CNS examination

محاضرة تم القائها فى مستشفى حميات كفر الشيخ عام 2014 على مدار 4 ساعات

1. Basics of CNS examination BY : Dr, WALAA SALAH MANAA SPECIALEST OF PEDIATRIC & FEVER مـستشفى حمـيات كـفر الشـيخ

2. 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

3. 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

4. 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.

5. I.Q.

6. 1-Immediate memory………………….. . عد 6 ارقام متتاليه اسال المريض انت حاسس بايه 2-Recent memory اسأله عن حاجه حصلت من اكثر من 5 سنوات 3-Remote memory memory

7. 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.

8. 3 rd & 4 th cranial nerves are located in the mid brain 5 th , 6 th , 7 th & 8 th cranial nerves are located in the pons 9 th , 10 th , 11 th & 12 th cranial nerves are located in the medulla oblongata Where CN Come From?

9. Common non irritant odours +to each nostril+ eye closed . Difficult in children. Anosmia =loss of smell. 1-OLFACTORY

10. 2-opitic 1-visual acuity 2-Field of vision 3-fundus examination

11. 3rd -4th -6th 1-Pupil size+ reaction to light 3-ptosis 2-Ocular movement

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

13. 1-Sensory : ophthalmic- maxillery - mandibuler . 2-motor: masseter - temporalis – pterigoid . 3-reflexes: corneal reflex-jaw reflex. Trigeminal N.

14. 2-motor: masseter – temporalis (palpation when clenching). – pterigoid . (side to side movement)

15. 3-reflexes: corneal reflex , ولو مش عارف تعمله انفخ فى عينه

16. 3-reflexes: jaw reflex. يجب ان يكون اتجاه الضرب لأسفل حتى ينفتح الفك   Normally this reflex is absent or very slight. However in individuals with UMNL the jaw jerk reflex can be quite pronounced.

17. 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) 7 th

18. Cochlear part(hearing) *At birth ---  moro reflex. *younger deviate to sound. *Later Renne s test+ Weber test. Vestibular part nystagmus +vertigo 8 th

19. 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. 9 th &10 th tested together

20. 11 th

21. Spinal accessory N. Sternomastoid ……ability to rotate head to healthy side. Trapezius …….dropping of shoulder in affected side 11 th

22. Hypoglossal N. ….. deviation of the tongue to the affected side on protrusion. 12 th

23. 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.

24. 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

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

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

27. 1-decubitus. 2-gait. 3-muscle status. 4-muscle power. 5-Muscle tone. 6-involuntery movement. 7-co-ordination. 4-motor system

28. Facial nerve

29. 1-decubitus

30. Ataxic gait……ataxic CP. Scissoring gait in spastic CP. Not able to walk. 2-gait.

31. 3-muscle status. pseudo hypertrophy muscle atrophy muscle hypertrophy

32. 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.

33. U.L. small muscle of hand الولد بيعرف يزرر القميص—بيعرف يكتب. Muscle of lbow Flexors… بيعرف يفتح الدرج او الشباك extensors= بيعرف يقفل الشباك او الدرج. Shoulder…. Flexor… بيعرف يحط ايده فى الكم Extensor بيعرف يشيل ايده من الكم Adductor .. يحط الكشكول تحت باطه History

34. L.L. Small muscle of LL…. الولد بقع منه الشبشب وهوماشى Knee…. طلوع السلم ونزوله Adductor …. يحط رجل على رجل Abductor…. يشيل رجل من على رجل

35. Trunk. -Flexor…. الولد لو نايم على ظهره يقدر يقوم من غير ما حد يساعده او بمساعدة زراعه -Extensor…. لو قاعد على الارض بيجى يقوم بيرفع الجذع من غير ما يسند .

36. Neck….pulling the child from both UL. Intercostal m. ……short breath لايستطيع العد حتى 10......لايستطيع اطفاء شمعه على بعد 30 سم. m. Of abdomen…….localize bulge of the abd .(e.g. poliomylitis ). Diaphragm…..paradoxical respiration.

37. *To detect hypertonia …….passive movement around big joint. *To detect hypotonia …….shaking movement wrist or ankle 5-Muscle tone.

38. 1-LMNL 2-UMNL.=pyramidal lesion (shock stage) 3-Extrapyramidal lesion (chorea). 4-cerebeller lesion (ataxia). 5-Down s syndrome. 6-Atonic CP. hypotonia

39. 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

40. = 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.

41. Athetosis dystonia tremors chorea

42. -1 st year ……grasp reflex & object transfer. - 2 nd 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 test Inco-ordination = ataxia. 7-co-ordination.

43. 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

44. Superficial sensation….(pain-tough-temp.). Deep sensation………(joint sense-vibration sense-deep pressure sense). Cortical sensation(tactile localization-tactile discrimination- steriogenosis ) 6-Sensory system

45. 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 !

46. Pain: pin prick, tooth picks Light touch: use a wisp of cotton wool. Temperature: use cold (5-10 C) /or hot (40-45 C ) test tubes.

47. 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 )

48. 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 ) .

49. Astereognosis . -Inability to identify an object by palpation

50. sudden passive stretch  sudden massive activation of AHCs  sudden massive contraction of all muscle fibers Superficial reflexes-deep –visceral-others 7-reflexes

51. *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)

52. Scratch abdominal wall by a pin from outward inward ….contraction of a segment of abdominal muscles. Abdominal reflex ( T7…T12) T7 T8 T9 T10 T11 T12

53. Light scratch along the inner aspect of the upper part of the thigh lead to elevation of the testicles. Cremastric reflexe (L1)

54. Scratch the peri anal region lead to contraction of external anal sphincter. ( Anal reflex(S 3-4-5

55. Biceps jerk (c5-6) Blow upon the thumb on the biceps tendon while the elbow is slightly extended Deep reflex

56. Blow upon the triceps tendon while the elbow is flexed. triceps jerk (c6-7)

57. Blow upon styloid process of radius….flexion & supination of elbow… ( brachioradialis ) Supinator reflex(c5-6)

58. Blow on the qudriceps tendon.. ( pateller tendon) Knee reflex (L 3-4)

59. Blow on tendoachilis …… Ankle jerk (S1-2)

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

61. 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

62. Let us to see? Video of abnormal movement

63. Thank You