness.2-emotion.( e.g. apathy)

3-behavior.(calm – irritable)4-intelligence.I.Q.

5-orientation.(P.P.T).6-Handness

( start to use dominant hemisphere 18m-3yrs.)

7-memory.

1-mental status

1-Lethargy=sleepy but fully arousable.

2-Drowsiness=light coma+arousable only to severe stimuli.

3-Stupor=moderate coma+unarousable+localize the pain .

4-Coma=deep coma.. unarousable..not localize the

pain.

1-consciousness.

I.Q.

1-Immediate memory………………….. . 6عد متتاليه ارقام

بايه حاسس انت المريض Recent memory-2اسال

اكثر من حصلت حاجه عن اسألهسنوات 5من

3-Remote memory

memory

Delayed speech = no word up to 18 m.

Or no sentence up to 3yrs. Causes

-MR-Deafness

-articulation defect-bilingolism-physiological.

Slurred speech……………………(pyramidal lesion).Monotonus speech …………….(extrapyramidal lesion).Staccato speech…………………(cerebeller lesion)

2-speech.

3rd & 4th cranial nerves are located in the mid brain

5th , 6th , 7th & 8th cranial nerves are located in the pons

9th , 10th , 11th & 12th cranial nerves are located in the medulla oblongata

Where CN Come From?

Common non irritant odours +to each nostril+ eye closed. Difficult in children .

Anosmia =loss of smell.

1-OLFACTORY

2-opitic 1-visual

acuity 2-Field of vision 3-fundus

examination

3rd -4th -6th 1-Pupil size+

reaction to light

3-ptosis2-Ocular

movement

Afferent….. Optic nerve.Center……..midbrain.(3rd nerve nuclei ).Efferent……3rd cr. N. to both eyes.

Light reflex

1-Sensory: ophthalmic-maxillery-mandibuler.

2-motor : masseter - temporalis –pterigoid.

3-reflexes : corneal reflex-jaw reflex.

Trigeminal N.

2-motor : masseter – temporalis

( palpation when clenching.)– pterigoid.

( side to side movement)

3-reflexes : corneal reflex

عينه , فى انفخ تعمله عارف مش ولو

3-reflexes :

jaw reflex. حتى ألسفل الضرب اتجاه يكون ان يجبالفك ينفتح

 Normally this reflex is absent or very slight. However in individuals with UMNL the jaw jerk reflex can be quite pronounced.

1-Sensory-----ant.2/3 of tongue.2-Motor-----forehead –eye -mouth.

Facial paralysis= (mouth deviation to healthy side

+weak eye closure +absent corrugation of forehead)

7th

Cochlear part(hearing)* At birth ---moro reflex.

* younger deviate to sound.* Later Renne s test+ Weber test .

Vestibular part nystagmus +vertigo

8th

Sensory ……loss of post 2/3 of tongue.

Motor……pharyngeal O/E.… 1-gag reflex…absent in bulber palsy UMNL…… exaggarated in pseudo bulber palsy LMNL.

2-Uvula ….normally central & mobile.

In unilateral lesion….uvula deviate to healthy side.In bilateral lesion…uvula is central but immobile.

9th &10th tested together

11th

Spinal accessory N.

Sternomastoid……ability to rotate head to healthy side.

Trapezius…….dropping of shoulder in affected side

11th

Hypoglossal N..… . deviation of the tongue to the affected side

on protrusion.

12th

Bulber palsy Pseudo –bulber palsy

It is LMNL of the bulber cranial nerve 8-9.

Lead to loss of gag reflex + flaccid paralysis of pharynx & larynx.

It is UMNL of the bulber cranial nerve nuclei

Lead to exaggerated gag reflex.Spastic paralysis of the pharynx & larynx .

3-signs of meningeal irritation

Late singes Neck stiffness. Back stiffness. +ve kernig’s sing. +veBrudziniski’

neck sign. +veBrudziniski’ leg

sign.

Early singe chin-chest test. Chin-knee kissing

test. Tripod singe

Rapid flexion of the head is accompanied by brisk flexion of both knee

Inability to extend the knee,when the thigh is flexed at the hip

1-decubitus.2-gait.

3-muscle status.4-muscle power.

5-Muscle tone.6-involuntery movement.

7-co-ordination.

4-motor system

Facial nerve

1-decubitus

Ataxic gait……ataxic CP.Scissoring gait in spastic CP.Not able to walk.

2-gait.

3-muscle status.

pseudo hypertrophy muscle atrophymuscle hypertrophy

1-Young child…….painful stimulation on the opposite side of the tested muscle.

2-Older child….ask to move against resistance.

3-Test every joint for its muscle group.4-Grading of muscle power

4-muscle power.

U.L.

small muscle of hand — يكتب بيعرف القميص يزرر بيعرف .الولدMuscle of lbow Flexors… الشباك او الدرج يفتح بيعرف extensors= الدرج او الشباك يقفل .بيعرفShoulder…. Flexor… الكم فى ايده يحط بيعرف Extensor الكم من ايده يشيل بيعرف Adductor .. باطه تحت الكشكول يحط

History

L.L.

