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Clinical Assessment of Children with Suspected Central Nervous
System Infections
Brain Infections Group University of Liverpool, United Kingdom
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ContentsUsing this presentationIntroductionChecking the sick childHistory taking
– General questions– JE-related questions– Neurological disease– Seizures or abnormal movements – Completion of patient history– Example of a history proforma
ExaminationNeurological examination
• 1.0 Observation• 2.0 Assessment of mental state or consc
ious level
– 2.1 Assessing mental state– 2.2 Assessing conscious level
• 3.0 Examination of the central nervous system
– 3.1 Cranial nerves
Neurological examination continued:– 3.2 Cerebellar tests– 3.3 Brainstem– 3.4 Special tests– 3.5 Clinical significance of findings
• 4.0 Examination of the peripheral nervous system
– 4.1 Tone – 4.2 Power – 4.3 Reflexes – 4.4 Sensation– 4.5 Gait
Examination General
Example of examination proforma
Example cases 1-4
Additional Resources
Acknowledgments
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Using this presentation (1)
• This presentation can be viewed by:
– Clicking through each slide consecutively.
– Clicking on the arrows on the bottom right and left of each screen.
– Clicking on items on the contents slide to go to that slide.
• To return to a slide after clicking a link, click
• To get back to the contents page from any slide click on the house image.
• To exit press the arrow and line image.
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Using this presentation (2)
• This presentation contains still images linked by an arrow button.
• There are notes below many of the slides to assist presenters.
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Introduction (1)• This presentation has been developed for use by doctors
and health care workers in areas where Japanese encephalitis (JE) is endemic.
• 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.
• 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.
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Introduction (2)
• At the end of the presentation participants will
– Be better able to take a history with specific questions for encephalitis patients.
– Be better able to examine a patient with encephalitis.
– Be aware of what neurological problems to look for and how to examine them.
• 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.
• The tool is freely available, but when using it, please acknowledge the University of Liverpool, UK, and PATH.
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Checking the sick child
Check the ABC’s:• Airway • Breathing• Circulation
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Patient history: general questions (1) • Presenting history
– What brought them to hospital, details, length of time complaint has been present, triggers (if any)
• Fever, history of fever– Note that even if a child is not febrile at this time, a
history of fever is important
• Cough, cold symptoms, redness of the eyes• Assess current hydration/nutritional state
– Diarrhoea, vomiting, recent food and fluid intake and urine output
• Immunization history
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Patient history: general questions (2)
• Social history– Economic circumstances
– Childcare/schooling
• Medication/Treatment – Ask about recent and current medications
– Ask specifically about traditional medicines
– Check for any known allergies
• Family history (e.g., history of tuberculosis, epilepsy, diabetes, or asthma)
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Patient history: JE-related questions (1)
• Is this an area where JE occurs?
• Is this the JE season?– In much of the tropics the season begins soon after the
rainy season
– However in many areas there is low level transmission even out of season
• Have other children had a similar illness?
• Does the child live in a rural area, where JE is more likely?– Note that JE also occurs on the edges of some cities in
Asia
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Patient history: JE-related questions (2)
• Are there epidemiological features to suggest that this is NOT JE? – Are animals sick? The virus does not cause disease
in birds or swine (though it may cause abortions in pregnant swine).
– Are many adults affected? • 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.
– Does it appear to be transmitted by a different route (e.g., direct contact, faecal-oral route, or aerosol) ?
• 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.
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Patient history: neurological disease (1)
Ask about:
• Stiff neck
• Photophobia (avoidance of light)
• Phonophobia (avoidance of noise)
• Confusion/irritability/restlessness
• Altered behaviour– Sometimes mistakenly attributed to psychiatric illness
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Ask about:
• Altered cry– High pitch cry is a late sign of raised intracranial
pressure (ICP)
• Limb weakness– Has the child stopped walking, or stopped using one
hand?
– Does he/she normally use the right or left hand, and are there any changes in this since illness?
Patient history: neurological disease (2)
14 Patient history: seizures or abnormal movements (1)
• Ask about abnormal movements of eyes, face, limbs.
