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Clinical Assessment of Children with Suspected Central Nervous System Infections Brain Infections Group   University of Li...
Contents <ul><li>Using this  presentation </li></ul><ul><li>Introduction </li></ul><ul><li>Checking the sick child </li></...
Using this presentation (1) <ul><li>This presentation can be viewed by: </li></ul><ul><ul><li>Clicking through each slide ...
Using this presentation (2) <ul><li>This presentation contains still images linked by an arrow button.  </li></ul><ul><li>...
Introduction (1) <ul><li>This presentation has been developed for use by doctors and health care workers in areas where Ja...
Introduction (2) <ul><li>At the end of the presentation participants will </li></ul><ul><ul><li>Be better able to take a h...
Checking the sick child <ul><li>Check the ABC’s: </li></ul><ul><li>Airway  </li></ul><ul><li>Breathing </li></ul><ul><li>C...
Patient history: general questions (1)   <ul><li>Presenting history </li></ul><ul><ul><li>What brought them to hospital, d...
Patient history: general questions (2) <ul><li>Social history </li></ul><ul><ul><li>Economic circumstances </li></ul></ul>...
Patient history: JE-related questions (1) <ul><li>Is this an area where JE occurs? </li></ul><ul><li>Is this the JE season...
Patient history: JE-related questions (2) <ul><li>Are there epidemiological features to suggest that this is  NOT  JE?  </...
Patient history: neurological disease (1) <ul><li>Ask about: </li></ul><ul><li>Stiff neck </li></ul><ul><li>Photophobia (a...
<ul><li>Ask about: </li></ul><ul><li>Altered cry </li></ul><ul><ul><li>High pitch cry is a late sign of raised intracrania...
Patient history:  seizures or abnormal movements (1) <ul><li>Ask about abnormal movements of eyes, face, limbs. </li></ul>...
Examples of seizures or abnormal movements <ul><li>Ask parent to mimic seizure / abnormal movements………………………………. </li></ul...
Asking parent to mimic child’s seizure or abnormal movements Return to examples
Seizure activity in JE patient Return to examples In this patient, the left arm was shaking slightly (subtle partial seizu...
Subtle seizure activity Return to examples
Orofacial movements are characteristic of patients with JE Return to examples
Patient history:  seizures or abnormal movements (2) <ul><li>If seizures are reported, ask about frequency and duration.  ...
Completion of patient history <ul><li>Growth chart  </li></ul><ul><ul><li>Height for age and weight or mid upper arm circu...
Example of  a history proforma
Neurological examination  <ul><li>Neurological examination includes: </li></ul><ul><li>Observation </li></ul><ul><li>Asses...
Neurological examination  <ul><li>Neurological examination includes: </li></ul><ul><li>Observation </li></ul><ul><li>Asses...
Observation <ul><li>Simple observation is vital </li></ul><ul><ul><li>A huge amount of information can be gained for the e...
Neurological examination  <ul><li>Neurological examination includes: </li></ul><ul><li>Observation </li></ul><ul><li>Asses...
2.1 Assessing mental state <ul><li>Assessing mental state can be difficult, particularly in young children. </li></ul><ul>...
2.2 Assessing conscious level <ul><li>The Glasgow Coma Score is the most widely used score  </li></ul><ul><ul><li>A modifi...
Glasgow Coma Score and the  James Modification for children <5 years AVPU Return to examples   Adults and children >5 year...
AVPU rapid assessment of consciousness level <ul><li>A  ALERT </li></ul><ul><li>V  responds to VOICE </li></ul><ul><li>P  ...
Glasgow Coma Score:  Sternal rub - patient localises to pain
Neurological examination  <ul><li>Neurological examination includes: </li></ul><ul><li>Observation </li></ul><ul><li>Asses...
3.1: Cranial nerves I-VII <ul><li>This examination can be done in older children and adults. </li></ul><ul><li>I  Olfactor...
<ul><li>VIII Vestibulocochlear </li></ul><ul><ul><li>Is hearing reduced? </li></ul></ul><ul><li>IX Glossopharyngeal </li><...
<ul><li>Optic (II)  </li></ul><ul><ul><li>Visual acuity: Snellen chart or “E” card  </li></ul></ul><ul><ul><li>Visual fiel...
Eye examination - examples <ul><li>Visual acuity charts………………...... </li></ul><ul><li>Direct light reflex……………………… </li></...
Visual acuity charts <ul><li>E  </li></ul>Ш E E  Ш  E   Ш  E  Ш  E   Ш  Ш  E   Ш  Ш Ш  E  Ш  E   Ш  E   Ш  E  E   Ш  E   Ш...
Direct light reflex Film credit: T Solomon Return to examples
Eye movements: head still,  instruction “follow my finger” Photo credit: Tom Shulz Return to examples
Right VI th  nerve palsy – right eye is unable to abduct (move outwards) Trying to look  this way Return to examples
Bilateral VI th  nerve palsy – look carefully, neither eye abducts Return to examples
Ophthalmoscopy:  examiner’s right eye to patient’s right eye Photo credit: Tom Shulz Return to examples
Ophthalmoscopy:   examiner’s left eye to patient’s left eye Photo credit: Tom Shulz Return to examples
Opthalmoscopy: young child Photo credit: Tom Shulz Return to examples
Cranial nerves V-XII examples <ul><li>V Trigeminal nerve examination..………………………. </li></ul><ul><li>V Trigeminal nerve: Jaw...
V Trigeminal nerve examination Photo credit: Tom Solomon Return to examples
V Trigeminal nerve:  jaw jerk normal Photo credit: Tom Solomon Return to examples
V Trigeminal nerve:  jaw jerk abnormal (brisk) Photo credit: Tom Solomon Return to examples
VII nerve examination: “Screw your eyes up” Return to examples
V and VII nerves: “Screw your eyes up, show me your teeth” Return to examples
Hearing: Otitis externa/otitis media Return to examples
VIII nerve examination: Hearing Return to examples
Profound hearing loss Return to examples
XI nerve examination: Neck and shoulders Return to examples
XII nerve examination: Stick out tongue Photo credit: Tom Solomon Return to examples
XII nerve: Tongue movements Normal Tongue deviated to right, Left nerve damage Return to examples
3.2 Cerebellar tests <ul><li>Finger-nose test </li></ul><ul><li>Rapid alternating hand movements (Dysdiadochokinesis) </li...
Cerebellar examples <ul><li>Finger-nose test normal…………………….. </li></ul><ul><li>Finger-nose test abnormal…………………. </li></u...
Cerebellar tests:  finger-nose test normal Photo credit: Tom Shulz Return to examples
Cerebellar tests:  finger-nose test abnormal Return to examples
Cerebellar tests: rapid alternating hand movements (dysdiadochokinesis)  abnormal (1 st ) and normal (2 nd ) Return to exa...
Cerebellar tests: nystagmus Return to examples This patient had downbeat nystagmus when looking to the right: i.e. nystagm...
Cerebellar tests: heel-toe walking Return to examples
Cerebellar tests: heel-shin test normal (1 st ) & abnormal (2 nd ) Return to examples
3.3 Brainstem <ul><li>Doll’s eye reflex </li></ul><ul><ul><li>(Occulocephalic reflex) </li></ul></ul><ul><li>Gag reflex   ...
Brainstem examples <ul><li>Doll’s eye reflex normal……………................... </li></ul><ul><li>Doll’s eye reflex abnormal……...
Doll’s eye reflex: present (normal) Return to examples
Doll’s eye reflex: absent (abnormal) Photo credit: Tom Solomon Return to examples
Opisthotonus in JE Return to examples
Extensor posturing in JE Photo credit: Tom Solomon Return to examples
Focal brain damage (for comparison) Return to examples
3.4 Special tests: Neck stiffness <ul><li>Neck stiffness </li></ul><ul><ul><li>Stiffness or rigidity in the neck indicates...
Neck stiffness examples <ul><li>Neck stiffness normal………………………. </li></ul><ul><li>Neck stiffness abnormal…………………… </li></u...
Neck stiffness: normal Return to examples
Neck stiffness: abnormal Return to examples
3.5 Clinical significance of neurological findings (1) <ul><li>Space occupying lesion  </li></ul><ul><ul><li>signs of unca...
<ul><li>Diffuse increased cerebral pressure  </li></ul><ul><ul><li>signs of central syndrome of herniation </li></ul></ul>...
Clinical significance of neurological findings (3) <ul><li>Brainstem dysfunction   </li></ul><ul><li>Signs </li></ul><ul><...
Neurological examination  <ul><li>Neurological examination includes: </li></ul><ul><li>Observation </li></ul><ul><li>Asses...
Peripheral nervous system examination <ul><li>First look at the patient carefully. Check for  any asymmetry, differences i...
4.1 Assessing tone in the arms <ul><li>Gently bend the arm at the wrist and elbow joints, using circular movements.  </li>...
Arm tone normal
4.1 Assessing tone in the legs <ul><li>Gently roll the leg from side to side </li></ul><ul><ul><li>Does the foot gently ro...
Examining tone examples <ul><li>Increased leg tone……………………………. </li></ul><ul><li>Decreased leg tone - “Frog’s legs” test……...
Increased leg tone Return to examples
The “frog’s legs” test for decreased tone <ul><li>The health care worker draws up the knees with the legs bent; when they ...
4.2 Assess power in the limbs <ul><li>If the child can cooperate, assess power of flexion and extension at each joint, usi...
Power upper limbs: normal
Power lower limbs: normal Photo credit: Tom Shulz
4.3 Examining the reflexes (1) <ul><li>First demonstrate the use of the tendon hammer on yourself or an assistant, so that...
4.3 Examining the reflexes (2) <ul><li>Plantar (Babinski) reflexes  </li></ul><ul><ul><li>Are they flexor? (down, normal) ...
Reflexes examination examples <ul><li>Upper limb abnormal……………….…….. </li></ul><ul><li>Supinator abnormal……………………….. </li>...
Reflexes: Upper limb  Right and left abnormal (brisk) Return to examples
Supinator reflexes abnormal Photo Credit: T Solomon Return to examples
Knee jerks abnormal (brisk) and normal Return to examples
Plantar reflex normal Return to examples
Plantar reflex abnormal Photo Credit: T Solomon Return to examples
Clonus (abnormal) Return to examples
Abdominal reflexes normal Return to examples
Abdominal reflexes absent (abnormal) Photo Credit: T Solomon Return to examples
4.4 Sensation <ul><li>The sensory exam is used to determine areas of abnormal sensation and the quality and type of any se...
4.5 Gait <ul><li>Observe the patient walking in different ways </li></ul><ul><ul><li>In a straight line </li></ul></ul><ul...
Gait example: abnormal
Examination general <ul><li>Observe the child’s behaviour and actions,  </li></ul><ul><li>even whilst taking the history. ...
Basic measurements and other systems <ul><ul><li>Basic measurements </li></ul></ul><ul><ul><ul><li>Blood pressure </li></u...
Other systems: Skin <ul><li>Look for: </li></ul><ul><li>Skin turgor </li></ul><ul><li>Capillary refill time </li></ul><ul>...
The tourniquet test for dengue Inflate the blood pressure cuff to half way between systolic and diastolic for 5 minutes. 2...