Small muscle of LL…. الشبشب منه بقع الولد وهوماشى

Knee…. ونزوله السلم طلوعAdductor …. رجل على رجل يحطAbductor…. رجل على من رجل يشيل

Trunk.

-Flexor…. ظهره على نايم لو الولديساعده حد ما غير من يقوم يقدر

زراعه بمساعدة او

-Extensor…. االرض على قاعد لوغير من الجذع بيرفع يقوم بيجى

يسند ما.

Neck….pulling the child from both UL.

Intercostal m. ……short breath

حتى العد بعد...... 10اليستطيع على شمعه اطفاء .30اليستطيع سم

m. Of abdomen…….localize bulge of the

abd.(e.g. poliomylitis) . Diaphragm…..paradoxical respiration.

*To detect hypertonia…….passive movement around big joint.

*To detect hypotonia…….shaking movement wrist or ankle

5-Muscle tone.

1-LMNL2-UMNL.=pyramidal lesion (shock stage)

3-Extrapyramidal lesion (chorea).4-cerebeller lesion (ataxia).

5-Down s syndrome.6-Atonic CP.

hypotonia

UMNL =Pyramidal lesion..… spasticity(clasp knife) resistance on

the start of movement.

Extrapyramidal lesion..… rigidity(resistance is all over

movement ). Rigidity may be (cog-weal or lead

pipe)

hypertonia

=usually with extrapyramidal lesion.

*Chorea….sudden irregular purposeless dancing movement affect big proximal joint.

*Athetosis…slow twisting movement affect distal joint.

*Dystonia….slow twisting movement in trunk.

*Tremors….rapid alternating movement around small joint.

6-involuntery movement.

Athetosisdystonia

tremors chorea

-1st year ……grasp reflex & object transfer.

-2nd year……button & unbutton.

->3years……U.L. 1- Finger to nose test 2-Finger to finger test 3-Dysdiadochokinesis…inability toperform rapidly

alternating movement(e.g. rapid pronation and supination) 4-Rebound test L.L. Heal to shin test Toe finger test Foot Tapping testInco-ordination = ataxia.

7-co-ordination.

Isolated fibers contraction not all the muscle.

Difficult to see in any muscle

Easily to seen in the tongue? purly muscle organ coverd by mucosa ,,,,no

submucosa or fat like other muscle.

=LMN

8-Muscle fasciculation

Superficial sensation….(pain-tough-temp.).

Deep sensation………(joint sense-vibration sense-deep pressure sense).

Cortical sensation(tactile localization-tactile discrimination-steriogenosis)

6-Sensory system

Special standpoints:

Requires good cooperation on the patient`s side.

Most often we compare different parts of the body.

The patient should not see the examined part of the body !

Pain: pin prick, tooth picks

Light touch: use a wisp of cotton wool.

Temperature: use cold (5-10 0C)/or hot (40-45 0C)

test tubes.

Joint position / motion: -Hold the sides of the patient’s

finger ! Move it up and down at random ! Ask to specify the

direction of movement !

Vibration: -Place a vibrating tuning fork

on a bony prominence ( ankle, knee,processus styloideus radii

and ulnae, elbow, clavicula)

Two point discrimination:

-The ability to discriminate two blunt points when applied simultaneously. (3-5 mm on the finger, 4-7 cm on the trunk) .

Astereognosis.- Inability to identify an object by palpation

sudden passive stretchsudden massive activation of AHCssudden massive contraction of all muscle fibers

Superficial reflexes-deep –visceral-others

7-reflexes

*Scratch the lateral part of the sole.…..…planter flexion of the toes.

+ve Babiniski s.=dorsiflexion of the big toe &

fanning of the other toes=UMNL

Normal up to 2yr…….why?

plantar reflex (S1)

Scratch abdominal wall by a pin from outward inward ….contraction of a segment of abdominal muscles.

Abdominal reflex (T7…T12)

T7T8T9

T10T11T12

Light scratch along the inner aspect of the upper part of the thigh lead to

elevation of the testicles.

Cremastric reflexe (L1)

Scratch the peri anal region

lead to contraction of external anal sphincter.

(Anal reflex(S 3-4-5

Biceps jerk (c5-6)

Blow upon the thumb on the biceps tendon while the elbow is slightly extended

Deep reflex

Blow upon the triceps tendon while the elbow is flexed.

triceps jerk (c6-7)

Blow upon styloid process of radius….flexion & supination of elbow… (brachioradialis)

Supinator reflex(c5-6)

Blow on the qudriceps tendon..( pateller tendon)

Knee reflex (L 3-4)

Blow on tendoachilis……

Ankle jerk (S1-2)

Only done if jerk is exaggerated (UMNL).ايه؟؟؟؟؟؟؟؟ شروطها

* Ensure that the pt is relaxed .* Apply sudden and sustained flexion to the

ankle ……* normally few oscillatory beats may occur..…

* if persist = +ve clonus.

clonus

Knee clonus.. Ankle clonus..

1-physiological < 18m.2 -pathological:

= lesion in the arc 1-afferrent ………...neuritis.

2-posterior horn…..disc protrusion. 3-AHC……………….Poliomylitis.

4-Efferrent………...neuritis. 5-muscle…………...myopathy.

Causes of absent jerk

Let us to see?

Video of abnormal movement

Thank You