• Distinguishing convulsions from spasms, tremors and rigors is difficult.
• 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.
• The distinction is important because
– Seizures may need anticonvulsant drugs.
– Characteristic spasms and tremors are seen in some types of viral encephalitis (e.g., JE) and so may point toward the diagnosis.
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Examples of seizures or abnormal movements
• Ask parent to mimic seizure / abnormal movements……………………………….
• Seizure…………………………………….
• Subtle seizure…………………………….
• Orofacial movements…………………….
• Go to slide 20: Seizures and abnormal movements (2)……………………………
16 Asking parent to mimic child’s seizure or abnormal movements
Return to examples
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Seizure activity in JE patient
Return to examples
In this patient, the left arm was shaking slightly (subtle partial seizure)
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Subtle seizure activity
Return to examples
19 Orofacial movements are characteristic of patients with JE
Return to examples
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Patient history: seizures or abnormal movements (2)
• If seizures are reported, ask about frequency and duration. – Changes in frequency and duration of seizures are used to
monitor treatment effectiveness.
• Ask if any seizure has been followed by unconsciousness for >30 minutes.
• Status epilepticus (seizure lasting >30 minutes) is important to look for.– It is a poor prognostic indicator.
– The seizures of status epilepticus may be subtle partial seizures.
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Completion of patient history• Growth chart
– Height for age and weight or mid upper arm circumference.
• Family tree and birth history• Previous illnesses• Systems review
– Respiratory system: coughs/colds/asthma– Cardiovascular system: palpitations, arrhythmias, rheumatic
heart disease, murmurs– Gastrointestinal: diarrhoea and vomiting, hepatitis, bladder and
bowel function– Central Nervous System: headaches, vision problems.
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Example of a history proforma
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Neurological examination Neurological examination includes:1. Observation2. Assessment of mental state or conscious level 3. Examination of the central nervous system (CNS)
– Cranial nerves I-XII– Cerebellar function – Brainstem tests– Special tests
4. Examination of the peripheral nervous system (PNS) – Muscle tone– Limb muscle power– Reflexes – Sensation in limbs – Gait
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Neurological examination Neurological examination includes:
1. Observation2. Assessment of mental state or conscious level 3. Examination of the central nervous system (CNS)
– Cranial nerves I-XII– Cerebellar function – Brainstem tests– Special tests
4. Examination of the peripheral nervous system (PNS) – Muscle tone– Limb muscle power– Reflexes – Sensation in limbs – Gait
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Observation
• Simple observation is vital
– A huge amount of information can be gained for the examination by observation alone.
– A full formal neurological examination is time consuming and will not be tolerated by small children.
• Observe as much as you can before disturbing the child, then begin to examine with minimal disturbance. Look for:– Any obvious abnormalities or asymmetry– Bulging fontanelle in young infants and children– Reduced spontaneous movements of one or more limbs– Abnormal posture– Abnormal movements, subtle seizures
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Neurological examination Neurological examination includes:
1. Observation
2. Assessment of mental state or conscious level 3. Examination of the central nervous system (CNS)
– Cranial nerves I-XII– Cerebellar function – Brainstem tests– Special tests
4. Examination of the peripheral nervous system (PNS) – Muscle tone– Limb muscle power– Reflexes – Sensation in limbs – Gait
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2.1 Assessing mental state
• Assessing mental state can be difficult, particularly in young children.
• Surrogate questions can be used, asking parents or carers about: – Behavioural changes– Mood swings and temper tantrums– Concentration levels– School work– Ability to help with tasks around the house
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2.2 Assessing conscious level
• The Glasgow Coma Score is the most widely used score
– A modified Glasgow Coma Score exists for children <5 years old
• A simple AVPU score (Alert/Voice/Pain/ Unconscious) allows a very rapid initial assessment, and is better than nothing
• An example of the sternal rub is provided, used with the Glasgow coma scale
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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
Glasgow Coma Score and the James Modification for children <5 years
AVPU
Return to examples
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AVPU rapid assessment of consciousness level
• A ALERT• V responds to VOICE• P responds to PAIN
• U UNRESPONSIVE GCS
Return to examples
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Glasgow Coma Score: Sternal rub - patient localises to pain
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Neurological examination Neurological examination includes:
1. Observation2. Assessment of mental state or conscious level
3. Examination of the central nervous system (CNS)
– Cranial nerves I-XII– Cerebellar function – Brainstem tests– Special tests
4. Examination of the peripheral nervous system (PNS) – Muscle tone– Limb muscle power– Reflexes – Sensation in limbs – Gait
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3.1: Cranial nerves I-VIIThis examination can be done in older children and adults.