Other systems: Ear, Nose and Throat <ul><li>Ear, nose and throat (ENT) examination is important, but it may be possible to...
Other systems: Respiratory <ul><li>Assess the breathing rate and pattern.  </li></ul><ul><li>Listen to the chest. An abnor...
Other systems: Cardiovascular <ul><li>Count pulse rate and assess rhythm (irregular or regular). </li></ul><ul><li>Measure...
Other systems: Gastrointestinal <ul><li>Check mouth for ulcers/infections </li></ul><ul><li>Feel abdomen  </li></ul><ul><l...
Example of an  examination proforma
History and examination complete! <ul><li>You have reviewed the history and examination of a child with a suspected centra...
Case examples <ul><li>Case 1………… </li></ul><ul><li>Case 2………… </li></ul><ul><li>Case 3………… </li></ul><ul><li>Case 4………… </...
Observation: case 1 <ul><li>Look at the child in the next pictures walking across the room normally, and then on her heels...
Case 1
Case 1 <ul><li>You have already done a large part of the neurological examination! </li></ul><ul><li>Not convinced? </li><...
Case 1 <ul><li>Ask yourself: </li></ul><ul><li>Is the child’s general appearance normal or abnormal?  </li></ul><ul><li>Is...
Case 1 <ul><li>Ask yourself: </li></ul><ul><li>Is the child’s general appearance normal or abnormal?  </li></ul><ul><ul><l...
Case 1 <ul><li>From this observation, we have information about the following: </li></ul><ul><ul><li>PNS:  </li></ul></ul>...
Case 1:  Additional testing to complete the exam <ul><li>This child needs further examination: </li></ul><ul><li>CNS exami...
Case 2 <ul><li>The next case is a little more difficult.  </li></ul><ul><li>But remember observation! </li></ul><ul><li>An...
Case 2  Photo credit: Tom Shulz
Case 2
Case 2 <ul><li>Ask yourself: </li></ul><ul><li>Is the child’s general appearance normal or abnormal?  </li></ul><ul><li>Is...
Case 2: Answers  <ul><li>Was the child’s general appearance normal or abnormal?  </li></ul><ul><ul><li>Answer: Generally l...
Case 2 <ul><li>Again we have a large amount of information about the CNS and PNS without formally examining the child. </l...
Case 3 <ul><li>As with the previous cases look at the pictures carefully.  </li></ul><ul><li>Remember to look at all the l...
Case 3  Photo credit: Tom Shulz  Notice the fixed position of her right arm
Case 3 The knee jerk was brisk
Case 3 <ul><li>Ask yourself: </li></ul><ul><li>Is the child’s general appearance normal or abnormal?  </li></ul><ul><li>Is...
Case 3 <ul><li>Ask yourself: </li></ul><ul><li>Is the child’s general appearance normal or abnormal?  </li></ul><ul><li>An...
Case 3: Additional testing <ul><li>This child needs: </li></ul><ul><li>CNS examination. We know that gross CNS function in...
Case 4  <ul><li>The next set of images is of a child with reduced consciousness. </li></ul><ul><li>His Glasgow Coma Score ...
Case 4 Note the position of his mouth carefully
Case 4  <ul><li>Can you see the oro-facial movements? These are typical of JE. </li></ul><ul><li>Click to look at the imag...
Additional resources <ul><li>There are many excellent resources available to help health care workers assess sick children...
Acknowledgments   and contacts Liverpool, UK Penny Lewthwaite, Tom Solomon, Rachel Kneen, Janet Lewthwaite Vijayanagar Ins...
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UOL Clinical Assessment Teaching Tool

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  • Before immediately beginning with the history and examination a rapid assessment of the child needs to be made. This takes priority. A quick assessment using the Acute paediatric life support system “ABC” is a good system to use for this. Any emergency treatment that is required, such as oxygen therapy, anticonvulsants, or intravenous fluids should then be started and the child stabilised. As this is being done the history and examination can begin. There are excellent training materials provided on emergency management of a sick child that are beyond the scope of this presentation.
  • Parents or carers of a child are often very keen to explain the acute problem with their child. But it is important to get the details clear by asking specific questions about length of illness. Any preceding illness or triggering factors. Anything unusual in the recent past and the severity of the illness. If this is the first episode or if there have been similar episodes before. And an open-ended question asking the parents if there is “anything else that they think is important or that hasn’t been asked.” Illness in children often presents with a fever and a cough and some gastrointestinal upset with diarrhoea and vomiting. Don’t let this put you off the diagnosis of encephalitis. Initial presenting symptoms can be very non specific particularly in young children. Dietary intake is important because children who are not eating and drinking become susceptible to secondary infections, especially if they are malnourished to start with. Dehydration may occur quite rapidly if they have diarrhoea and vomiting with a high fever. A history of immunization is helpful as it may make some diseases less likely. However it should not exclude those diseases, as an incomplete course of vaccination or a problem with the cold chain may mean that the vaccination was not successful.
  • Social and economic status are important to clarify as malnutrition is sadly a common problem among those of lower socioeconomic status. It’s important to check who looks after the child normally. For example if the father brings the child to hospital but the grandmother normally looks after the child at home, then the father may not know how long the child has been ill and the details of the illness. If the child was away at school when they became ill the family may not have any reliable information about the illness. Medications and recent medications are important to know as patients may have had antibiotics prior to hospital admission which may effect the interpretation of lumbar puncture results and make it more difficult to identify bacterial infections. Family history is important to check because if there has been TB in the family then that must be higher in the child’s differential diagnosis.
  • JE is common in rural areas, particularly areas close to rice paddy fields or other areas of still water where Culex mosquitoes that transmit JE breed. The incubation period for JE is from 5-15 days.
  • When West Nile virus first reached the USA large numbers of birds died which alerted the public health teams before humans also became ill. The 2006 outbreak of Chikungunya virus on the Indian Subcontinent is an example of another arborviral disease. It affected adults as well as children, causing severe arthralgia (joint pains) and fever. It can rarely cause neurological disease. If the area is known to have JE then JE is a reasonable differential diagnosis. But malaria and dengue often coexist with JE. A thick and thin blood film or a rapid test can be used to rule out malaria. There are ELISA tests and rapid tests available for dengue testing. Other diagnostic tests should be requested depending on the organisms suspected by the clinician with the help of the public health team. New organisms, or organisms new to an area, may occur, like the Nipah virus outbreaks in Malaysia and Bangladesh.
  • The questions on this slide and the next are designed to find out if the child has features of a meningitic or encephalitic illness.
  • Limb weakness has been reported with JE, similar to that seen with polio. If a child presents with acute flaccid paralysis, it’s important to think of JE too. It is important to ask if the child normally uses the right or left hand. The dominant hand is often slightly stronger and better co-ordinated than the non-dominant one. After brain injury, such as JE, the hand the child uses can change due to weakness or damage to the previously dominant hand. This will be illustrated in one of the cases for review at the end of the presentation.
  • The doctor has just asked the child’s father to demonstrate what happened when the child had a seizure. The father mimes the shaking of the arms and head and eyes rolling back with drooling from the mouth.
  • Seizures are not always generalised tonic-clonic ones involving the whole body with tongue biting and urination. Often in encephalitis they are more subtle partial seizures. This child had shaking (seizure) of her left arm only. Seizures like this may go unnoticed by parents and health care staff.
  • This child had a very subtle tremor of the fingers of the right hand. The child was also in a state of reduced consciousness so she may well be in partial seizure status. This is a poor prognostic indicator.
  • This child had abnormal lip and face movements. Orofacial dyskinesias are characteristic of JE.
  • Treatment for seizures will vary with the drugs that are available locally. Lorazepam or diazepam (intravenously or per rectum) may be used acutely to stop a seizure. For ongoing treatment in hospital, if an intravenous drug is required, phenytoin or phenobarbitone can be used. Phenytoin is not ideal for long-term outpatient use as it causes gum hypertrophy and hirsuitism (male pattern hair growth). Anticonvulsants should always be stopped by gradually reducing the dose over a period of weeks rather than suddenly stopping the drug. If there has been prolonged unconsciousness after a seizure check carefully to ensure the child has not developed an aspiration pneumonia whilst unconscious. It may be best to start empiric antibiotic treatment with a penicillin or cephalosporin and metrondiazole to cover both Streptococcus pneumoniae and an anaerobic infection. Recognising subtle partial seizures is important as children with status epilepticus are much more likely to die. Subtle seizures may be subtle intermittent minimal clonic movements of a digit, eyebrow or mouth.
  • This is an example of a form to record the history. It can be modified to suit local needs.
  • Parents and carers may notice changes in the child’s behaviour. The changes may be subtle. The child’s concentration may not be as good.
  • The doctor applies pressure to the child’s sternum (breastbone). The child has a decreased consciousness level but is able to “localize to pain” by moving her knee towards her chest and her left hand onto her chest. This gives her a score of 5 for the motor part of the Glasgow Coma Score.
  • For examples see links on slide 36. X: To test the gag reflex, use a soft implement such as a long cotton bud or swab. The back of the throat should be touched (to right or left of uvula). The uvula should lift up. lX: To test the glossopharyngeal nerve, the gag reflex can be repeated by touching the other side of the uvula and the patient asked to compare the difference between the left and right side. Loss of movement of one side suggests damage to the vagus nerve on that side.
  • Examples of the visual acuity tests are given later in the presentation. A confrontation test is a rough method of testing visual fields as follows: the patient sits opposite the examiner, closes his/her left eye and focuses on the left eye of the examiner. The examiner also shuts his/her right eye. The examiner wiggles his index finger, held halfway between him and the patient, and moves it in from the periphery from all directions. The patient states when he first sees the moving finger, and the examiner compares with this own field of vision. The left field is then done the same way. Assess the pupillary reactions to light. Poorly reactive or asymmetrical pupils may indicate brain stem damage. Examine the optic discs for papilloedema, which is a sign of raised intracranial pressure. Papilloedema is not often seen in JE. Examples of the doll’s eye reflex are given later in the presentation.
  • For older children and adults visual acuity can be tested formally. To test visual acuity using a Snellen chart ( chart with large letters at the top going down in rows to smaller letters) the chart should be 6 metres from the patient. Ask the patient to read down the letters from largest to smallest. Results are recorded as distance in metres from chart/ distance in metres at which letters should be visible –( written on chart). Eg 6/6 letter is read at correct distance. 6/60 when the largest letter which should be visible from 60 metres is only read at 6 metres. For those able to read the Cyrillic (abc) alphabet a letter chart can be used. For those with different alphabets an E or M chart is used. The patient is asked to say which way round the letter is. The patient can be given an E/M shape and asked to turn to match the letter he/she sees.
  • Cranial nerves II and II. Direct light reflex. Use a bright light and bring it in from the side and then move it away. The pupil should constrict. At the same time if you look at the other eye, (the contralateral one) it should also constrict. This is the indirect reflex or consensual reflex. Here neither eye reacts. Both pupils are fixed and dilated. This is a poor prognostic indicator, suggestive of brainstem herniation To test for accommodation, ask a patient to focus on a distant object then ask them to focus on an object close to their nose. The pupils should reduce in size.
