Date post: | 18-Jan-2017 |
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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