BY: Dr, WALAA SALAH MANAA

SPECIALEST OF PEDIATRIC & FEVER مـستشفى حمـيات كـفر الشـيخ

1-mental status.2-speech3-cranial nerves.

Sign of meningeal irritation.-45-motor system

-posture.-gait.-muscle(status-tone –power).-Involuntary movement-coordination.

6-sensory system.7-reflexes

-superficial.-deep-others

1-consciousness.2-emotion.( e.g. apathy)

3-behavior.(calm – irritable)

4-intelligence.I.Q.

5-orientation.(P.P.T).

6-Handness

(start to use dominant hemisphere 18m-3yrs).

7-memory.

1-Lethargy=sleepy but fully arousable.

2-Drowsiness=light coma+arousable only to severe stimuli.

3-Stupor=moderate coma+unarousable+localize the pain.

4-Coma=deep coma.. unarousable..not localize the pain.

1-Immediate memory………………….. . ارقام متتاليه6عد

Recent memory-2اسال المريض انت حاسس بايه

Remote memory-3سنوات5اسأله عن حاجه حصلت من اكثر من

memory

Delayed speech

=no word up to 18 m.Or no sentence up to 3yrs.

Causes-MR-Deafness

-articulation defect-bilingolism-physiological .Slurred speech……………………(pyramidal lesion).

Monotonus speech …………….(extrapyramidal lesion).Staccato speech…………………(cerebeller lesion)

3rd & 4th cranial nerves are located in the mid brain

5th , 6th , 7th & 8th cranial nerves are located in the pons

9th , 10th , 11th & 12th cranial nerves are located in the medulla oblongata

Common non irritant odours +to each nostril+ eye closed .

Difficult in children.

Anosmia =loss of smell.

1-visual acuity 2-Field of vision

3-fundus examination

1-Pupil size+ reaction to light

3-ptosis

2-Ocular movement

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

1-Sensory :

ophthalmic-maxillery-mandibuler.

2-motor:

masseter - temporalis –pterigoid.

3-reflexes:

corneal reflex-jaw reflex.

2-motor:

masseter – temporalis

(palpation when clenching).

–pterigoid.

(side to side movement)

3-reflexes:

corneal reflex

ولو مش عارف تعمله انفخ فى عينه,

3-reflexes:

jaw reflex.فكيجب ان يكون اتجاه الضرب ألسفل حتى ينفتح ال

Normally this reflex is absent or very slight. However in individuals with UMNL the jaw jerk reflex can be quite pronounced.

1-Sensory-----ant.2/3 of tongue.

2-Motor-----forehead –eye -mouth .

Facial paralysis =

(mouth deviation to healthy side

+weak eye closure

+ absent corrugation of forehead)

Cochlear part(hearing)*At birth ---moro reflex.*younger deviate to sound.*Later Renne s test+ Weber test.

Vestibular part nystagmus +vertigo

Sensory ……loss of post 2/3 of tongue.

Motor……pharyngeal O/E….1-gag reflex…absent in bulber palsy UMNL

……exaggarated in pseudo bulber palsy LMNL.2-Uvula ….normally central & mobile.

In unilateral lesion….uvula deviate to healthy side.In bilateral lesion…uvula is central but immobile.

Spinal accessory N.

Sternomastoid……ability to rotate head to healthy side.

Trapezius…….dropping of shoulder in affected side

Hypoglossal N. …..deviation of the tongue to the affected side on

protrusion.

Bulber palsy Pseudo –bulber palsy

It is LMNL of the bulbercranial nerve 8-9.

Lead to loss of gag reflex + flaccid paralysis of pharynx & larynx.

It is UMNL of the bulbercranial nerve nuclei

Lead to exaggerated gag reflex.Spastic paralysis of the pharynx & larynx.

Late singes Neck stiffness. Back stiffness. +ve kernig’s sing. +veBrudziniski’ neck

sign. +veBrudziniski’ leg

sign.

Early singe chin-chest test. Chin-knee kissing

test. Tripod singe

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

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

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

Facial nerve

Ataxic gait……ataxic CP.

Scissoring gait in spastic CP.

Not able to walk.

pseudo hypertrophy muscle atrophymuscle hypertrophy

1-Young child…….painful stimulation on the

opposite side of the tested muscle.

2-Older child….ask to move against resistance.

3-Test every joint for its muscle group.

4-Grading of muscle power

U.L.

small muscle of hand.بيعرف يكتب—الولد بيعرف يزرر القميص

Muscle of lbowFlexors…بيعرف يفتح الدرج او الشباكextensors= .بيعرف يقفل الشباك او الدرج

Shoulder….Flexor… بيعرف يحط ايده فى الكمExtensor بيعرف يشيل ايده من الكمAdductor ..يحط الكشكول تحت باطه

L.L.