  • Instruct the patient to keep their head still. As illustrated here, it is sometimes necessary to place a hand on the patient’s forehead. Then starting at the centre move your finger in an “H” shape (across and up and down to the left and right) to test eye movements. This is testing nerves III, IV and VI.
  • Raised intracranial pressure is a common cause of sixth nerve palsy. Papilloedema is another sign of raised intracranial pressure.
  • A small child is unable to be examined formally but by careful observation an abnormality can be seen. At rest the child appears to be looking to her left, but her left eye is not abducting. As she follows the toy, her left eye is able to follow the movement and adduct (move inwards) but the right eye fails to abduct (move outwards). Bilateral Vl th cranial nerve palsies are an indicator of raised intracranial pressure.
  • Using an ophthalmoscope is important to check for papilloedema (intracerebral oedema, which causes compression of the optic nerve root) To use the ophthalmoscope first look at your thumb with it. This helps gauge the distance needed to be to the eye. Then check the lens is set to zero, ask the patient to focus on a dark object in the distance (Instruction – “look straight ahead at the wall/ door” etc). Use your right eye to look at their right eye, and your left eye to look at their left eye, otherwise the patient is unable to focus in the distance.
  • Use your left eye to look at their left eye, otherwise the patient is unable to focus in the distance.
  • For a very young child, it may be easiest to examine them whilst they sit on their parent’s lap. Using the ophthalmoscope allows the optic disc and retina to be viewed. Swelling of the optic disc, or papilloedema, is seen in raised intracranial pressure. Retinal changes may indicate vascular disease, diabetes etc.
  • Ask patient to clench their teeth then palpate for equal contraction of the masseter muscles in the cheeks . Then ask them to open their mouth and stop you trying to close it (only gentle force is necessary). The trigeminal nerve is also responsible for sensation on the face and the cornea.
  • Ask the patient to slightly open their mouth. The examiner places his finger on the patient’s chin and hits it with the tendon hammer. See the contraction of the jaw - this is normal.
  • Ask the patient to slightly open their mouth. The examiner places his finger on the patient’s chin and hits it with the tendon hammer. In this patient there was a brisk contraction of the jaw. This is abnormal. This indicates an upper motor neurone lesion.
  • Ask the child to screw their eyes up. It’s often best to demonstrate this first. Once they’ve done this, say “try and stop me opening your eyes” and gently try and open their eyes.
  • See the difficulty she has in smiling. There is dystonic movement of the mouth with deviation of the lips to the right (the damaged side.) There is probably damage to both V and Vllth (trigeminal and facial) cranial nerves.
  • Look at the excoriated ear. This has been weeping and has been chronically infected. A common organism is Pseudomonas aeruginosa. Ear infections may cause temporary hearing loss in children.
  • Check that the child is able to hear something by making a “rustling” noise with the fingers. Then whisper a number in one ear and mask the noise by making the rustling noise next to the other ear. Ask the child to say what the word or number was. Repeat on the other ear. This is a crude method of detecting hearing loss. Parents are often aware if a child is deaf or has reduced hearing compared to other children so always check with them too.
  • Profound hearing loss is likely to be reported by the parents or caregiver. In this picture, a loud clap is being made behind the child’s head but she does not hear.
  • Both the trapezius and sternocleidomastoid muscles are innervated by the spinal accessory nerve (Xl). Ask the patient to shrug their shoulders and try and push against them. Look for muscle wasting in the neck. Then ask the patient to turn their head whilst pushing against your hand. This tests the sternocleidomastoid muscle. Both left and right should be tested.
  • Xll hypoglossal nerve: Is child able to stick the tongue out and does it look normal and move normally?
  • Xll hypoglossal nerve: If nerve supply to the muscles of the tongue of one side is damaged, the tongue muscles on that side relax. The muscles of the undamaged side maintain their resting tone. The tongue will deviate (bend) away from the damaged side. In the picture, the tongue is curled to the patient’s right. So the nerve to the right sided tongue muscles is working but as the muscle to the left is damaged the tongue is pulled over to the right.
  • The child is asked to touch the tip of her nose with her finger and then touch the doctor’s fingertip. The doctor then moves his hand around and the child has to keep touching the finger tip and her nose as fast as possible. This test of cerebellar function cannot be assessed in very young children.
  • In contrast to the previous slide, the finger to nose movements here were slow and hesitant. The patient misses the finger with both her right hand and her left hand, suggesting she has some cerebellar problems. In cerebellar disease hesitancy or tremor is often seen before touching the fingertip. “Past pointing” can also be seen, where the patient misses the fingertip.
  • 1 st image: The left hand is clumsy. Some allowance must be given as she is right handed and usually the dominant hand is more accurate, and she also has a cannula in her left hand which may be hindering her. 2 nd image: Her left hand much less awkward 5 days later as she recovers from the acute illness.
  • Here the doctor is testing for nystagmus by asking the patient to follow her finger. The patient had downbeat horizontal nystagmus when looking to her right. Downbeat nystagmus means that the fast phase of the nystagmus is on the initial movement rather than on the return. This can occur in brainstem encephalitis as in this patient and is also seen in cerebellar disease and drug toxicity particularly due to lithium, pheyntoin and carbemazepine.
  • The patient is instructed to walk in a line placing one foot directly in front of the other. In cerebellar disease, as here, the movements are very unsteady. She has an ataxic gait.
  • 1 st image: In the heel-shin test, ankle should be placed on the knee of the opposite leg and moved down the shin, lifted up and the movement repeated from the knee. If this is too difficult then the ankle can be moved up and down the lower leg from knee to foot along the shin. The example here is normal. 2 nd image: In cerebellar disease the heel wobbles from side to side, missing the leg.
  • The normal doll’s eye or oculocephalic reflex is being illustrated here. A normal doll’s eye response is seen when the head is gently but rapidly turned form side to side. The eyes move in the opposite direction to the movement of the head in order to maintain focus on the same point.
  • In an abnormal response, as was being illustrated here, when the head is gently but rapidly turned form side to side, the eyes remain in midposition, which is abnormal. In the normal response, they move in the opposite direction to the movement of the head in order to maintain focus (as happens in dolls with moving eyes). As the doll’s eye or oculocephalic reflex is absent here it suggests brainstem damage.
  • The child has his left arm straightened and hyperextended, in contrast to the right which is held in a more normal position, flexed at elbow and wrist. This is due to focal brain damage, causing hemiparesis or monoparesis. This example of abnormal posturing due to focal brain damage is included for comparison with abnormal posturing seen in brainstem damage (previous slide).
  • Meningeal irritation can be caused by meningitis (bacterial, viral and fungal), subarachnoid haemorrhage and more rarely carcinomatosis. Kernig’s sign and Brudzinski’s sign may be present in severe meningeal irritation although they are not always found. See reference: Clinical Infectious Diseases . 2002 Jul 1;35(1):46-52. The diagnostic accuracy of Kernig&apos;s sign, Brudzinski&apos;s sign, and nuchal rigidity in adults with suspected meningitis. Thomas KE , Hasbun R , Jekel J , Quagliarello VJ .
  • Head tone is normal. Head moves easily when flexed onto chest.
  • Here the neck is rigid. On attempting to flex the neck the whole body lifts up too. This is abnormal. If neck stiffness is found then Kernig’s test should be performed too. A positive Kernig’s sign occurs when, with the child lying on their back with hip and knee flexed, forced extension of the knee causes back and neck pain.
  • When the signs listed are seen together, then the problem described is the most likely cause. Decerebrate posturing (extensor posturing) In decerebrate posturing, the head is arched back, the arms are extended by the sides, and the legs are extended. Decerebrate posturing indicates brain stem damage. A patient with decorticate posturing may begin to show decerebrate posturing, or may go from one form of posturing to the other. Progression from decorticate posturing to decerebrate posturing is often indicative of uncal (transtentorial) or tonsilar brain herniation. Decorticate posturing Patients with decorticate posturing present with the arms flexed, or bent inward on the chest, the hands clenched into fists, and the legs extended. Decorticate posturing indicates damage to the mesencephalic region, or the corticospinal tract along which impulses travel from the brain to the spinal cord.
  • When the signs listed are seen together, then the problem described is the most likely cause. Decorticate posturing Patients with decorticate posturing present with the arms flexed or bent inward on the chest, the hands clenched into fists, and the legs extended. Decorticate posturing indicates damage to the mesencephalic region, or the corticospinal tract along which impulses travel from the brain to the spinal cord.
  • Decerebrate posturing ( extensor posturing) In decerebrate posturing, the head is arched back, the arms are extended by the sides, and the legs are extended. Decerebrate posturing indicates brainstem damage. A patient with decorticate posturing may begin to show decerebrate posturing, or may go from one form of posturing to the other. Progression from decorticate posturing to decerebrate posturing is often indicative of uncal (transtentorial) or tonsilar brain herniation.
  • Increased tone occurs with Upper Motor Neurone lesions. Reduced tone occurs with Lower Motor Neurone lesions. Cog wheel rigidity is classically seen in Parkinson’s disease but it can also be seen in JE. On passively moving a limb, the movements are stiff and then “give” and then are stiff again, as if on a ratchet or cog wheel.
  • Normal tone is illustrated here. The examiner moves the arm freely backwards and forwards
  • Whilst rolling the legs notice that the feet remain stiff and roll with the leg instead of flopping about more loosely. The muscle tone is increased in both legs.
  • Nerves responsible for muscle group: Shoulder Abduction C5,C6, Adduction C6,C7, Elbow flexion C5, C6, Elbow extension C7,C8, Wrist flexion C6, C7 &amp; C8, Wrist extension C6,C7,C8, Fingers extension C8, T1, Fingers flexion C8, Fingers Abduction C8, T1 Hip flexion L2, L3, Hip extension L5, S1, Hip abduction L4,L5, S1, Hip adduction L2,L3,L4, Knee flexion L5, S1, Knee extension L3, L4, Ankle plantar flexion S1, Ankle dorsiflexion L4, L5, Ankle eversion L5, S1, Ankle inversion L4
  • Testing power can be fun: making a “game” of the examination can make children more co-operative! Flexion and then extension at the elbow joint is tested in the right and then the left arm. The examiner gives verbal instructions and demonstrates with his arms what he wants the child to do.
  • Assessing power of leg muscles: For the thigh, ask the child to lift their leg straight up in the air, then push their leg down onto the bed. For the knee, first flex the knee, then ask them to kick out. Then pull their ankle towards their bottom trying to push against your hand as they do. For the ankle, ask them to push their foot down, and try to push against them. Then ask them to pull the foot up, and again push against them.
  • Reflexes innervation: Biceps C5, C6, Triceps C7,C8, Supinator C5,C6, Finger jerks C8, Knee jerk L3,L4, Ankle jerk L5, S1, Plantar reflex S1
  • Reflexes innervation: Plantar reflex S1
  • When the examiner tests the reflexes, the right triceps reflex and right supinator reflex are brisk. The left triceps reflex is also brisk.
  • The supinator reflexes are brisk and abnormal. Note the abnormal laughter. This is a sign of frontal lobe damage; each time the supinator reflex is tested the patient laughs. Be careful not to dismiss this as normal.
  • In this example, the right knee jerk (first image) was abnormal (brisk), but the left knee jerk was normal.