I Olfactory– Is the sense of smell normal?
II Optic– Is visual acuity normal?– Do the pupils react to light and to accommodation?– Are the visual fields normal to confrontation?– Are the optic fundi normal?
III, lV, Vl Oculomotor, Trochlear, Abducens – Are the eye movements normal?– Is one pupil dilated (IIIrd nerve lesion)?
V Trigeminal – Is sensation normal on the face (and cornea), and is jaw power
normal?
VII Facial – Is there facial weakness?
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VIII Vestibulocochlear– Is hearing reduced?
IX Glossopharyngeal– Is sensation in the pharynx normal (tested by eliciting the gag
reflex)?
X Vagus– Do both sides of the palate move when the patient says “Agh”?
(And during the gag reflex?)
XI Accessory – Do the shoulders lift? Is power of head turning normal?
XII Hypoglossal– Does the tongue look and protrude normally?
3.1(cont.): Cranial nerves Vlll-XII
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• Optic (II) – Visual acuity: Snellen chart or “E” card – Visual fields: confrontation test
• Optic and oculomotor (II, III)– Light reflexes: direct and consensual
• Oculomotor, Trochlear, Abducens (III, IV, VI)– Eye movements
• Examine the optic discs• Doll’s eye reflex
3.1 (cont.): Eye examination
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Eye examination - examples
• Visual acuity charts………………......• Direct light reflex………………………• Eye movements……………………....• Right VIth nerve palsy:.………………• Bilateral VIth nerve palsy: video….....• Ophthalmoscopy right eye……………• Ophthalmoscopy left eye…………….• Ophthalmoscopy young child………..• Go to slide 45: Cranial nerves V-Xll…
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Visual acuity charts
E 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
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Direct light reflex
Film credit: T Solomon
Return to examples
39 Eye movements: head still, instruction “follow my finger”
Photo credit: Tom Shulz
Return to examples
40 Right VIth nerve palsy–right eye is unable to abduct (move outwards)
Trying to look this wayReturn to examples
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Bilateral VIth nerve palsy–look carefully, neither eye abducts
Return to examples
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Ophthalmoscopy: examiner’s right eye to patient’s right eye
Photo credit: Tom Shulz
Return to examples
43 Ophthalmoscopy: examiner’s left eye to patient’s left eye
Photo credit: Tom Shulz
Return to examples
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Opthalmoscopy: young child
Photo credit: Tom Shulz
Return to examples
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Cranial nerves V-XII examples
• V Trigeminal nerve examination..……………………….• V Trigeminal nerve: Jaw jerk normal…………………….• V Trigeminal nerve: Jaw jerk abnormal…...…………….• VII Facial nerve - “Screw your eyes up” ………………..• V and VII nerves .…………………………………………• Hearing: Otitis externa/otitis media …………………….• VIII nerve examination: Hearing ………………………..• Vlll nerve: Profound hearing loss……………………….• XI nerve examination: Neck and shoulders…………...• XII nerve: “Stick out your tongue” ………………………• XII nerve: Tongue movements…………………………..• Go to slide 57: Cerebellar tests………………………….
