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CNS Examination in children | Higher mental functions | Pediatrics — Transcript

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0:00[Music]
0:01hello everyone today in this video i
0:03will perform the central nervous system
0:06examination
0:07so first we have to assess the higher
0:10mental function in the cns examination
0:13then we have to check signs of meningeal
0:15irritations are present or not
0:18then cranial no examination then motor
0:21system then sensory system then
0:23autonomic nervous system then we have to
0:26check the cerebellar sign
0:27then skull spine so today i will cover
0:31the first part of the central nervous
0:33system examination
0:36in higher mental function we have to
0:38assess the consciousness
0:41then we have to check the appearance and
0:42behavior of the patient
0:44then orientation memory intelligence
0:47speech
0:48any history of delusion hallucination
0:50and emotional status of the patient
0:54to remember all these point there is a
0:56trick b c d e miss o
0:59where a stands for the appearance b for
1:01behavior c for the conscious level d4
1:04any history of delusion hallucinations e
1:07for emotional status m for memory i for
1:10intelligent s for speech
1:12and or for orientation
1:14this trick is just to remember all the
1:16point but in higher mental function
1:19first we have to assess the level of
1:22consciousness
1:23so
1:25if you find that the child is alert
1:27awake we label as a fully conscious so
1:30in this video you can see the child is
1:32fully conscious and alert
1:34if you find child is erosible but not
1:37alert we label as a lethargy
1:40if child is erosible by verbal stimuli
1:44when you are speaking and the child is
1:47erosible and again go into the sleep
1:50stage
1:52we label as a light coma or drowsiness
1:55if the child is not erosible by the
1:58verbal stimuli then we have to give the
1:59pain full stimuli
2:02for painful stimuli we prefer either
2:04supraorbital pressure
2:07or we can give the pressure over the
2:09nail bit
2:10by painful stimuli if child is
2:14giving the withdrawal response
2:16and again once the painful stimuli is
2:19removed child goes back to the sleep
2:22stage we label as a stuporous or
2:25semi-conscious or the moderate coma
2:28and last stage is coma
2:31or unconscious when child is not
2:34erosible even by the painful stimuli
2:37so when you are giving the painful
2:39stimuli child is
2:42flexing
2:43all four limbs we label as a decorticate
2:46posture it is due to the lesion in the
2:48brain stem or the basal nuclei
2:51if due to hyperextending all four limbs
2:54we label as a d celebrate posture it is
2:57because of the lesion in the midbrain
2:59between superior coliculus
3:02and
3:02bones and if child is not showing any
3:06response we will label as a
3:08unconsciousness
3:10and unresponsiveness to the painful
3:13stimuli
3:15now there is a another terminology
3:17vegetative state coma
3:19whistle
3:20in which patient is unresponsive
3:24but patient remain awake
3:27and patient will gives a blank staring
3:29look
3:30it is seen whenever there is a extensive
3:32brain damage
3:34there are various coma scales also to
3:37assess the level of consciousness
3:39example glasgow comma scale in which we
3:41calculate the eye response motor
3:43response and the verbal response maximum
3:46score in glasgow my scale
3:48are 15 and minimum three whenever total
3:53score are less than eight we considered
3:55as a severe brain injury
3:58this scale is useful for more than five
4:00years age group children
4:02but for the less than five year age
4:05group children
4:06verbal response in
4:08glasgow coma scale is
4:11not appropriate
4:12so some modification is done in the
4:14verbal response
4:16in adelaide comma scale while the
4:20eye opening and the motor response is
4:22similar in both glasgow comma and
4:24adelaide coma scale
4:27there is another score four score
4:30which is very useful in pedetic patient
4:33in which four components
4:35eye response motor response respiratory
4:38pattern and the brain stem reflex
4:414 score is very useful in intubated
4:44patients
4:45so we generally use the 4 score to
4:48assess the level of consciousness
4:49whenever patient is intubated having the
4:51altered breathing pattern and also we
4:54are assessing the brain stem reflex
4:56in this score
4:58so all three scales are very useful
5:01glasgow my scale adelaide comma scale
5:03and the four score
5:05so this is all about the level of
5:06consciousness
5:08then check the appearance of the child
5:11and the behavior of the child
5:13so if you find any abnormal appearance
5:16or any abnormal behavior example if the
5:19child is having down syndrome mental
5:21retardation
5:23then the appearance will be abnormal
5:25or cp child
5:27then child will have the different look
5:31so we will label as a abnormal
5:33appearance then we have to check the
5:35behavior of the child is the child
5:38behaving as a
5:40normal response according to the age
5:43then we will mention as a normal
5:45behavior
5:46and also check the
5:48eye to eye contact is there or not child
5:51is showing the interest and surrounding
5:53or not
5:54if you find any abnormal behavior
5:56example in a child of adhd child will be
5:59hyperactive attention deficit
6:02abnormal response example in
6:05autistic child they will not interact
6:08socially
6:09not showing the interest in the social
6:11activity
6:13now the fourth point is as a history of
6:16any delusion or hallucination both are
6:18the false
6:20in delusion patient will have the false
6:22belief