  • It is important when testing the plantar reflex to use a firm tool such as the tip of a tendon hammer, or keys. Start on the lateral aspect of the sole of the foot and move up and then across medially. The big toe moves downwards. This is normal.
  • The big toe moves upwards. This is a positive or abnormal plantar (Babinski) reflex.
  • Up to 5 beats of clonus are normal. Sustained clonus is abnormal and can be seen in upper motor neurone lesions. An upper motor neuron lesion is a lesion of the neural pathway above the anterior horn cell, or motor nuclei of the cranial nerves. A lower motor neurone lesion affects nerve fibres travelling from the anterior horn of the spinal cord to the relevant muscle(s).
  • Stroking the abdomen with the tip of the tendon hammer should cause constriction of the umbilicus, as shown here. However abdominal reflexes may be absent in up to 15% of the normal population.
  • The abdominal reflex is absent here, suggesting an upper motor neurone lesion. This can be seen in JE when the spinal cord is involved. (Abdominal reflexes may be absent in up to 15% of the normal population.)
  • It is important to observe the patient’s gait, while walking normally and then on toes and heels. Problems, such as foot drop, can be detected in this way. The unsteady, wide-based gait of cerebellar ataxia may also be observed.
  • Clearly this child is walking abnormally. She has foot drop of her right foot and has to walk using a swinging gait to lift it up and move it forwards.
  • Respiratory rate is a particularly good indicator of severity of illness.
  • Skin turgor gives a measure of how dehydrated the child is. Normal capillary refill time is less than 2 seconds. It is measured by pressing a finger nail until it turns white and then measuring the time to for it’s colour to return. It is used as a measure of peripheral vascular perfusion. Rashes are important as many illnesses may have a rash e.g. dengue, chickungunya. The crucial rash to recognise in children is the petechial or purpuric rash of meningococcal septicaemia. The classic meningococcal rash is non-blanching. Tourniquet test is shown on the next slide. Bruising may suggest severe sepsis, clotting abnormalities or thrombocytopaenia (low platelets). Low platelets can be seen in dengue and severe Plasmodium falciparum malaria. It is important to look for scratch marks which may indicate liver disease (itching causes scratching) – or be associated with eczema or psoriasis. Scabies and fleas also cause itching. Ticks may leave a black eschar at the site of the bite. It is important to look carefully for these eschars in areas where tick borne rickettsial diseases or tick borne encephalitis occur. If the child is unconscious and there were no witnesses to what happened then an examination of the skin may give important clues as to the illness.
  • Ear, nose and throat examination is important. It may be possible to combine the ENT examination with the CNS examination so as not to repeat parts of the examination and overtire the child. Severe tonsillitis may mimic meningitis. Otitis externa can be associated with otitis media which can sometimes (rarely) be associated with meningitis. If it is then “ear” organisms such as Pseudomonas aeruginosa, which can be quite antibiotic resistant, need to be covered by the treatments used. Local microbiology advice regarding antibiotic sensitivities is important for this.
  • Respiratory rate is a particularly good indicator of severity of illness.
  • For further information about cardiovascular examination see reference texts listed at the end of the presentation.
  • For further information about gastrointestinal examination see reference texts listed at the end of the presentation.
  • In the examples following: Clinical cases are given with some history and pictures/ clips to illustrate each case. Questions are asked about each case to encourage careful observation and show how much information can be gained from even short observation. Answers are given after each question slide. It may be useful to split the audience into groups and ask them to look at the clips and work out the answers together.
  • More detailed examination is essential to rule out more subtle problems but on initial view she appears to be a normal child.
  • Skin, cardiovascular system respiratory system, gastrointestinal system.
  • This child was unconscious for 2 weeks with JE which caused problems with her left side, brisk reflexes and increased tone. Then she suffered a stroke which caused the right sided damage as well.
  • Brisk left knee jerk suggests upper motor neurone damage.
  • If her higher mental functions are preserved it is important that she receives as much support as possible to develop these. She will not be able to work in a physically demanding job as an a adult but with training and support she might be able to carry out more clerical type of work e.g. with a telephone or computer and thus be able to bring some income in to her family.
  • GCS Glasgow Coma Score ( see slide 29).
  • Transcript of "UOL Clinical Assessment Teaching Tool"

    1. 1. Clinical Assessment of Children with Suspected Central Nervous System Infections Brain Infections Group University of Liverpool, United Kingdom
    2. 2. Contents <ul><li>Using this presentation </li></ul><ul><li>Introduction </li></ul><ul><li>Checking the sick child </li></ul><ul><li>History taking </li></ul><ul><ul><li>General questions </li></ul></ul><ul><ul><li>JE-related questions </li></ul></ul><ul><ul><li>Neurological disease </li></ul></ul><ul><ul><li>Seizures or abnormal movements </li></ul></ul><ul><ul><li>Completion of patient history </li></ul></ul><ul><ul><li>Example of a history proforma </li></ul></ul><ul><li>Examination </li></ul><ul><li>Neurological examination </li></ul><ul><li>1.0 Observation </li></ul><ul><li>2.0 Assessment of mental state or conscious level </li></ul><ul><ul><li>2.1 Assessing mental state </li></ul></ul><ul><ul><li>2.2 Assessing conscious level </li></ul></ul><ul><li>3.0 Examination of the central nervous system </li></ul><ul><ul><li>3.1 Cranial nerves </li></ul></ul><ul><li>Neurological examination continued: </li></ul><ul><ul><li>3.2 Cerebellar tests </li></ul></ul><ul><ul><li>3.3 Brainstem </li></ul></ul><ul><ul><li>3.4 Special tests </li></ul></ul><ul><ul><li>3 .5 Clinical significance of findings </li></ul></ul><ul><li>4.0 Examination of the peripheral nervous system </li></ul><ul><ul><li>4.1 Tone </li></ul></ul><ul><ul><li>4.2 Power </li></ul></ul><ul><ul><li>4.3 Reflexes </li></ul></ul><ul><ul><li>4.4 Sensation </li></ul></ul><ul><ul><li>4.5 Gait </li></ul></ul><ul><li>Examination General </li></ul><ul><li>Example of examination proforma </li></ul><ul><li>Example cases 1-4 </li></ul><ul><li>Additional Resources </li></ul><ul><li>Acknowledgments </li></ul>
    3. 3. Using this presentation (1) <ul><li>This presentation can be viewed by: </li></ul><ul><ul><li>Clicking through each slide consecutively. </li></ul></ul><ul><ul><li>Clicking on the arrows on the bottom right and left of each screen. </li></ul></ul><ul><ul><li>Clicking on items on the contents slide to go to that slide. </li></ul></ul><ul><li>To return to a slide after clicking a link, click </li></ul><ul><li>To get back to the contents page from any slide click on the house image. </li></ul><ul><li>To exit press the arrow and line image. </li></ul>
    4. 4. Using this presentation (2) <ul><li>This presentation contains still images linked by an arrow button. </li></ul><ul><li>There are notes below many of the slides to assist presenters. </li></ul>
    5. 5. Introduction (1) <ul><li>This presentation has been developed for use by doctors and health care workers in areas where Japanese encephalitis (JE) is endemic. </li></ul><ul><li>It is designed to identify key aspects of the clinical assessment and neurological examination which are of particular importance in encephalitis patients, with particular emphasis given to JE. </li></ul><ul><li>There are examples of normal and abnormal cases illustrated using photos and video clips of normal children and children with Japanese encephalitis or who presented with an acute encephalitis syndrome. Additional case examples at the end of the presentation may be used for small group discussion. </li></ul>
    6. 6. Introduction (2) <ul><li>At the end of the presentation participants will </li></ul><ul><ul><li>Be better able to take a history with specific questions for encephalitis patients. </li></ul></ul><ul><ul><li>Be better able to examine a patient with encephalitis. </li></ul></ul><ul><ul><li>Be aware of what neurological problems to look for and how to examine them. </li></ul></ul><ul><li>It is not meant to give exhaustive instruction in clinical examination as there are many excellent textbooks available for this. Some are listed at the end of this presentation. </li></ul><ul><li>The tool is freely available, but when using it, please acknowledge the University of Liverpool, UK, and PATH. </li></ul>
    7. 7. Checking the sick child <ul><li>Check the ABC’s: </li></ul><ul><li>Airway </li></ul><ul><li>Breathing </li></ul><ul><li>Circulation </li></ul>
    8. 8. Patient history: general questions (1) <ul><li>Presenting history </li></ul><ul><ul><li>What brought them to hospital, details, length of time complaint has been present, triggers (if any) </li></ul></ul><ul><li>Fever, history of fever </li></ul><ul><ul><li>Note that even if a child is not febrile at this time, a history of fever is important </li></ul></ul><ul><li>Cough, cold symptoms, redness of the eyes </li></ul><ul><li>Assess current hydration/nutritional state </li></ul><ul><ul><li>Diarrhoea, vomiting, recent food and fluid intake and urine output </li></ul></ul><ul><li>Immunization history </li></ul>
    9. 9. Patient history: general questions (2) <ul><li>Social history </li></ul><ul><ul><li>Economic circumstances </li></ul></ul><ul><ul><li>Childcare/schooling </li></ul></ul><ul><li>Medication/Treatment </li></ul><ul><ul><li>Ask about recent and current medications </li></ul></ul><ul><ul><li>Ask specifically about traditional medicines </li></ul></ul><ul><ul><li>Check for any known allergies </li></ul></ul><ul><li>Family history (e.g., history of tuberculosis, epilepsy, diabetes, or asthma) </li></ul>
