محاضرة تم القائها فى مستشفى حميات كفر الشيخ عام 2014 على مدار 4 ساعات

1. BY:
Dr, WALAA SALAH MANAA
SPECIALEST OF PEDIATRIC & FEVER
‫ـيخ‬‫ش‬‫ال‬‫ـفر‬‫ك‬ ‫ـيات‬‫م‬‫ح‬‫ـستشفى‬‫م‬

2. 1-mental status.
2-speech
3-cranial nerves.
Sign of meningeal irritation.-4
5-motor system
-posture.
-gait.
-muscle(status-tone –power).
-Involuntary movement-coordination.
6-sensory system.
7-reflexes
-superficial.
-deep
-others

3. 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.

4. 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.

7. 1-Immediate memory………………….. . ‫عد‬6‫متتاليه‬ ‫ارقام‬
‫بايه‬ ‫حاسس‬ ‫انت‬ ‫المريض‬ ‫اسال‬2-Recent memory
‫من‬ ‫اكثر‬ ‫من‬ ‫حصلت‬ ‫حاجه‬ ‫عن‬ ‫اسأله‬5‫سنوات‬3-Remote memory
memory

8. 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)

10.  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

11. Common non irritant odours +to each
nostril+eye closed .
Difficult in children.
Anosmia =loss of smell.

12. 1-visual
acuity 2-Field of vision
3-fundus examination

13. 1-Pupil size+
reaction to light
3-ptosis
2-Ocular
movement

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

15. 1-Sensory :
ophthalmic-maxillery-mandibuler.
2-motor:
masseter - temporalis –pterigoid.
3-reflexes:
corneal reflex-jaw reflex.

16. 2-motor:
masseter – temporalis
(palpation when clenching).
–pterigoid.
(side to side movement)

17. 3-reflexes:
corneal reflex
,‫عينه‬ ‫فى‬ ‫انفخ‬ ‫تعمله‬ ‫عارف‬ ‫مش‬ ‫ولو‬

18. 3-reflexes:
jaw reflex.‫ال‬ ‫ينفتح‬ ‫حتى‬ ‫ألسفل‬ ‫الضرب‬ ‫اتجاه‬ ‫يكون‬ ‫ان‬ ‫يجب‬‫فك‬
Normally this reflex is absent or very slight.
However in individuals with UMNL the jaw
jerk reflex can be quite pronounced.

21. 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)

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

29. 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.

34. Spinal accessory N.
Sternomastoid……ability to
rotate head to healthy
side.
Trapezius…….dropping of
shoulder in affected side

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

37. Bulber palsy Pseudo –bulber palsy
It is LMNL of the bulber
cranial nerve 8-9.
Lead to loss of gag reflex
+ flaccid paralysis of
pharynx & larynx.
It is UMNL of the bulber
cranial nerve nuclei
Lead to exaggerated gag
reflex.
Spastic paralysis of the
pharynx & larynx.

38. 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

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

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

41. 1-decubitus.
2-gait.
3-muscle status.
4-muscle power.
5-Muscle tone.
6-involuntery movement.
7-co-ordination.

43. Facial nerve

46. Ataxic gait……ataxic CP.
Scissoring gait in spastic CP.
Not able to walk.

47. pseudo hypertrophy muscle atrophymuscle hypertrophy

48. 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

51. U.L.
small muscle of hand
‫القميص‬ ‫يزرر‬ ‫بيعرف‬ ‫الولد‬—‫يكتب‬ ‫بيعرف‬.
Muscle of lbow
Flexors…‫الشباك‬ ‫او‬ ‫الدرج‬ ‫يفتح‬ ‫بيعرف‬
extensors= ‫الدرج‬ ‫او‬ ‫الشباك‬ ‫يقفل‬ ‫بيعرف‬.
Shoulder….
Flexor… ‫الكم‬ ‫فى‬ ‫ايده‬ ‫يحط‬ ‫بيعرف‬
Extensor ‫الكم‬ ‫من‬ ‫ايده‬ ‫يشيل‬ ‫بيعرف‬
Adductor ..‫باطه‬ ‫تحت‬ ‫الكشكول‬ ‫يحط‬

52. L.L.
Small muscle of LL…. ‫وهوماشى‬ ‫الشبشب‬ ‫منه‬ ‫بقع‬ ‫الولد‬
Knee…. ‫ونزوله‬ ‫السلم‬ ‫طلوع‬
Adductor ….‫رجل‬ ‫على‬ ‫رجل‬ ‫يحط‬
Abductor….‫رجل‬ ‫على‬ ‫من‬ ‫رجل‬ ‫يشيل‬

53. Trunk.
-Flexor…. ‫ظهره‬ ‫على‬ ‫نايم‬ ‫لو‬ ‫الولد‬
‫او‬ ‫يساعده‬ ‫حد‬ ‫ما‬ ‫غير‬ ‫من‬ ‫يقوم‬ ‫يقدر‬
‫زراعه‬ ‫بمساعدة‬
-Extensor…. ‫االرض‬ ‫على‬ ‫قاعد‬ ‫لو‬
‫غير‬ ‫من‬ ‫الجذع‬ ‫بيرفع‬ ‫يقوم‬ ‫بيجى‬
‫يسند‬ ‫ما‬
.

54. Neck….pulling the child from both UL.
Intercostal m. ……short breath
‫حتى‬ ‫العد‬ ‫اليستطيع‬10......‫بعد‬ ‫على‬ ‫شمعه‬ ‫اطفاء‬ ‫اليستطيع‬30‫سم‬.
m. Of abdomen…….localize bulge of the
abd.(e.g. poliomylitis).
Diaphragm…..paradoxical respiration.

55. *To detect hypertonia…….passive movement
around big joint.
*To detect hypotonia…….shaking movement wrist
or ankle

56. 1-LMNL
2-UMNL.=pyramidal lesion (shock stage)
3-Extrapyramidal lesion (chorea).
4-cerebeller lesion (ataxia).
5-Down s syndrome.
6-Atonic CP.

57. 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)

58. =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.

59. Athetosis
dystonia
tremorschorea

60. -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.

61. 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

62.  Superficial sensation….(pain-tough-temp.).
 Deep sensation………(joint sense-vibration
sense-deep pressure sense).
 Cortical sensation(tactile localization-tactile
discrimination-steriogenosis)

63. 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 !

64. 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.

65. 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)

66. 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).

67. Astereognosis.
-Inability to identify an object by palpation

69. sudden passive stretchsudden massive
activation of AHCssudden massive
contraction of all muscle fibers
Superficial reflexes-deep –visceral-others

70. *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?

71. Scratch abdominal wall by a pin from outward
inward ….contraction of a segment of
abdominal muscles.
T7
T8
T9
T10
T11
T12

72. Light scratch along the inner aspect of the
upper part of the thigh lead to
elevation of the testicles.

73. Scratch the peri anal region
lead to contraction of external anal sphincter.

74. Biceps jerk (c5-6)
Blow upon the thumb on the biceps tendon while
the elbow is slightly extended

75. Blow upon the triceps tendon while the elbow
is flexed.

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

77. Blow on the qudriceps tendon..
(pateller tendon)

78. Blow on tendoachilis……

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

80. 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.

82. Let us to see?