1
Clinical Assessment of Children
with Suspected Central Nervous
System Infections
Brain Infections Group
University of Liverpool, United Kingdom
2
Contents
Using this presentation
Introduction
Checking the sick child
History taking
– General questions
– JE-related questions
– Neurological disease
– Seizures or abnormal movements
– Completion of patient history
– Example of a history proforma
Examination
Neurological examination
• 1.0 Observation
• 2.0 Assessment of mental state or
conscious 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
Patient history: neurological disease (2)
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?
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. 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
24
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
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
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
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
Glasgow Coma Score and the
James Modification for children <5 years
29
Adults and children >5 years
Children <5 years
4
Spontaneous
Spontaneous
3
To voice
To voice
2
To pain
To pain
1
None
None
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
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
Eye opening
Return to
examples
Verbal
Motor
AVPU
30
AVPU rapid assessment of
consciousness level
• A ALERT
• V responds to VOICE
• P responds to PAIN
Return to
examples
• U UNRESPONSIVE
GCS
31
Glasgow Coma Score:
Sternal rub - patient localises to pain
32
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
33
3.1: Cranial nerves I-VII
This 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
3.1(cont.): Cranial nerves Vlll-XII
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?
35
3.1 (cont.): Eye examination
• 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
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
ШE
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
EШEШШEШE
E Ш Ш Ш E E Ш E
E Ш Ш Ш E E Ш E
Return to
examples
38
Direct light reflex
Return to
examples
Film credit: T Solomon
39
Eye movements: head still,
instruction “follow my finger”
Return to
examples
Photo credit: Tom Shulz
40
Right VIth nerve palsy–right eye is
unable to abduct (move outwards)
Trying to look this way
Return 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
Photo credit: Tom Shulz
43
Ophthalmoscopy:
examiner’s left eye to patient’s left eye
Return to
examples
Photo credit: Tom Shulz
44
Opthalmoscopy: young child
Return to
examples
Photo credit: Tom Shulz
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
Return to
examples
Photo credit: Tom Solomon
47
V Trigeminal nerve:
jaw jerk normal
Return to
examples
Photo credit: Tom Solomon
48
V Trigeminal nerve:
jaw jerk abnormal (brisk)
Return to
examples
Photo credit: Tom Solomon
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
Photo credit: Tom Solomon
56
XII nerve: Tongue movements
Return to
examples
Normal
Tongue deviated to right,
Left nerve damage
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
Photo credit: Tom Shulz
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 test
normal (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
Photo credit: Tom Solomon
69
Opisthotonus in JE
Return to
examples
70
Extensor posturing in JE
Return to
examples
Photo credit: Tom Solomon
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
Clinical significance of neurological findings (2)
• 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)
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
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
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
Return to
flaccid (floppy)- decreased leg tone
examples
Photo Credit: T Solomon
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
Photo credit: Tom Shulz
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
Photo Credit: T Solomon
95
Knee jerks abnormal (brisk) and normal
Return to
examples
96
Plantar reflex normal
Return to
examples
97
Plantar reflex abnormal
Return to
examples
Photo Credit: T Solomon
98
Clonus (abnormal)
Return to
examples
99
Abdominal reflexes normal
Return to
examples
100
Abdominal reflexes absent (abnormal)
Return to
examples
Photo Credit: T Solomon
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
107
10
7
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 1
Ask 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 1
Ask yourself:
1. Is the child’s general appearance normal or abnormal?
– Answer: Normal
2. Is the child ill or well?
– Answer: Well
3. Is she conscious and alert?
– Answer: Yes, conscious and alert
4. Is her gait (walk) normal or abnormal?
– Answer: normal
5. 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: Yes
8. 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
Photo credit: Tom Shulz
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?
Back to
– Answer: Generally looked OK, but abnormal.
images
2. Was she ill or well?
– Answer: Smiling and although not normal, looked “well”
3. Was she conscious and alert?
– Answer: Clearly conscious and alert
4. Was her gait (walk) normal or abnormal?
– Answer: Abnormal
5. 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.
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
Photo credit: Tom Shulz
Notice the fixed position of her right
arm
130
Case 3
The knee jerk was brisk
131
Case 3
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 appear to look around and see where she is
going?
8. Is she able to walk without help?
Back to images
132
Case 3
Ask 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.
133
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, 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