    10. 10. Patient history: JE-related questions (1) <ul><li>Is this an area where JE occurs? </li></ul><ul><li>Is this the JE season? </li></ul><ul><ul><li>In much of the tropics the season begins soon after the rainy season </li></ul></ul><ul><ul><li>However in many areas there is low level transmission even out of season </li></ul></ul><ul><li>Have other children had a similar illness? </li></ul><ul><li>Does the child live in a rural area, where JE is more likely? </li></ul><ul><ul><li>Note that JE also occurs on the edges of some cities in Asia </li></ul></ul>
    11. 11. Patient history: JE-related questions (2) <ul><li>Are there epidemiological features to suggest that this is NOT JE? </li></ul><ul><ul><li>Are animals sick? The virus does not cause disease in birds or swine (though it may cause abortions in pregnant swine). </li></ul></ul><ul><ul><li>Are many adults affected? </li></ul></ul><ul><ul><ul><li>JE causes less disease in adults than children (or no disease in adults at all) because most individuals have been exposed to the virus and developed immunity during childhood. </li></ul></ul></ul><ul><ul><li>Does it appear to be transmitted by a different route (e.g., direct contact, faecal-oral route, or aerosol) ? </li></ul></ul><ul><ul><ul><li>There are many viruses, bacteria, and parasites which could be included in the differential diagnosis. Malaria, dengue, and typhoid are just a few important ones to consider. </li></ul></ul></ul>
    12. 12. Patient history: neurological disease (1) <ul><li>Ask about: </li></ul><ul><li>Stiff neck </li></ul><ul><li>Photophobia (avoidance of light) </li></ul><ul><li>Phonophobia (avoidance of noise) </li></ul><ul><li>Confusion/irritability/restlessness </li></ul><ul><li>Altered behaviour </li></ul><ul><ul><li>Sometimes mistakenly attributed to psychiatric illness </li></ul></ul>
    13. 13. <ul><li>Ask about: </li></ul><ul><li>Altered cry </li></ul><ul><ul><li>High pitch cry is a late sign of raised intracranial pressure (ICP) </li></ul></ul><ul><li>Limb weakness </li></ul><ul><ul><li>Has the child stopped walking, or stopped using one hand? </li></ul></ul><ul><ul><li>Does he/she normally use the right or left hand, and are there any changes in this since illness? </li></ul></ul>Patient history: neurological disease (2)
    14. 14. Patient history: seizures or abnormal movements (1) <ul><li>Ask about abnormal movements of eyes, face, limbs. </li></ul><ul><li>Distinguishing convulsions from spasms, tremors and rigors is difficult. </li></ul><ul><li>It is often easier to ask the parent to mimic the movements the child made rather than describing them. They are more likely to do this if the health care worker sets an example. </li></ul><ul><li>The distinction is important because </li></ul><ul><ul><li>Seizures may need anticonvulsant drugs. </li></ul></ul><ul><ul><li>Characteristic spasms and tremors are seen in some types of viral encephalitis (e.g., JE) and so may point toward the diagnosis. </li></ul></ul>
    15. 15. Examples of seizures or abnormal movements <ul><li>Ask parent to mimic seizure / abnormal movements………………………………. </li></ul><ul><li>Seizure……………………………………. </li></ul><ul><li>Subtle seizure……………………………. </li></ul><ul><li>Orofacial movements……………………. </li></ul><ul><li>Go to slide 20: Seizures and abnormal movements (2)…………………………… </li></ul>
    16. 16. Asking parent to mimic child’s seizure or abnormal movements Return to examples
    17. 17. Seizure activity in JE patient Return to examples In this patient, the left arm was shaking slightly (subtle partial seizure)
    18. 18. Subtle seizure activity Return to examples
    19. 19. Orofacial movements are characteristic of patients with JE Return to examples
    20. 20. Patient history: seizures or abnormal movements (2) <ul><li>If seizures are reported, ask about frequency and duration. </li></ul><ul><ul><li>Changes in frequency and duration of seizures are used to monitor treatment effectiveness. </li></ul></ul><ul><li>Ask if any seizure has been followed by unconsciousness for >30 minutes. </li></ul><ul><li>Status epilepticus (seizure lasting >30 minutes) is important to look for. </li></ul><ul><ul><li>It is a poor prognostic indicator. </li></ul></ul><ul><ul><li>The seizures of status epilepticus may be subtle partial seizures. </li></ul></ul>
    21. 21. Completion of patient history <ul><li>Growth chart </li></ul><ul><ul><li>Height for age and weight or mid upper arm circumference. </li></ul></ul><ul><li>Family tree and birth history </li></ul><ul><li>Previous illnesses </li></ul><ul><li>Systems review </li></ul><ul><ul><li>Respiratory system: coughs/colds/asthma </li></ul></ul><ul><ul><li>Cardiovascular system: palpitations, arrhythmias, rheumatic heart disease, murmurs </li></ul></ul><ul><ul><li>Gastrointestinal: diarrhoea and vomiting, hepatitis, bladder and bowel function </li></ul></ul><ul><ul><li>Central Nervous System: headaches, vision problems. </li></ul></ul>
    22. 22. Example of a history proforma
    23. 23. Neurological examination <ul><li>Neurological examination includes: </li></ul><ul><li>Observation </li></ul><ul><li>Assessment of mental state or conscious level </li></ul><ul><li>Examination of the central nervous system (CNS) </li></ul><ul><ul><li>Cranial nerves I-XII </li></ul></ul><ul><ul><li>Cerebellar function </li></ul></ul><ul><ul><li>Brainstem tests </li></ul></ul><ul><ul><li>Special tests </li></ul></ul><ul><li>Examination of the peripheral nervous system (PNS) </li></ul><ul><ul><li>Muscle tone </li></ul></ul><ul><ul><li>Limb muscle power </li></ul></ul><ul><ul><li>Reflexes </li></ul></ul><ul><ul><li>Sensation in limbs </li></ul></ul><ul><ul><li>Gait </li></ul></ul>
    24. 24. Neurological examination <ul><li>Neurological examination includes: </li></ul><ul><li>Observation </li></ul><ul><li>Assessment of mental state or conscious level </li></ul><ul><li>Examination of the central nervous system (CNS) </li></ul><ul><ul><li>Cranial nerves I-XII </li></ul></ul><ul><ul><li>Cerebellar function </li></ul></ul><ul><ul><li>Brainstem tests </li></ul></ul><ul><ul><li>Special tests </li></ul></ul><ul><li>Examination of the peripheral nervous system (PNS) </li></ul><ul><ul><li>Muscle tone </li></ul></ul><ul><ul><li>Limb muscle power </li></ul></ul><ul><ul><li>Reflexes </li></ul></ul><ul><ul><li>Sensation in limbs </li></ul></ul><ul><ul><li>Gait </li></ul></ul>
    25. 25. Observation <ul><li>Simple observation is vital </li></ul><ul><ul><li>A huge amount of information can be gained for the examination by observation alone. </li></ul></ul><ul><ul><li>A full formal neurological examination is time consuming and will not be tolerated by small children. </li></ul></ul><ul><li>Observe as much as you can before disturbing the child, then begin to examine with minimal disturbance. Look for: </li></ul><ul><ul><li>Any obvious abnormalities or asymmetry </li></ul></ul><ul><ul><li>Bulging fontanelle in young infants and children </li></ul></ul><ul><ul><li>Reduced spontaneous movements of one or more limbs </li></ul></ul><ul><ul><li>Abnormal posture </li></ul></ul><ul><ul><li>Abnormal movements, subtle seizures </li></ul></ul>
    26. 26. Neurological examination <ul><li>Neurological examination includes: </li></ul><ul><li>Observation </li></ul><ul><li>Assessment of mental state or conscious level </li></ul><ul><li>Examination of the central nervous system (CNS) </li></ul><ul><ul><li>Cranial nerves I-XII </li></ul></ul><ul><ul><li>Cerebellar function </li></ul></ul><ul><ul><li>Brainstem tests </li></ul></ul><ul><ul><li>Special tests </li></ul></ul><ul><li>Examination of the peripheral nervous system (PNS) </li></ul><ul><ul><li>Muscle tone </li></ul></ul><ul><ul><li>Limb muscle power </li></ul></ul><ul><ul><li>Reflexes </li></ul></ul><ul><ul><li>Sensation in limbs </li></ul></ul><ul><ul><li>Gait </li></ul></ul>
    27. 27. 2.1 Assessing mental state <ul><li>Assessing mental state can be difficult, particularly in young children. </li></ul><ul><li>Surrogate questions can be used, asking parents or carers about: </li></ul><ul><ul><li>Behavioural changes </li></ul></ul><ul><ul><li>Mood swings and temper tantrums </li></ul></ul><ul><ul><li>Concentration levels </li></ul></ul><ul><ul><li>School work </li></ul></ul><ul><ul><li>Ability to help with tasks around the house </li></ul></ul>
    28. 28. 2.2 Assessing conscious level <ul><li>The Glasgow Coma Score is the most widely used score </li></ul><ul><ul><li>A modified Glasgow Coma Score exists for children <5 years old </li></ul></ul><ul><li>A simple AVPU score (Alert/Voice/Pain/ Unconscious) allows a very rapid initial assessment, and is better than nothing </li></ul><ul><li>An example of the sternal rub is provided, used with the Glasgow coma scale </li></ul>
    29. 29. Glasgow Coma Score and the James Modification for children <5 years AVPU Return to examples   Adults and children >5 years Children <5 years Eye opening   4 Spontaneous Spontaneous 3 To voice To voice 2 To pain To pain 1 None None Verbal     5 Orientated Alert, babbles, coos, words or normal sentences 4 Confused Less than usual ability, irritable cry 3 Inappropriate words Cries to pain 2 Incomprehensible sounds Moans to pain 1 No response to pain No response to pain Motor     6 Obeys commands Normal spontaneous movements 5 Localises to pain Localises to supraocular pain or withdraws to touch in infant <9/12 4 Withdraws from pain Withdraws from pain 3 Flexion from pain Flexion from pain 2 Extension to pain Extension to pain 1 No response to pain No response to pain
    30. 30. AVPU rapid assessment of consciousness level <ul><li>A ALERT </li></ul><ul><li>V responds to VOICE </li></ul><ul><li>P responds to PAIN </li></ul><ul><li>U UNRESPONSIVE </li></ul>GCS Return to examples
    31. 31. Glasgow Coma Score: Sternal rub - patient localises to pain
    32. 32. Neurological examination <ul><li>Neurological examination includes: </li></ul><ul><li>Observation </li></ul><ul><li>Assessment of mental state or conscious level </li></ul><ul><li>Examination of the central nervous system (CNS) </li></ul><ul><ul><li>Cranial nerves I-XII </li></ul></ul><ul><ul><li>Cerebellar function </li></ul></ul><ul><ul><li>Brainstem tests </li></ul></ul><ul><ul><li>Special tests </li></ul></ul><ul><li>Examination of the peripheral nervous system (PNS) </li></ul><ul><ul><li>Muscle tone </li></ul></ul><ul><ul><li>Limb muscle power </li></ul></ul><ul><ul><li>Reflexes </li></ul></ul><ul><ul><li>Sensation in limbs </li></ul></ul><ul><ul><li>Gait </li></ul></ul>