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V Trigeminal nerve examination
Photo credit: Tom Solomon
Return to examples
47 V Trigeminal nerve: jaw jerk normal
Photo credit: Tom Solomon
Return to examples
48 V Trigeminal nerve: jaw jerk abnormal (brisk)
Photo credit: Tom Solomon
Return to examples
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VII nerve examination: “Screw your eyes up”
Return to examples
50 V and VII nerves: “Screw your eyes up,show me your teeth”
Return to examples
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Hearing: Otitis externa/otitis media
Return to examples
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VIII nerve examination: Hearing
Return to examples
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Profound hearing loss
Return to examples
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XI nerve examination: Neck and shoulders
Return to examples
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XII nerve examination: Stick out tongue
Photo credit: Tom Solomon
Return to examples
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XII nerve: Tongue movements
Normal Tongue deviated to right,Left nerve damage
Return to examples
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3.2 Cerebellar tests
• Finger-nose test• Rapid alternating hand movements
(Dysdiadochokinesis)• Eye movements to look for nystagmus• Heel-shin test• Heel-toe walking
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Cerebellar examples
• Finger-nose test normal……………………..• Finger-nose test abnormal………………….• Rapid alternating hand movements…..……• Nystagmus………………………….…………• Heel-toe walking……………………………..• Heel-shin test…………………………………
• Go to slide 65: Brainstem tests…………..
59 Cerebellar tests: finger-nose test normal
Photo credit: Tom Shulz
Return to examples
60 Cerebellar tests: finger-nose test abnormal
Return to examples
61 Cerebellar tests: rapid alternating hand movements (dysdiadochokinesis)
abnormal (1st) and normal (2nd)
Return to examples
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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
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Cerebellar tests: heel-toe walking
Return to examples
64 Cerebellar tests: heel-shin testnormal (1st) & abnormal (2nd)
Return to examples
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3.3 Brainstem
• Doll’s eye reflex– (Occulocephalic reflex)
• Gag reflex
– Lost in deep coma, or brainstem damage
• Facial (or body) asymmetry– In response to pain, or temperature
• Abnormal posture– Opisthotonus
– Flexor (“decorticate”) posturing
– Extensor (“decerebrate”) posturing
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Brainstem examples
• Doll’s eye reflex normal……………...................
• Doll’s eye reflex abnormal…………..................
• Abnormal posture – Opisthotonus……………………...............................
– Extensor (“decerebrate”) posturing…......................
– Focal brain damage (for comparison)…..................
• Go to slide 72: Neck stiffness……………..
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Doll’s eye reflex: present (normal)
Return to examples
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Doll’s eye reflex: absent (abnormal)
Photo credit: Tom Solomon
Return to examples
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Opisthotonus in JE
Return to examples
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Extensor posturing in JE
Photo credit: Tom Solomon
Return to examples
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Focal brain damage (for comparison)
Return to examples
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3.4 Special tests: Neck stiffness
• Neck stiffness– Stiffness or rigidity in the neck indicates meningeal
irritation.
• Kernig’s sign– Flex leg at hip with knee flexed then try to extend the
knee.– Forced extension of the knee causes back and neck
pain indicating meningeal irritation.
• Brudzinski’s sign– Hip and knee flexion in response to neck flexion
indicates meningeal irritation.
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Neck stiffness examples
• Neck stiffness normal……………………….• Neck stiffness abnormal……………………• Go to slide 76: Clinical significance of
neurological findings……………………..
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Neck stiffness: normal
Return to examples
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Neck stiffness: abnormal
Return to examples
76 3.5 Clinical significance of neurological findings (1)
• Space occupying lesion – signs of uncal herniation -- transtentorial or lateral– Example: intracranial haemorrhage or brain abscess
• Signs:– Unequal pupils– Bilateral up-going Babinski reflexes– Hemiplegia– Decerebrate (extensor) posturing
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• Diffuse increased cerebral pressure – signs of central syndrome of herniation
– Example: Reye’s syndrome or encephalitis
• Signs:– Changes in alertness with frequent sighs or yawns
– Pupils small, roving eye movements
– Bilateral up-going Babinski reflexes
– Decorticate posturing (flexed arms, extended legs)
Clinical significance of neurological findings (2)
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Clinical significance of neurological findings (3)
• Brainstem dysfunction
• Signs– Dilation of both pupils
– Absent Doll’s eye reflex
– Bilateral decerebrate rigidity
– Ataxic (irregular) respiratory pattern
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Neurological examination Neurological examination includes:
1. Observation2. Assessment of mental state or conscious level 3. Examination of the central nervous system (CNS)
– Cranial nerves I-XII– Cerebellar function – Brainstem tests– Special tests
4. Examination of the peripheral nervous system (PNS)
– Muscle tone– Limb muscle power– Reflexes – Sensation in limbs – Gait
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Peripheral nervous system examination
• First look at the patient carefully. Check for any asymmetry, differences in muscle bulk/wasting.
