cns case,exmaination and case presentation.pptx

case presentation examination

1. EXAMINATION:

2. At the time of examination, child was sitting comfortably on the bed with cannula in right hand. Vitals: PR-102/ min,good volume,regular in rhythm,all peripheral pulses were palpable RR-24/min regular and abdominothoracic Temperature- BP- CFT<3 secs SpO2-

3. Pallor-Present Icterus-absent, cyanosis-absent, clubbing-absent, pedal edema -absent Lymphadenopathy-present Submental-not enlarged Bilateral submandibular lymph nodes enlarged largest measuring 3.5 X 3 cm in size,firm in consistency,mobile,non-tender,no erythema overlying the skin Upper ,middle and lower cervical enlarged-largest measuring 3x3 cm in size, firm in consistency,mobile,non-tender,no erythema overlying the skin Bilateral posterior auricular lymph nodes were enlarged measuring 2x2 cm in size firm in consistency,mobile,non-tender,no erythema overlying the skin Bilateral supraclavicular lymph nodes were palpable Axillary-Right side: 2 lymph nodes palpable right anterior and right medial axillary measuring 2x2 cm in size, firm in consistency,mobile,non-tender,no erythema overlying the skin Axillary-Left side: 2 lymph nodes palpable left medial and apical axillary measuring 2x2 cm in size, Axillary-Right side: 2 lymph nodes palpable right anterior and right medial axillary measuring 2x2 cm in size, firm in consistency,mobile,non-tender,no erythema overlying the skin Multiple bilateral inguinal lymph nodes palpable,largest measuring 3.5x2.5 cm in size , firm in consistency,mobile,non-tender,no erythema overlying the skin

4. Anthropometry: Weight-21.8 kg Height-126.5 cm BMI-13.62 kg/m2 Weight/age [-1.13 SD] Normal Height/Age[-0.62 SD] Normal BMI/age[-1.15]

5. Head to toe- Hair is normal in color and texture,Head no shape or size abnormality, Eyes-pallor present,inability to close left eye completely Oral cavity-no ulcers,no oral thrush,gums normal,dental caries Tonsils Facial deviation to right side and loss of nasolabial fold described in facial nerve examination Neck-lymph nodes swelling present as described earlier BCG scar- No petechiae,No purpura,No rahs Testes-not enlarged Bony tenderness Spine-normal no tenderness

6. Per abdomen examination: Inspection-abdomen is normal in shape,all quadrants move equally with respiration,umbilicus is inverted, no visible peristalsis,no dilated veins,no visible pulsations,no visible scars or sinuses. Palpation- superficial palpation-no tenderness/guarding/rigidity Deep palpation: Liver-palpated 7 cm below the costal margin in the mid clavicular line,firm in consistency,surface is smooth,non-tender,margin is rounded Liver span is 12.5 cm Spleen-palpable 10 cm below the costal margin along the splenic axis,hard in consistency,sharp margin,non-tender,splenic notch palpable Percussion-no shifting dullness or fluid thrill Auscultation-Bowel sounds present 2-3/ min,no bruit

7. Neurological examination: Higher Mental Functions: Child is conscious,alert,oriented in time,place and person. Speech-normal Memory-intact Cranial Nerves- 1 st nerve:Normal 2 nd nerve:visual acuity- normal,field of vision- normal,fundus -normal Pupils-bilateral pupils are normal in size and shape and symmetrical Direct light reflex and accommodation reflex-present 3 rd ,4 th ,6 th nerve: extraocular movements teted in all directions were normal No ptosis/squint 5 th nerve:Sensory : sensations present over the face in areas of all 3 divisions of the nerve Motor: Massester,temporalis , medial and lateral pterygoid functions are normal(child is able to open/close/protrude/retract and move jaw from side to side mouth.No deviation of jaw Reflex-corneal and conjunctival reflex-present

8. 7 th nerve: Wrinkling over the left part of the forehead lost,unable to raise the left eyebrow(frontalis) Unable to close the left eye completely (orbicularis occuli ) Deviation of angle of mouth to the right side on smiling Loss of nasolabial folds on the left side of the face Unable to blow out cheek 8 th nerve: rinne’s test + ve,weber test-equal on both sides 9 th and 10 th nerve:uvula central,normal palatal movements on saying ah,gag reflex present 11 th nerve: SCM and trapezius intacts,able to shrug shoulders and turn head to one side 12 th nerve: Tongue is normal in size,shape,no deviation of tongue,no wasting,no fasiculations

9. Motor system : Bulk - the muscles bulk is B/L symmetrical Tone : UL – normal LL – normal Power-is 5/5 in all joints in upper limb and lower limb Reflexes: Superficial reflexes: Abdominal reflexes -Present Plantar reflex- Bilateral flexor Superficial reflexes: • Abdominal reflexes Present Present • Plantar reflex NE NE DTRs Right Left Biceps reflex + + Triceps reflex + + Supinator reflex + Knee reflex ++ ++ Ankle reflex + +

10. Sensory System: Touch,Pain,Temperature sensation intact on all dermatomes • Vibration sense,Joint position sense intact Cortical sensation : Tactile localisation,tactile discrimination and stereognosis is intact Cerebellar signs: No nystagmus, Gait – normal, Romberg’s test – negative, Finger-nose test – no intention tremor, no dysmetria (past pointing), No dysdiadokinesia • Involuntary movements : no abnormal movements seen • Meningeal signs : no signs of meningeal irritation • Skull and Spine : no spinal deformity, no spinal tenderness Other system exam : WNL