    33. 33. 3.1: Cranial nerves I-VII <ul><li>This examination can be done in older children and adults. </li></ul><ul><li>I Olfactory </li></ul><ul><ul><li>Is the sense of smell normal? </li></ul></ul><ul><li>II Optic </li></ul><ul><ul><li>Is visual acuity normal? </li></ul></ul><ul><ul><li>Do the pupils react to light and to accommodation? </li></ul></ul><ul><ul><li>Are the visual fields normal to confrontation? </li></ul></ul><ul><ul><li>Are the optic fundi normal? </li></ul></ul><ul><li>III, lV, Vl Oculomotor, Trochlear, Abducens </li></ul><ul><ul><li>Are the eye movements normal? </li></ul></ul><ul><ul><li>Is one pupil dilated (IIIrd nerve lesion)? </li></ul></ul><ul><li>V Trigeminal </li></ul><ul><ul><li>Is sensation normal on the face (and cornea), and is jaw power normal? </li></ul></ul><ul><li>VII Facial </li></ul><ul><ul><li>Is there facial weakness? </li></ul></ul>
    34. 34. <ul><li>VIII Vestibulocochlear </li></ul><ul><ul><li>Is hearing reduced? </li></ul></ul><ul><li>IX Glossopharyngeal </li></ul><ul><ul><li>Is sensation in the pharynx normal (tested by eliciting the gag reflex)? </li></ul></ul><ul><li>X Vagus </li></ul><ul><ul><li>Do both sides of the palate move when the patient says “Agh”? (And during the gag reflex?) </li></ul></ul><ul><li>XI Accessory </li></ul><ul><ul><li>Do the shoulders lift? Is power of head turning normal? </li></ul></ul><ul><li>XII Hypoglossal </li></ul><ul><ul><li>Does the tongue look and protrude normally? </li></ul></ul>3.1(cont.): Cranial nerves Vlll-XII
    35. 35. <ul><li>Optic (II) </li></ul><ul><ul><li>Visual acuity: Snellen chart or “E” card </li></ul></ul><ul><ul><li>Visual fields: confrontation test </li></ul></ul><ul><li>Optic and oculomotor (II, III) </li></ul><ul><ul><li>Light reflexes: direct and consensual </li></ul></ul><ul><li>Oculomotor, Trochlear, Abducens (III, IV, VI) </li></ul><ul><ul><li>Eye movements </li></ul></ul><ul><li>Examine the optic discs </li></ul><ul><li>Doll’s eye reflex </li></ul>3.1 (cont.): Eye examination
    36. 36. Eye examination - examples <ul><li>Visual acuity charts………………...... </li></ul><ul><li>Direct light reflex……………………… </li></ul><ul><li>Eye movements…………………….... </li></ul><ul><li>Right VIth nerve palsy:.……………… </li></ul><ul><li>Bilateral VIth nerve palsy: video…..... </li></ul><ul><li>Ophthalmoscopy right eye…………… </li></ul><ul><li>Ophthalmoscopy left eye……………. </li></ul><ul><li>Ophthalmoscopy young child……….. </li></ul><ul><li>Go to slide 45: Cranial nerves V-Xll… </li></ul>
    37. 37. Visual acuity charts <ul><li>E </li></ul>Ш E E Ш E Ш E Ш E Ш Ш E Ш Ш Ш E Ш E Ш E Ш E E Ш E Ш E E E Ш E Ш Ш E Ш E E Ш Ш Ш E E Ш E E Ш Ш Ш E E Ш E Return to examples
    38. 38. Direct light reflex Film credit: T Solomon Return to examples
    39. 39. Eye movements: head still, instruction “follow my finger” Photo credit: Tom Shulz Return to examples
    40. 40. Right VI th nerve palsy – right eye is unable to abduct (move outwards) Trying to look this way Return to examples
    41. 41. Bilateral VI th nerve palsy – look carefully, neither eye abducts Return to examples
    42. 42. Ophthalmoscopy: examiner’s right eye to patient’s right eye Photo credit: Tom Shulz Return to examples
    43. 43. Ophthalmoscopy: examiner’s left eye to patient’s left eye Photo credit: Tom Shulz Return to examples
    44. 44. Opthalmoscopy: young child Photo credit: Tom Shulz Return to examples
    45. 45. Cranial nerves V-XII examples <ul><li>V Trigeminal nerve examination..………………………. </li></ul><ul><li>V Trigeminal nerve: Jaw jerk normal……………………. </li></ul><ul><li>V Trigeminal nerve: Jaw jerk abnormal…...……………. </li></ul><ul><li>VII Facial nerve - “Screw your eyes up” ……………….. </li></ul><ul><li>V and VII nerves .………………………………………… </li></ul><ul><li>Hearing: Otitis externa/otitis media ……………………. </li></ul><ul><li>VIII nerve examination: Hearing ……………………….. </li></ul><ul><li>Vlll nerve: Profound hearing loss………………………. </li></ul><ul><li>XI nerve examination: Neck and shoulders…………... </li></ul><ul><li>XII nerve: “Stick out your tongue” ……………………… </li></ul><ul><li>XII nerve: Tongue movements………………………….. </li></ul><ul><li>Go to slide 57: Cerebellar tests…………………………. </li></ul>
    46. 46. V Trigeminal nerve examination Photo credit: Tom Solomon Return to examples
    47. 47. V Trigeminal nerve: jaw jerk normal Photo credit: Tom Solomon Return to examples
    48. 48. V Trigeminal nerve: jaw jerk abnormal (brisk) Photo credit: Tom Solomon Return to examples
    49. 49. VII nerve examination: “Screw your eyes up” Return to examples
    50. 50. V and VII nerves: “Screw your eyes up, show me your teeth” Return to examples
    51. 51. Hearing: Otitis externa/otitis media Return to examples
    52. 52. VIII nerve examination: Hearing Return to examples
    53. 53. Profound hearing loss Return to examples
    54. 54. XI nerve examination: Neck and shoulders Return to examples
    55. 55. XII nerve examination: Stick out tongue Photo credit: Tom Solomon Return to examples
    56. 56. XII nerve: Tongue movements Normal Tongue deviated to right, Left nerve damage Return to examples
    57. 57. 3.2 Cerebellar tests <ul><li>Finger-nose test </li></ul><ul><li>Rapid alternating hand movements (Dysdiadochokinesis) </li></ul><ul><li>Eye movements to look for nystagmus </li></ul><ul><li>Heel-shin test </li></ul><ul><li>Heel-toe walking </li></ul>
    58. 58. Cerebellar examples <ul><li>Finger-nose test normal…………………….. </li></ul><ul><li>Finger-nose test abnormal…………………. </li></ul><ul><li>Rapid alternating hand movements…..…… </li></ul><ul><li>Nystagmus………………………….………… </li></ul><ul><li>Heel-toe walking…………………………….. </li></ul><ul><li>Heel-shin test………………………………… </li></ul><ul><li>Go to slide 65: Brainstem tests ………….. </li></ul>
    59. 59. Cerebellar tests: finger-nose test normal Photo credit: Tom Shulz Return to examples
    60. 60. Cerebellar tests: finger-nose test abnormal Return to examples
    61. 61. Cerebellar tests: rapid alternating hand movements (dysdiadochokinesis) abnormal (1 st ) and normal (2 nd ) Return to examples
    62. 62. Cerebellar tests: nystagmus Return to examples This patient had downbeat nystagmus when looking to the right: i.e. nystagmus with the fast phase beating in a downward direction
    63. 63. Cerebellar tests: heel-toe walking Return to examples
    64. 64. Cerebellar tests: heel-shin test normal (1 st ) & abnormal (2 nd ) Return to examples
    65. 65. 3.3 Brainstem <ul><li>Doll’s eye reflex </li></ul><ul><ul><li>(Occulocephalic reflex) </li></ul></ul><ul><li>Gag reflex </li></ul><ul><ul><li>Lost in deep coma, or brainstem damage </li></ul></ul><ul><li>Facial (or body) asymmetry </li></ul><ul><ul><li>In response to pain, or temperature </li></ul></ul><ul><li>Abnormal posture </li></ul><ul><ul><li>Opisthotonus </li></ul></ul><ul><ul><li>Flexor (“decorticate”) posturing </li></ul></ul><ul><ul><li>Extensor (“decerebrate”) posturing </li></ul></ul>
    66. 66. Brainstem examples <ul><li>Doll’s eye reflex normal……………................... </li></ul><ul><li>Doll’s eye reflex abnormal………….................. </li></ul><ul><li>Abnormal posture </li></ul><ul><ul><li>Opisthotonus……………………............................... </li></ul></ul><ul><ul><li>Extensor (“decerebrate”) posturing…...................... </li></ul></ul><ul><ul><li>Focal brain damage (for comparison)….................. </li></ul></ul><ul><li>Go to slide 72: Neck stiffness…………….. </li></ul>
    67. 67. Doll’s eye reflex: present (normal) Return to examples
    68. 68. Doll’s eye reflex: absent (abnormal) Photo credit: Tom Solomon Return to examples
    69. 69. Opisthotonus in JE Return to examples
    70. 70. Extensor posturing in JE Photo credit: Tom Solomon Return to examples
    71. 71. Focal brain damage (for comparison) Return to examples
    72. 72. 3.4 Special tests: Neck stiffness <ul><li>Neck stiffness </li></ul><ul><ul><li>Stiffness or rigidity in the neck indicates meningeal irritation. </li></ul></ul><ul><li>Kernig’s sign </li></ul><ul><ul><li>Flex leg at hip with knee flexed then try to extend the knee. </li></ul></ul><ul><ul><li>Forced extension of the knee causes back and neck pain indicating meningeal irritation. </li></ul></ul><ul><li>Brudzinski’s sign </li></ul><ul><ul><li>Hip and knee flexion in response to neck flexion indicates meningeal irritation. </li></ul></ul>
    73. 73. Neck stiffness examples <ul><li>Neck stiffness normal………………………. </li></ul><ul><li>Neck stiffness abnormal…………………… </li></ul><ul><li>Go to slide 76: Clinical significance of neurological findings…………………….. </li></ul>
    74. 74. Neck stiffness: normal Return to examples
    75. 75. Neck stiffness: abnormal Return to examples
    76. 76. 3.5 Clinical significance of neurological findings (1) <ul><li>Space occupying lesion </li></ul><ul><ul><li>signs of uncal herniation -- transtentorial or lateral </li></ul></ul><ul><ul><li>Example: intracranial haemorrhage or brain abscess </li></ul></ul><ul><li>Signs: </li></ul><ul><ul><li>Unequal pupils </li></ul></ul><ul><ul><li>Bilateral up-going Babinski reflexes </li></ul></ul><ul><ul><li>Hemiplegia </li></ul></ul><ul><ul><li>Decerebrate (extensor) posturing </li></ul></ul>
    77. 77. <ul><li>Diffuse increased cerebral pressure </li></ul><ul><ul><li>signs of central syndrome of herniation </li></ul></ul><ul><ul><li>Example: Reye’s syndrome or encephalitis </li></ul></ul><ul><li>Signs: </li></ul><ul><ul><li>Changes in alertness with frequent sighs or yawns </li></ul></ul><ul><ul><li>Pupils small, roving eye movements </li></ul></ul><ul><ul><li>Bilateral up-going Babinski reflexes </li></ul></ul><ul><ul><li>Decorticate posturing (flexed arms, extended legs) </li></ul></ul>Clinical significance of neurological findings (2)
    78. 78. Clinical significance of neurological findings (3) <ul><li>Brainstem dysfunction </li></ul><ul><li>Signs </li></ul><ul><ul><li>Dilation of both pupils </li></ul></ul><ul><ul><li>Absent Doll’s eye reflex </li></ul></ul><ul><ul><li>Bilateral decerebrate rigidity </li></ul></ul><ul><ul><li>Ataxic (irregular) respiratory pattern </li></ul></ul>
    79. 79. Neurological examination <ul><li>Neurological examination includes: </li></ul><ul><li>Observation </li></ul><ul><li>Assessment of mental state or conscious level </li></ul><ul><li>Examination of the central nervous system (CNS) </li></ul><ul><ul><li>Cranial nerves I-XII </li></ul></ul><ul><ul><li>Cerebellar function </li></ul></ul><ul><ul><li>Brainstem tests </li></ul></ul><ul><ul><li>Special tests </li></ul></ul><ul><li>Examination of the peripheral nervous system (PNS) </li></ul><ul><ul><li>Muscle tone </li></ul></ul><ul><ul><li>Limb muscle power </li></ul></ul><ul><ul><li>Reflexes </li></ul></ul><ul><ul><li>Sensation in limbs </li></ul></ul><ul><ul><li>Gait </li></ul></ul>