• Examine the patient– Tone– Power– Reflexes – Sensation (if abnormality suspected)– Gait
• The examination can be done in any order.• A formal examination is often not possible in children
with encephalitis.
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4.1 Assessing tone in the arms
• Gently bend the arm at the wrist and elbow joints, using circular movements. – Is tone normal, increased or decreased?– Is there cog-wheel rigidity?
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Arm tone normal
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4.1 Assessing tone in the legs
• Gently roll the leg from side to side– Does the foot gently rock? (normal)– Does it flop about too much? (decreased or flaccid
tone)– Is it stiff? (increased tone)
• Hold the leg behind the knee and quickly pull the knee off the bed– Does the whole leg lift up? (increased tone)– Does the heel remain on the bed? (normal)
• Test for flaccid tone with the “frog’s legs test”– Do the legs flop out because of reduced tone?
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Examining tone examples
• Increased leg tone…………………………….
• Decreased leg tone - “Frog’s legs” test……..
• Go to slide 87: Further PNS examination…..
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Increased leg tone
Return to examples
86 The “frog’s legs” test for decreased tone
• 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
Photo Credit: T Solomon
Return to examples
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4.2 Assess power in the limbs
• If the child can cooperate, assess power of flexion and extension at each joint, using the MRC Grading:– Grade 5 – normal– Grade 4 – reduced– Grade 3 – only just strong enough to overcome gravity– Grade 2 – not strong enough to overcome gravity– Grade 1 – a flicker of movement– Grade 0 – no movement at all
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Power upper limbs: normal
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Power lower limbs: normal
Photo credit: Tom Shulz
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4.3 Examining the reflexes (1)• First demonstrate the use of the tendon hammer on
yourself or an assistant, so that the child is not frightened.
• Upper limbs reflexes
– Biceps, triceps, supinator
• Lower limbs reflexes
– Knee jerk, ankle jerk
• Are the deep tendon reflexes
– Normal?
– Increased? (upper motor neuron damage)
– Decreased/absent? (lower motor neuron damage)
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4.3 Examining the reflexes (2)
• Plantar (Babinski) reflexes – Are they flexor? (down, normal)– Are they extensor? (up, abnormal)
• Extra tests: Abdominal reflexes– Present or absent
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Reflexes examination examples
• Upper limb abnormal……………….……..• Supinator abnormal………………………..• Knee jerk abnormal and normal…………• Plantar normal……………………………..• Plantar abnormal…………………………..• Clonus………………………………………• Abdominal reflexes normal……………….• Abdominal reflexes abnormal…………….• Go to slide 102: Gait………………….…..
93 Reflexes: Upper limb Right and left abnormal (brisk)
Return to examples
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Supinator reflexes abnormal
Photo Credit: T Solomon
Return to examples
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Knee jerks abnormal (brisk) and normal
Return to examples
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Plantar reflex normal
Return to examples
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Plantar reflex abnormal
Photo Credit: T Solomon
Return to examples
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Clonus (abnormal)
Return to examples
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Abdominal reflexes normal
Return to examples
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Abdominal reflexes absent (abnormal)
Photo Credit: T Solomon
Return to examples
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4.4 Sensation• The sensory exam is used to determine areas of
abnormal sensation and the quality and type of any sensation impairment
• Assess different types of sensation including pressure, pain, temperature, and position.
• Assess both sides and upper/lower parts of the body
• Examples– Test touch sensation with a cotton wool ball– Test temperature sensation with a cold or warm object– 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).
– Children also may be asked to identify objects with their eyes closed or identify numbers or letters traced on their body.
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4.5 Gait
• Observe the patient walking in different ways– In a straight line– Walking on the toes and then the heels– Heel-to-toe (if not done already in cerebellar
examination)
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Gait example: abnormal
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Examination general
• Observe the child’s behaviour and actions,
even whilst taking the history.• The examination is not complete without taking
basic measurements and examining other systems.