Small muscle of LL…. الولد بقع منه الشبشب وهوماشى

Knee…. طلوع السلم ونزوله

Adductor ….يحط رجل على رجل

Abductor….يشيل رجل من على رجل

Trunk.

-Flexor…. الولد لو نايم على ظهرهيقدر يقوم من غير ما حد يساعده او بمساعدة زراعه

-Extensor…. لو قاعد على االرضبيجى يقوم بيرفع الجذع من غير

ما يسند

.

Neck….pulling the child from both UL.

Intercostal m. ……short breath .سم30اليستطيع اطفاء شمعه على بعد ......10اليستطيع العد حتى

m. Of abdomen…….localize bulge of the abd.(e.g. poliomylitis).

Diaphragm…..paradoxical respiration.

*To detect hypertonia…….passive movement around big joint.

*To detect hypotonia…….shaking movement wrist or ankle

1-LMNL2-UMNL.=pyramidal lesion (shock stage)3-Extrapyramidal lesion (chorea).4-cerebeller lesion (ataxia).5-Down s syndrome.6-Atonic CP.

UMNL =Pyramidal lesion…..

spasticity(clasp knife) resistance on the start of movement.

Extrapyramidal lesion…..

rigidity(resistance is all over movement ).

Rigidity may be (cog-weal or lead pipe)

=usually with extrapyramidal lesion.

*Chorea….sudden irregular purposeless dancing movement affect big proximal joint.

*Athetosis…slow twisting movement affect distal joint.

*Dystonia….slow twisting movement in trunk.

*Tremors….rapid alternating movement around small joint.

Athetosis

dystonia

tremorschorea

-1st year ……grasp reflex & object transfer.

-2nd year……button & unbutton.

->3years……U.L.

1- Finger to nose test 2-Finger to finger test 3-Dysdiadochokinesis…inability toperform rapidly

alternating movement(e.g. rapid pronation and supination) 4-Rebound test

L.L. Heal to shin test Toe finger test Foot Tapping test

Inco-ordination = ataxia.

Isolated fibers contraction not all the muscle .

Difficult to see in any muscle

Easily to seen in the tongue?purly muscle organ coverd by mucosa ,,,,no

submucosa or fat like other muscle.

=LMN

Superficial sensation….(pain-tough-temp.).

Deep sensation………(joint sense-vibration sense-deep pressure sense).

Cortical sensation(tactile localization-tactile discrimination-steriogenosis)

Special standpoints:

Requires good cooperation on the patient`s side.

Most often we compare different parts of the body.

The patient should not see the examined part of the body !

Pain: pin prick, tooth picks

Light touch: use a wisp of cotton wool.

Temperature: use cold (5-10 0C)/or hot (40-45 0C) test tubes.

Joint position / motion:

-Hold the sides of the patient’s finger ! Move it up and down at

random ! Ask to specify the direction of movement !

Vibration:-Place a vibrating tuning fork

on a bony prominence ( ankle, knee,processus styloideus

radii and ulnae, elbow, clavicula)

Two point discrimination:

-The ability to discriminate two blunt points when applied simultaneously. (3-5 mm on the finger, 4-7 cm on the trunk).

Astereognosis.

-Inability to identify an object by palpation

sudden passive stretchsudden massive activation of AHCssudden massive contraction of all muscle fibers

Superficial reflexes-deep –visceral-others

*Scratch the lateral part of the sole….

…..planter flexion of the toes.

+ve Babiniski s.=dorsiflexion of the big toe &

fanning of the other toes=UMNL

Normal up to 2yr…….why?

Scratch abdominal wall by a pin from outward inward ….contraction of a segment of abdominal muscles.

T7T8T9

T10T11T12

Light scratch along the inner aspect of the upper part of the thigh lead to

elevation of the testicles.

Scratch the peri anal region

lead to contraction of external anal sphincter.

Biceps jerk (c5-6)

Blow upon the thumb on the biceps tendon while the elbow is slightly extended

Blow upon the triceps tendon while the elbow is flexed.

Blow upon styloid process of radius….flexion & supination of elbow… (brachioradialis)

Blow on the qudriceps tendon..

(pateller tendon)

Blow on tendoachilis……

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

*Ensure that the pt is relaxed.

*Apply sudden and sustained flexion to the ankle……

*normally few oscillatory beats may occur…..

*if persist = +ve clonus.

Knee clonus.. Ankle clonus..

1-physiological < 18m.

2- pathological:

=lesion in the arc

1-afferrent ………...neuritis.

2-posterior horn…..disc protrusion.

3-AHC……………….Poliomylitis.

4-Efferrent………...neuritis.

5-muscle…………...myopathy.

Let us to see?