    80. 80. Peripheral nervous system examination <ul><li>First look at the patient carefully. Check for any asymmetry, differences in muscle bulk/wasting. </li></ul><ul><li>Examine the patient </li></ul><ul><ul><li>Tone </li></ul></ul><ul><ul><li>Power </li></ul></ul><ul><ul><li>Reflexes </li></ul></ul><ul><ul><li>Sensation (if abnormality suspected) </li></ul></ul><ul><ul><li>Gait </li></ul></ul><ul><li>The examination can be done in any order. </li></ul><ul><li>A formal examination is often not possible in children with encephalitis. </li></ul>
    81. 81. 4.1 Assessing tone in the arms <ul><li>Gently bend the arm at the wrist and elbow joints, using circular movements. </li></ul><ul><ul><li>Is tone normal, increased or decreased? </li></ul></ul><ul><ul><li>Is there cog-wheel rigidity? </li></ul></ul>
    82. 82. Arm tone normal
    83. 83. 4.1 Assessing tone in the legs <ul><li>Gently roll the leg from side to side </li></ul><ul><ul><li>Does the foot gently rock? (normal) </li></ul></ul><ul><ul><li>Does it flop about too much? (decreased or flaccid tone) </li></ul></ul><ul><ul><li>Is it stiff? (increased tone) </li></ul></ul><ul><li>Hold the leg behind the knee and quickly pull the knee off the bed </li></ul><ul><ul><li>Does the whole leg lift up? (increased tone) </li></ul></ul><ul><ul><li>Does the heel remain on the bed? (normal) </li></ul></ul><ul><li>Test for flaccid tone with the “frog’s legs test” </li></ul><ul><ul><li>Do the legs flop out because of reduced tone? </li></ul></ul>
    84. 84. Examining tone examples <ul><li>Increased leg tone……………………………. </li></ul><ul><li>Decreased leg tone - “Frog’s legs” test…….. </li></ul><ul><li>Go to slide 87: Further PNS examination ….. </li></ul>
    85. 85. Increased leg tone Return to examples
    86. 86. The “frog’s legs” test for decreased tone <ul><li>The health care worker draws up the knees with the legs bent; when they are released they flop out into a frog’s legs position, because they are flaccid (floppy)- decreased leg tone </li></ul>Photo Credit: T Solomon Return to examples
    87. 87. 4.2 Assess power in the limbs <ul><li>If the child can cooperate, assess power of flexion and extension at each joint, using the MRC Grading: </li></ul><ul><ul><li>Grade 5 – normal </li></ul></ul><ul><ul><li>Grade 4 – reduced </li></ul></ul><ul><ul><li>Grade 3 – only just strong enough to overcome gravity </li></ul></ul><ul><ul><li>Grade 2 – not strong enough to overcome gravity </li></ul></ul><ul><ul><li>Grade 1 – a flicker of movement </li></ul></ul><ul><ul><li>Grade 0 – no movement at all </li></ul></ul>
    88. 88. Power upper limbs: normal
    89. 89. Power lower limbs: normal Photo credit: Tom Shulz
    90. 90. 4.3 Examining the reflexes (1) <ul><li>First demonstrate the use of the tendon hammer on yourself or an assistant, so that the child is not frightened. </li></ul><ul><li>Upper limbs reflexes </li></ul><ul><ul><li>Biceps, triceps, supinator </li></ul></ul><ul><li>Lower limbs reflexes </li></ul><ul><ul><li>Knee jerk, ankle jerk </li></ul></ul><ul><li>Are the deep tendon reflexes </li></ul><ul><ul><li>Normal? </li></ul></ul><ul><ul><li>Increased? (upper motor neuron damage) </li></ul></ul><ul><ul><li>Decreased/absent? (lower motor neuron damage) </li></ul></ul>
    91. 91. 4.3 Examining the reflexes (2) <ul><li>Plantar (Babinski) reflexes </li></ul><ul><ul><li>Are they flexor? (down, normal) </li></ul></ul><ul><ul><li>Are they extensor? (up, abnormal) </li></ul></ul><ul><li>Extra tests: Abdominal reflexes </li></ul><ul><ul><li>Present or absent </li></ul></ul>
    92. 92. Reflexes examination examples <ul><li>Upper limb abnormal……………….…….. </li></ul><ul><li>Supinator abnormal……………………….. </li></ul><ul><li>Knee jerk abnormal and normal………… </li></ul><ul><li>Plantar normal…………………………….. </li></ul><ul><li>Plantar abnormal………………………….. </li></ul><ul><li>Clonus……………………………………… </li></ul><ul><li>Abdominal reflexes normal………………. </li></ul><ul><li>Abdominal reflexes abnormal……………. </li></ul><ul><li>Go to slide 102: Gait………………….….. </li></ul>
    93. 93. Reflexes: Upper limb Right and left abnormal (brisk) Return to examples
    94. 94. Supinator reflexes abnormal Photo Credit: T Solomon Return to examples
    95. 95. Knee jerks abnormal (brisk) and normal Return to examples
    96. 96. Plantar reflex normal Return to examples
    97. 97. Plantar reflex abnormal Photo Credit: T Solomon Return to examples
    98. 98. Clonus (abnormal) Return to examples
    99. 99. Abdominal reflexes normal Return to examples
    100. 100. Abdominal reflexes absent (abnormal) Photo Credit: T Solomon Return to examples
    101. 101. 4.4 Sensation <ul><li>The sensory exam is used to determine areas of abnormal sensation and the quality and type of any sensation impairment </li></ul><ul><li>Assess different types of sensation including pressure, pain, temperature, and position. </li></ul><ul><li>Assess both sides and upper/lower parts of the body </li></ul><ul><li>Examples </li></ul><ul><ul><li>Test touch sensation with a cotton wool ball </li></ul></ul><ul><ul><li>Test temperature sensation with a cold or warm object </li></ul></ul><ul><ul><li>Test position by asking the child to close their eyes and tell the examiner in which the examiner is moving a part of their body (e.g., big toe). </li></ul></ul><ul><ul><li>Children also may be asked to identify objects with their eyes closed or identify numbers or letters traced on their body. </li></ul></ul>
    102. 102. 4.5 Gait <ul><li>Observe the patient walking in different ways </li></ul><ul><ul><li>In a straight line </li></ul></ul><ul><ul><li>Walking on the toes and then the heels </li></ul></ul><ul><ul><li>Heel-to-toe (if not done already in cerebellar examination) </li></ul></ul>
    103. 103. Gait example: abnormal
    104. 104. Examination general <ul><li>Observe the child’s behaviour and actions, </li></ul><ul><li>even whilst taking the history. </li></ul><ul><li>The examination is not complete without taking basic measurements and examining other systems. </li></ul>
    105. 105. Basic measurements and other systems <ul><ul><li>Basic measurements </li></ul></ul><ul><ul><ul><li>Blood pressure </li></ul></ul></ul><ul><ul><ul><li>Pulse rate </li></ul></ul></ul><ul><ul><ul><li>Respiratory rate </li></ul></ul></ul><ul><ul><ul><li>Temperature </li></ul></ul></ul><ul><ul><li>Other systems </li></ul></ul><ul><ul><ul><li>Skin </li></ul></ul></ul><ul><ul><ul><li>Ear, nose and throat </li></ul></ul></ul><ul><ul><ul><li>Respiratory </li></ul></ul></ul><ul><ul><ul><li>Cardiovascular </li></ul></ul></ul><ul><ul><ul><li>Gastrointestinal </li></ul></ul></ul>
    106. 106. Other systems: Skin <ul><li>Look for: </li></ul><ul><li>Skin turgor </li></ul><ul><li>Capillary refill time </li></ul><ul><li>Rashes </li></ul><ul><ul><li>flat/raised/discoloured/red/inflamed </li></ul></ul><ul><li>Petechial haemorrhages (small areas of bleeding into the skin, non-blanching) </li></ul><ul><ul><li>Do the tourniquet test </li></ul></ul><ul><li>Bruises/blisters </li></ul><ul><li>Scratch marks, eczema, or psoriasis </li></ul><ul><li>Bites – insect bites/black eschar of tick bite/fang marks of snake bite/scorpion bite/dog bite/cat scratch marks </li></ul>
    107. 107. The tourniquet test for dengue Inflate the blood pressure cuff to half way between systolic and diastolic for 5 minutes. 20 or more petechiae per 2.5 cm 2 is a positive test for dengue (sensitivity 40% specificity 95%) Cao et al 2002 Photos Solomon, T. (2003) In Manson's Tropical Diseases 2003
    108. 108. Other systems: Ear, Nose and Throat <ul><li>Ear, nose and throat (ENT) examination is important, but it may be possible to conduct the ENT examination within the CNS examination so as not to repeat parts of the examination and over tire the child. </li></ul><ul><li>Points to remember in the ENT examination: </li></ul><ul><ul><li>Severe tonsillitis may mimic meningitis </li></ul></ul><ul><ul><li>Otitis media may be associated with meningitis </li></ul></ul>
    109. 109. Other systems: Respiratory <ul><li>Assess the breathing rate and pattern. </li></ul><ul><li>Listen to the chest. An abnormal rate and pattern may indicate: </li></ul><ul><ul><li>Aspiration pneumonia, which is common in JE. </li></ul></ul><ul><ul><li>Metabolic acidosis, which is common in any sick, dehydrated child. </li></ul></ul><ul><ul><li>Brain stem damage, which is common in JE. </li></ul></ul>
    110. 110. Other systems: Cardiovascular <ul><li>Count pulse rate and assess rhythm (irregular or regular). </li></ul><ul><li>Measure the blood pressure. </li></ul><ul><li>Listen to the heart for murmurs/additional sounds. </li></ul>
    111. 111. Other systems: Gastrointestinal <ul><li>Check mouth for ulcers/infections </li></ul><ul><li>Feel abdomen </li></ul><ul><li>Palpate liver, spleen, and kidneys </li></ul><ul><li>Palpate bladder </li></ul><ul><ul><li>Distension of bladder is common in JE </li></ul></ul><ul><li>Listen for bowel sounds </li></ul>
    112. 112. Example of an examination proforma
    113. 113. History and examination complete! <ul><li>You have reviewed the history and examination of a child with a suspected central nervous system infection, with a particular focus on problems seen in Japanese encephalitis. </li></ul><ul><li>Further reference material is given on the next slide. </li></ul><ul><li>There are some examples of clinical cases which you may like to look at to revise what you have learned. </li></ul>
    114. 114. Case examples <ul><li>Case 1………… </li></ul><ul><li>Case 2………… </li></ul><ul><li>Case 3………… </li></ul><ul><li>Case 4………… </li></ul>
    115. 115. Observation: case 1 <ul><li>Look at the child in the next pictures walking across the room normally, and then on her heels. </li></ul><ul><li>Think about the neurological examination </li></ul><ul><li>How much of the examination can be done by simple observation? </li></ul><ul><li>Link to images of child walking </li></ul>
    116. 116. Case 1
    117. 117. Case 1 <ul><li>You have already done a large part of the neurological examination! </li></ul><ul><li>Not convinced? </li></ul><ul><li>Look at the questions on the next slide. You may want to look at the pictures again </li></ul>
    118. 118. Case 1 <ul><li>Ask yourself: </li></ul><ul><li>Is the child’s general appearance normal or abnormal? </li></ul><ul><li>Is the child ill or well? </li></ul><ul><li>Is she conscious and alert? </li></ul><ul><li>Is her gait (walk) normal or abnormal? </li></ul><ul><li>Is she moving both arms normally? </li></ul><ul><li>Is she moving both legs normally? </li></ul><ul><li>Does she appear to look around and see where she is going? </li></ul><ul><li>Is she able to walk without help? </li></ul>