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Basic measurements and other systems– Basic measurements
• Blood pressure
• Pulse rate
• Respiratory rate
• Temperature
– Other systems
• Skin
• Ear, nose and throat
• Respiratory
• Cardiovascular
• Gastrointestinal
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Other systems: Skin
Look for:• Skin turgor• Capillary refill time• Rashes
– flat/raised/discoloured/red/inflamed
• Petechial haemorrhages (small areas of bleeding into the skin, non-blanching)– Do the tourniquet test
• Bruises/blisters• Scratch marks, eczema, or psoriasis• Bites – insect bites/black eschar of tick bite/fang marks
of snake bite/scorpion bite/dog bite/cat scratch marks
107107 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 cm2 is a positive test for dengue (sensitivity 40% specificity 95%) Cao et al 2002
Photos Solomon, T. (2003) In Manson's Tropical Diseases 2003
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Other systems: Ear, Nose and Throat
• 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.
• Points to remember in the ENT examination:– Severe tonsillitis may mimic meningitis– Otitis media may be associated with meningitis
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Other systems: Respiratory
• Assess the breathing rate and pattern.
• Listen to the chest. An abnormal rate and pattern may indicate:– Aspiration pneumonia, which is common in JE.
– Metabolic acidosis, which is common in any sick, dehydrated child.
– Brain stem damage, which is common in JE.
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Other systems: Cardiovascular
• Count pulse rate and assess rhythm (irregular or regular).
• Measure the blood pressure.• Listen to the heart for murmurs/additional
sounds.
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Other systems: Gastrointestinal
• Check mouth for ulcers/infections• Feel abdomen • Palpate liver, spleen, and kidneys• Palpate bladder
– Distension of bladder is common in JE• Listen for bowel sounds
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Example of an
examination proforma
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History and examination complete!
• 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.
• Further reference material is given on the next slide.
• There are some examples of clinical cases which you may like to look at to revise what you have learned.
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Case examples
• Case 1…………• Case 2…………• Case 3…………• Case 4…………
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Observation: case 1
• Look at the child in the next pictures walking across the room normally, and then on her heels.
• Think about the neurological examination• How much of the examination can be done by
simple observation?
Link to images of child walking
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Case 1
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Case 1
• You have already done a large part of the neurological examination!
• Not convinced?
• Look at the questions on the next slide. You may want to look at the pictures again
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Case 1Ask yourself:1. Is the child’s general appearance normal or
abnormal? 2. Is the child ill or well?3. Is she conscious and alert?4. Is her gait (walk) normal or abnormal?5. Is she moving both arms normally?6. Is she moving both legs normally?7. Does she appear to look around and see where
she is going?8. Is she able to walk without help?
119 Case 1Ask yourself:1. Is the child’s general appearance normal or abnormal?
– Answer: Normal2. Is the child ill or well?
– Answer: Well3. Is she conscious and alert?
– Answer: Yes, conscious and alert4. Is her gait (walk) normal or abnormal?
– Answer: normal5. Is she moving both arms normally?
– Answer: Yes, both arms normal 6. Is she moving both legs normally?
– Answer: Yes, both legs normal 7. Does she appear to look around and see where she is going?
– Answer: Yes8. Is she able to walk without help?
– Answer: Yes
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Case 1
• From this observation, we have information about the following:– PNS:
• Gross motor function in all 4 limbs appears to be normal• Gait looked normal
– CNS:• Vision and overall facial expression was crudely examined
and appears to be normal• Higher mental functions are grossly normal as child was able
to obey the instruction to walk on tip toes and then on her heels
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Case 1: Additional testing to complete the exam
This child needs further examination:• CNS examination• 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)
• General examination: skin, ENT, respiratory, cardiovascular, gastrointestinal
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Case 2
• The next case is a little more difficult.
• But remember observation!
• Answer the questions after the images. It may help to view the pictures more than once.
