Dr. Amit VatkarMBBS, DCH, DNB Pediatrics

Fellow in Pediatric Neurology, MumbaiTrained in Neurophysiology & Epilepsy, USA

Contact No. : +91-8767844488Email: vatkaramit@yahoo.com

Clinical Neurology and Neuro- Examination

CLINICAL NEUROLOGY• Is it Difficult… RITUAL…Formula Based…!• MANOUVERES-MYSTERIOUS SIGNS… (Pronunciation PERPLEXITIES)

• Rare Diseases with too many details.

BASIC PRINCIPLES1) History of Physical Examination2) Anatomic Diagnosis3) Syndromic Diagnosis4) Etiologic ->Pathological diagnosis5) Functional Diagnosis->Potential Restoration of function

CLINICAL EXAMINATION OF NERVOUS SYSTEM

1.Higher functions2.Cranial nerves3.Motor system4.Sensory system5.Cerebellar system6.Stance and gait7.Spine and cranium8.Signs of meningeal irritation

HIGHER FUNCTIONS

• conciousness• orientation• attention• memory• language• psychological status• lobar functions• cognitive skills

Level of consciousness

• Alert: an awake person with a normal level of consciousness.

• Lethargic: a sleepy patient who requires stimulation to maintain an awake state.

• Stuporous: patient can not be aroused to a fully awake state, although they may respond semi-purposefully with withdrawal or moaning to stimulation.

• Comatose: patients with no purposeful response to any type of stimulation.

Orientation

• Classically to person, place, and time (day, date, month, & year).

Memory: • Immediate: name three objects such as “apple, table,

and penny” (ask the patient to • repeat them back to you now). After 5 minutes, ask

the patient to recall those three • objects again. • Short & Long Term: usually assessed at the time of

the medical interview and history.

LANGUAGE

• Comprehension• Repetition• Expression• Confrontation naming• Reading• Writing• Calculation• Constructional ability

Speech / Language

• Usually assessed at the time of the medical interview and history.

• Useful terms involving language/speech include the following:• Aphasia: disorders of understanding, thought, and/or word

finding.• Dysphonia: difficulty with voice production. • Dysarthria: difficulties with the articulation of speech because

of coordination problems • of breath, vocal cords, larynx, palate, tongue, and/or lips.

PSYCOLOGICAL STATUS

• Sleep

• Affect & mood

• Appearance & behaviour

• Abnormal perceptions

LOBAR FUNCTIONS

• FRONTAL• Classical – Motor• Apathy• Disinhibition• Apraxia• Primitive reflexes

• PARIETAL• Dominant – Cortical sensation,Dyscalculia,Dyslexia• Nondominant - Visuospatial

• TEMPORAL• Memory

• OCCIPITAL• Agnosia

COGNITIVE SKILLS

• Planning & sequencing

• Fund of knowledge

• Insight & judgement

• Problem solving & decision making

CRANIAL NERVES

• OLFACTORY– Pathway– Method of examination– Disorders

OPTIC NERVE

• Components of examination– Visual acuity– Field of vision– Colour vision– Fundus

• Pathway• Method of examination• Disorders

THIRD , FOURTH & SIXTH

• Pathway• Method of examination

– Movements of eyeballs & eyelids– Pupillary reflexes / APRD– Nystagmus

• Disorders

TRIGEMINAL NERVE

• Sensory– Ophthalmic– Maxillary– Mandibular

• Motor– Muscles of mastication

• Pathway• Method of examination• Disorders

FACIAL NERVE

• Motor– Muscles of facial expression

• Pathway• Method of examination• Disorders• Difference between UMN & LMN palsy• Causes for facial nerve palsy in children

VESTIBULOCOCHLEAR NERVE

• Pathway

• Method of examination

• Fundamentals of BERA

• Disorders

NINTH, TENTH, ELEVENTH & TWELFTH

• Pathway• Method of examination• Disorders

Cranial Nerves II-XII

• CN II: visual acuity, visual fields, pupillary reaction, & fundi• CN III, IV, and VI: pupillary reaction & extra-ocular movements• CN V: facial sensation, corneal response, & muscles of

mastication • CN VII: muscles of facial expression• CN VIII: hearing, nystagmus, & balance • CN IX & X: palatal rise to phonation & coordinated swallowing • CN XI: sternocleidomastoid & upper trapezius strength • CN XII: tongue size & movement

• ANATOMY OF CRANIAL NERVES

• STRUCTRES INVOLVED

• LOCALISATION

MOTOR SYSTEM

• Bulk• Tone• Power• Coordination• Abnormal movements• Reflexes

– Superficial– Deep– Autonomic– Primitive / Developmental

POWER

• KNOW • Strength is graded on a 0-5 scale as follows: • 0 = no movement • 1 = flicker of movement or slight twitch • 2 = moves with gravity eliminated • 3 = moves against gravity but not against resistance • 4 = moderate movement against resistance (sometimes

qualified as 4 + if patient can • generate moderate resistance or 4 – if patient can only move

against mild resistance) • 5 = normal strength or power

REFLEXES

• KNOW • Reflexes are graded on a 0-4 scale as follows:• 0 = absent• 1 = present, but depressed • 2 = normal• 3 = increased (hyperactive) • 4 = clonusspasmodc alternaton of muscuar contractons secondary to an

upper motor • neuron lesion) • The foowng refex nerve roots: AchillesS1, S2, PatearL3, L4), BcepsC5), • BrachioradiaC6), and TricepsC7) • A posve Babinski’s signndcates an upper motor neuron process

MOTOR SYSTEM

• Myotomes

• Basics of reflexes

• Reflexes of bladder & bowel

• Localisation especially in spinal cord

SENSORY SYSTEM

• Superficial• Deep• Pathways• Method of examination• Dysfunction

CEREBELLAR SYSTEM

• Anatomy• Mode of examination

– Coordination– Nystagmus– Tremor

• Disorders

STANCE & GAIT

• Types of gait

• AFP

SPINE & CRANIUM

• Spinal defects

• Measurements

• Macewan`s sign

• Auscultation

SIGNS OF MENINGEAL IRRITATION

• Neck stiffness

• Kernig sign

• Brudzinski sign

Dr. Amit VatkarPediatric Neurologist, Navi Mumbai

MBBS, DNB

Email: vatkaramit@yahoo.comContact No.: +91-8767844488

Visit us at: http://pediatricneurology.in/

THANK YOU !