    119. 119. Case 1 <ul><li>Ask yourself: </li></ul><ul><li>Is the child’s general appearance normal or abnormal? </li></ul><ul><ul><li>Answer: Normal </li></ul></ul><ul><li>Is the child ill or well? </li></ul><ul><ul><li>Answer: Well </li></ul></ul><ul><li>Is she conscious and alert? </li></ul><ul><ul><li>Answer: Yes, conscious and alert </li></ul></ul><ul><li>Is her gait (walk) normal or abnormal? </li></ul><ul><ul><li>Answer: normal </li></ul></ul><ul><li>Is she moving both arms normally? </li></ul><ul><ul><li>Answer: Yes, both arms normal </li></ul></ul><ul><li>Is she moving both legs normally? </li></ul><ul><ul><li>Answer: Yes, both legs normal </li></ul></ul><ul><li>Does she appear to look around and see where she is going? </li></ul><ul><ul><li>Answer: Yes </li></ul></ul><ul><li>Is she able to walk without help? </li></ul><ul><ul><li>Answer: Yes </li></ul></ul>
    120. 120. Case 1 <ul><li>From this observation, we have information about the following: </li></ul><ul><ul><li>PNS: </li></ul></ul><ul><ul><ul><li>Gross motor function in all 4 limbs appears to be normal </li></ul></ul></ul><ul><ul><ul><li>Gait looked normal </li></ul></ul></ul><ul><ul><li>CNS: </li></ul></ul><ul><ul><ul><li>Vision and overall facial expression was crudely examined and appears to be normal </li></ul></ul></ul><ul><ul><ul><li>Higher mental functions are grossly normal as child was able to obey the instruction to walk on tip toes and then on her heels </li></ul></ul></ul>
    121. 121. Case 1: Additional testing to complete the exam <ul><li>This child needs further examination: </li></ul><ul><li>CNS examination </li></ul><ul><li>PNS examination, including reflexes and a formal assessment of power (but we already have a fairly good idea that at least in the legs this is probably normal just from observation) </li></ul><ul><li>General examination: skin, ENT, respiratory, cardiovascular, gastrointestinal </li></ul>
    122. 122. Case 2 <ul><li>The next case is a little more difficult. </li></ul><ul><li>But remember observation! </li></ul><ul><li>Answer the questions after the images. It may help to view the pictures more than once. </li></ul>
    123. 123. Case 2 Photo credit: Tom Shulz
    124. 124. Case 2
    125. 125. Case 2 <ul><li>Ask yourself: </li></ul><ul><li>Is the child’s general appearance normal or abnormal? </li></ul><ul><li>Is she ill or well? </li></ul><ul><li>Is she conscious and alert? </li></ul><ul><li>Is her gait (walk) normal or abnormal? </li></ul><ul><li>Is she moving one or both arms normally or abnormally? </li></ul><ul><li>Is she moving one or both legs normally or abnormally? </li></ul><ul><li>Does she turn her head to sound? </li></ul><ul><li>Does she appear to look around and see where she is going? </li></ul><ul><li>Is she able to walk without help? </li></ul><ul><li> Back to images </li></ul>
    126. 126. Case 2: Answers <ul><li>Was the child’s general appearance normal or abnormal? </li></ul><ul><ul><li>Answer: Generally looked OK, but abnormal. </li></ul></ul><ul><li>Was she ill or well? </li></ul><ul><ul><li>Answer: Smiling and although not normal, looked “well” </li></ul></ul><ul><li>Was she conscious and alert? </li></ul><ul><ul><li>Answer: Clearly conscious and alert </li></ul></ul><ul><li>Was her gait (walk) normal or abnormal? </li></ul><ul><ul><li>Answer: Abnormal </li></ul></ul><ul><li>Was she moving one or both arms normally or abnormally ? </li></ul><ul><ul><li>Answer: The arms moved abnormally as she walked. Probably to help her balance as she moves. It may help to look at the pictures again. She was unable to pick up the paper clip with her left hand and only with her right hand with help from her left hand. </li></ul></ul><ul><li>Was she moving one or both legs normally or abnormally? </li></ul><ul><ul><li>Answer: Both legs appeared to be abnormal in their movements especially the right. </li></ul></ul><ul><li>Did she turn her head to sound? </li></ul><ul><ul><li>Answer: Although there is no sound on the clip, she did look round and this may have been in response to sound or someone calling her name. </li></ul></ul><ul><li>Did she look around and see where she was going? </li></ul><ul><ul><li>Answer: She manages to walk and is able to see obstacles like the bed frame in her way and move to avoid them. </li></ul></ul><ul><li>Was she able to walk without help? </li></ul><ul><ul><li>Answer: She is able to walk but with obvious difficulty. It’s unlikely she could walk a long distance and probably couldn’t carry heavy objects. </li></ul></ul>Back to images
    127. 127. Case 2 <ul><li>Again we have a large amount of information about the CNS and PNS without formally examining the child. </li></ul><ul><li>For the CNS she can see and avoid objects but how much she is able to hear or understand will need further testing. </li></ul><ul><li>We know her limbs are abnormal so it will be important to concentrate on those in the PNS examination. </li></ul><ul><li>General examination is also needed to complete our assessment. </li></ul>
    128. 128. Case 3 <ul><li>As with the previous cases look at the pictures carefully. </li></ul><ul><li>Remember to look at all the limbs and their movements. </li></ul><ul><li>Then answer the questions on the next slide. It may help to view the images more than once. </li></ul>
    129. 129. Case 3 Photo credit: Tom Shulz Notice the fixed position of her right arm
    130. 130. Case 3 The knee jerk was brisk
    131. 131. Case 3 <ul><li>Ask yourself: </li></ul><ul><li>Is the child’s general appearance normal or abnormal? </li></ul><ul><li>Is she ill or well? </li></ul><ul><li>Is she conscious and alert? </li></ul><ul><li>Is her gait (walk) normal or abnormal? </li></ul><ul><li>Is she moving one or both arms normally or abnormally? </li></ul><ul><li>Is she moving one or both legs normally or abnormally? </li></ul><ul><li>Does she appear to look around and see where she is going? </li></ul><ul><li>Is she able to walk without help? </li></ul><ul><li>Back to images </li></ul>
    132. 132. Case 3 <ul><li>Ask yourself: </li></ul><ul><li>Is the child’s general appearance normal or abnormal? </li></ul><ul><li>Answer: Normal on first look but abnormal on closer review as she doesn’t move her right arm or legs. </li></ul><ul><li>Is she ill or well? Answer: Well. </li></ul><ul><li>Is she conscious and alert? Answer: Conscious and alert. </li></ul><ul><li>Is her gait (walk) normal or abnormal? Answer: Abnormal, her mother has to lift her and even then she is unable to walk. </li></ul><ul><li>Is she moving one or both arms normally or abnormally? Answer: She isn’t using her right hand (she uses her left hand to draw with). </li></ul><ul><li>Is she moving one or both legs normally or abnormally? Answer: Abnormal, she doesn’t appear to move them at all and her left knee jerk is brisk. </li></ul><ul><li>Does she appear to look around and see what she is doing? Answer: Yes, and she is able pick out a book and a pen to draw. </li></ul><ul><li>Is she able to walk without help? Answer: No. She is unable to walk at all without support. </li></ul>
    133. 133. Case 3: Additional testing <ul><li>This child needs: </li></ul><ul><li>CNS examination. We know that gross CNS function in terms of vision and facial expression is normal as well as some higher mental function as she is able to play and draw, although further testing is required. </li></ul><ul><li>PNS examination, including reflexes and a formal assessment of power. (We already have a fairly good idea that there is problem with her limbs just from observation). </li></ul><ul><li>General examination: skin, ENT, respiratory, cardiovascular, gastrointestinal </li></ul>
    134. 134. Case 4 <ul><li>The next set of images is of a child with reduced consciousness. </li></ul><ul><li>His Glasgow Coma Score is </li></ul><ul><ul><li>Eye opening = 3 </li></ul></ul><ul><ul><li>Verbal = 4 </li></ul></ul><ul><ul><li>Motor = 3 </li></ul></ul><ul><ul><li>Giving a total of 10/15 </li></ul></ul>
    135. 135. Case 4 Note the position of his mouth carefully
    136. 136. Case 4 <ul><li>Can you see the oro-facial movements? These are typical of JE. </li></ul><ul><li>Click to look at the images again </li></ul>
    137. 137. Additional resources <ul><li>There are many excellent resources available to help health care workers assess sick children, and examine the nervous system. The following are some examples: . </li></ul><ul><ul><li>Posner E. Advanced Paediatric Life Support – the Practical Approach . 4th ed. London: BMJ Books; 2005. </li></ul></ul><ul><ul><li>Gunn VL, Nechyba C, eds. The Harriet Lane Handbook: a manual for pediatric house officers .17th ed. St. Louis, MO: Mosby-Year Book, Inc; 2006. </li></ul></ul><ul><ul><li>Behrman R, Kliegman R, Jenson HB, eds. Nelson Textbook of Pediatrics . St. Louis, MO: W B Saunders; 2003. </li></ul></ul><ul><ul><li>Fuller G. Neurological Examination made easy . Churchill Livingstone Elsevier; 2008. </li></ul></ul><ul><ul><li>Teasdale, G and Jennett, B. Assessment of coma and impaired consciousness. A practical scale. Lancet . 1974;2(7872):81-4. </li></ul></ul><ul><ul><li>James H, Trauner D. The Glasgow coma scale. In: James H, Anas N, Perkin RM. Brain Insults in Infants and Children: Pathophysiology and Management . New York: Grune & Stratton; 1985 . </li></ul></ul>
    138. 138. Acknowledgments and contacts Liverpool, UK Penny Lewthwaite, Tom Solomon, Rachel Kneen, Janet Lewthwaite Vijayanagar Institute of Medical Sciences, Bellary, India Ravikumar R,Veerashankar, Ashia, Begum, Sri Hari, Subhashinai, Asma, Prathiba, Kailash, Sangeetha, Gaurav, Abhishek, Indy Sandaradura, Tom Shulz, Hospital Director, Nursing staff Universiti Malaysia Sarawak Malaysia , Mong How Ooi, M Cardosa MJ Sibu Hosptial, Sarawak, Malaysia Wong See Chang, Lai Boon Foo, Anand, Hospital Director, Nursing staff, Occupational Therapy staff National Institute of Mental Health and Neurological Sciences, Bangalore, India , Ravi V, Desai A Photo and film credits: Penny Lewthwaite (unless otherwise stated) All the parents, and caregivers and children who have helped with the development of this tool. Funders: PATH JE Project, PATH , Seattle USA Medical Research Council, UK Wellcome Trust, UK Further information and contacts: PATH JE Project Brain Infections Group
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