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Case 2
Photo credit: Tom Shulz
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Case 2
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Case 2
Ask yourself:1. Is the child’s general appearance normal or abnormal? 2. Is she ill or well?3. Is she conscious and alert?4. Is her gait (walk) normal or abnormal?5. Is she moving one or both arms normally or
abnormally?6. Is she moving one or both legs normally or abnormally?7. Does she turn her head to sound? 8. Does she appear to look around and see where she is
going?9. Is she able to walk without help?
Back to images
126 Case 2: Answers 1. Was the child’s general appearance normal or abnormal?
– Answer: Generally looked OK, but abnormal. 2. Was she ill or well?
– Answer: Smiling and although not normal, looked “well”3. Was she conscious and alert?
– Answer: Clearly conscious and alert4. Was her gait (walk) normal or abnormal?
– Answer: Abnormal5. Was she moving one or both arms normally or abnormally?
– 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.
6. Was she moving one or both legs normally or abnormally? – Answer: Both legs appeared to be abnormal in their movements especially the
right.7. Did she turn her head to sound?
– 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.
8. Did she look around and see where she was going? – Answer: She manages to walk and is able to see obstacles like the bed frame in
her way and move to avoid them.9. Was she able to walk without help?
– 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.
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Case 2
• Again we have a large amount of information about the CNS and PNS without formally examining the child.
• For the CNS she can see and avoid objects but how much she is able to hear or understand will need further testing.
• We know her limbs are abnormal so it will be important to concentrate on those in the PNS examination.
• General examination is also needed to complete our assessment.
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Case 3
• As with the previous cases look at the pictures carefully.
• Remember to look at all the limbs and their movements.
• Then answer the questions on the next slide. It may help to view the images more than once.
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Case 3
Photo credit: Tom Shulz
Notice the fixed position of her right arm
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Case 3
The knee jerk was brisk
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Case 3Ask yourself:1. Is the child’s general appearance normal or abnormal? 2. Is she ill or well?3. Is she conscious and alert?4. Is her gait (walk) normal or abnormal?5. Is she moving one or both arms normally or
abnormally?6. Is she moving one or both legs normally or abnormally?7. Does she appear to look around and see where she is
going?8. Is she able to walk without help?
Back to images
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Case 3Ask yourself:1. Is the child’s general appearance normal or abnormal?
Answer: Normal on first look but abnormal on closer review as she doesn’t move her right arm or legs.
2. Is she ill or well? Answer: Well.3. Is she conscious and alert? Answer: Conscious and alert.4. Is her gait (walk) normal or abnormal? Answer: Abnormal, her
mother has to lift her and even then she is unable to walk.5. 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).6. 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.
7. 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.
8. Is she able to walk without help? Answer: No. She is unable to walk at all without support.
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Case 3: Additional testing
This child needs:• 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.
• 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).
• General examination: skin, ENT, respiratory, cardiovascular, gastrointestinal
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Case 4
• The next set of images is of a child with reduced consciousness.
• His Glasgow Coma Score is – Eye opening = 3– Verbal = 4– Motor = 3 – Giving a total of 10/15
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Case 4
Note the position of his mouth carefully
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Case 4
• Can you see the oro-facial movements? These are typical of JE.
• Click to look at the images again
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Additional resources• There are many excellent resources available to help
health care workers assess sick children, and examine the nervous system. The following are some examples: .
– Posner E. Advanced Paediatric Life Support – the Practical Approach. 4th ed. London: BMJ Books; 2005.
– 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.
– Behrman R, Kliegman R, Jenson HB, eds. Nelson Textbook of Pediatrics. St. Louis, MO: W B Saunders; 2003.
– Fuller G. Neurological Examination made easy. Churchill Livingstone Elsevier; 2008.
– Teasdale, G and Jennett, B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-4.
– 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.
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Acknowledgments and contacts
Liverpool, UKPenny Lewthwaite, Tom Solomon,
Rachel Kneen, Janet Lewthwaite
Vijayanagar Institute of Medical Sciences, Bellary, IndiaRavikumar 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, MalaysiaWong 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 USAMedical Research Council, UKWellcome Trust, UK
Further information and contacts:PATH JE ProjectBrain Infections Group