uol clinical assessment teaching tool

1

Clinical Assessment of Children with Suspected Central Nervous

System Infections

Brain Infections Group University of Liverpool, United Kingdom

2

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

3

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.

4

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.

5

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.

6

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.

7

Checking the sick child

Check the ABC’s:• Airway • Breathing• Circulation

8

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

9

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)

10

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

11

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.

12

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

13

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.

15

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

17

Seizure activity in JE patient

Return to examples

In this patient, the left arm was shaking slightly (subtle partial seizure)

18

Subtle seizure activity

Return to examples

19 Orofacial movements are characteristic of patients with JE

Return to examples

20

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.

21

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.

22

Example of a history proforma

23

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

24

Neurological examination Neurological examination includes:

1. Observation2. Assessment of mental state or conscious level 3. Examination of the central nervous system (CNS)



25

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

26


1. Observation

2. Assessment of mental state or conscious level 3. Examination of the central nervous system (CNS)



27

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

28

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

29

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

30

AVPU rapid assessment of consciousness level

• A ALERT• V responds to VOICE• P responds to PAIN

• U UNRESPONSIVE GCS

Return to examples

31

Glasgow Coma Score: Sternal rub - patient localises to pain

32


1. Observation2. Assessment of mental state or conscious level

3. Examination of the central nervous system (CNS)



33

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?

34

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

35

• 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

36

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…

37

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

38

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

41

Bilateral VIth nerve palsy–look carefully, neither eye abducts

Return to examples

42

Ophthalmoscopy: examiner’s right eye to patient’s right eye


Return to examples

43 Ophthalmoscopy: examiner’s left eye to patient’s left eye


Return to examples

44

Opthalmoscopy: young child


Return to examples

45

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………………………….

46

V Trigeminal nerve examination

Photo credit: Tom Solomon

Return to examples

47 V Trigeminal nerve: jaw jerk normal


Return to examples

48 V Trigeminal nerve: jaw jerk abnormal (brisk)


Return to examples

49

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

51

Hearing: Otitis externa/otitis media

Return to examples

52

VIII nerve examination: Hearing

Return to examples

53

Profound hearing loss

Return to examples

54

XI nerve examination: Neck and shoulders

Return to examples

55

XII nerve examination: Stick out tongue


Return to examples

56

XII nerve: Tongue movements

Normal Tongue deviated to right,Left nerve damage

Return to examples

57

3.2 Cerebellar tests

• Finger-nose test• Rapid alternating hand movements

(Dysdiadochokinesis)• Eye movements to look for nystagmus• Heel-shin test• Heel-toe walking

58

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


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

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

Cerebellar tests: heel-toe walking

Return to examples

64 Cerebellar tests: heel-shin testnormal (1st) & abnormal (2nd)

Return to examples

65

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

66

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……………..

67

Doll’s eye reflex: present (normal)

Return to examples

68

Doll’s eye reflex: absent (abnormal)


Return to examples

69

Opisthotonus in JE

Return to examples

70

Extensor posturing in JE


Return to examples

71

Focal brain damage (for comparison)

Return to examples

72

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.

73

Neck stiffness examples

• Neck stiffness normal……………………….• Neck stiffness abnormal……………………• Go to slide 76: Clinical significance of

neurological findings……………………..

74

Neck stiffness: normal

Return to examples

75

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

77

• 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)

78

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

79


1. Observation2. Assessment of mental state or conscious level 3. Examination of the central nervous system (CNS)


4. Examination of the peripheral nervous system (PNS)

– Muscle tone– Limb muscle power– Reflexes – Sensation in limbs – Gait

80

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.

81

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?

82

Arm tone normal

83

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?

84

Examining tone examples

• Increased leg tone…………………………….

• Decreased leg tone - “Frog’s legs” test……..

• Go to slide 87: Further PNS examination…..

85

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

87

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

88

Power upper limbs: normal

89

Power lower limbs: normal


90

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)

91

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

92

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

94

Supinator reflexes abnormal


Return to examples

95

Knee jerks abnormal (brisk) and normal

Return to examples

96

Plantar reflex normal

Return to examples

97

Plantar reflex abnormal


Return to examples

98

Clonus (abnormal)

Return to examples

99

Abdominal reflexes normal

Return to examples

100

Abdominal reflexes absent (abnormal)


Return to examples

101

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.

102

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)

103

Gait example: abnormal

104

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.

105

Basic measurements and other systems– Basic measurements

• Blood pressure

• Pulse rate

• Respiratory rate

• Temperature

– Other systems

• Skin

• Ear, nose and throat

• Respiratory

• Cardiovascular

• Gastrointestinal

106

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

108

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

109

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.

110

Other systems: Cardiovascular

• Count pulse rate and assess rhythm (irregular or regular).

• Measure the blood pressure.• Listen to the heart for murmurs/additional

sounds.

111

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

112

Example of an

examination proforma

113

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.

114

Case examples

• Case 1…………• Case 2…………• Case 3…………• Case 4…………

115

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

116

Case 1

117

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

118

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

120

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

121

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

122

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.

123

Case 2


124

Case 2

125

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.

Back to images

127

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.

128

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.

129

Case 3


Notice the fixed position of her right arm

130

Case 3

The knee jerk was brisk

131

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

132132

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.

133133

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

134

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

135

Case 4

Note the position of his mouth carefully

136

Case 4

• Can you see the oro-facial movements? These are typical of JE.

• Click to look at the images again

137

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.

138

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

uol clinical assessment teaching tool

Documents

history of fever

presenting history

history of tuberculosis

sick child history

je season

clinical examination

japanese encephalitis

known allergies family