6:23which will not be resolved even
6:26parents are showing the evidence against
6:29the
6:30false belief
6:31and hallucinations are the false sensory
6:33perception example visual hallucination
6:37when child is seeing someone which is
6:39actually not there
6:41in the
6:42surrounding
6:44after that we have to check the
6:45emotional status of the patient
6:48any abnormal you know impulsiveness or
6:52excessive crying or anger is there then
6:55we have to further
6:57ask the history part
6:59after that in more than five years age
7:01group children we have to assess the
7:03orientation of the child to the time
7:06place and person in time we can ask
7:09about the day
7:10month or season in place we can ask
7:12about the is it home or hospital then
7:16about the city and state
7:18and in person we can ask the name of the
7:21relative
7:22or is the child able to recognize the
7:25relatives or not
7:28after that we have to assess the memory
7:30of child it is possible in more than
7:32five years age group in this we have to
7:34assess the immediate memory recent
7:36memory and the past and remote memory so
7:38in immediate memory we will tell them a
7:41brief story and then if child is able to
7:44repeat the same story that means
7:45immediate memory is the normal or we can
7:48perform the digit repetition test which
7:51is digit forward or digit backward test
7:54in which we will tell them some random
7:56numbers and child is supposed to repeat
7:59forward and backward so in six year old
8:02children child can repeat up to the five
8:04digit
8:05forward and three digit backward and in
8:08ten years old children normally six
8:11digit forward and four digit backward
8:14and for recent memory we have to answer
8:16some daily to daily activities example
8:19we can ask what was eaten like last
8:22night or in the breakfast
8:24then we can ask the some
8:26specific event in the
8:29last week
8:30and in pass or remote memory
8:32we can ask any event that occurred
8:35months to years ago
8:37example
8:38we can ask some common questions also
8:41name of the school name of the teachers
8:43friends
8:44and
8:45how they have celebrated last
8:48festival or birthday
8:50so now in this video i am assessing
8:59[Music]
9:02um
9:14[Music]
9:19um
9:39foreign
9:50then assess the intelligence in younger
9:53children just we have to check the
9:54alertness and interest in environment
9:57and whenever age is more than five years
10:00so according to the level of schooling
10:02we can ask the some
10:04calculation
10:05or we can ask the days in a week or
10:08months in a year
10:09also check the attention span of the
10:11child
10:12by all these simple questions and
10:16buy a digit repetition test also
10:18after that we have to assess the speech
10:21of the child there are various level of
10:23the speech production which should be
10:25assessed in terms of expressive verbal
10:28skill
10:28comprehensive or understanding the
10:31language
10:32fluency and repetition articulation
10:35voice production or phonology in which
10:38volume quality and pitch
10:40reading and writing
10:42to assess all these component of the
10:44speech we have to ask some simple things
10:47example
10:48we can ask what is your name where do
10:51you live how old are you then check
10:54child is able to answer fluently or not
10:58so fluency will be affected whenever
11:00child is having the
11:03lesion in the broca's area which is
11:05located in the inferior frontal gyrus of
11:07the dominant hemisphere
11:09so if child is not able to express the
11:12verbal scale
11:14due to the lesion in broca's area we
11:17label as a broca's aphasia in this child
11:20will have the known fluent speech but
11:22child has understand whatever we have
11:25asked
11:27and if the child
11:28is having the difficulty in
11:30understanding the meaning of
11:32spoken words
11:34in this case child is having the lesion
11:36in vernix area which is located in the
11:39superior temporal gyrus
11:41so child will have the meaningless
11:43speech
11:45because child is not able to understand
11:48child will have the fluent speech in
11:50vernix aphasia
11:53while non-fluent speech in broca's
11:55aphasia
11:57then we have to check the repetition
11:59also so we just say any sentence and we
12:03will tell the child to repeat the same
12:05sentence
12:06if child is not able to repeat the
12:09sentence
12:11that means child is having the lesion
12:13either in the broca's or vernix
12:17area
12:18the child is having normal expressive
12:21verbal skill normal understanding but
12:23not able to repeat the sentence
12:26that means child is having the lesion in
12:29arcuate fasciculus
12:31which connect the broca's area and the
12:33vernix area so lesion in the arcuate
12:36vesicles will be labeled as a conductive
12:38aphasia
12:40after that we have to assess the
12:42articulation is proper or not so for the
12:45normal articulation child should have
12:48the normal
12:50vocal tract in which nasal cavity
12:53throat
12:54tongue
12:55lips all should be normal
12:57and
12:58for assessment of the articulation we
13:00have to tell the child to speak
13:05in which power is produced by the lips
13:08da by tongue and car by
13:10throat
13:11so if child is able to speak papa tata
13:15kaka pataka
13:17that means child is having normal
13:20articulation if you find child is not
13:23able to speak
13:25an articulation is affected we label as
13:28a dysarthria or disorder of articulation
13:31example when the child is having bulbar
13:33palsy due to 9 10th and 12th cranial
13:36nerve involvement
13:38child will have the slurring of his
13:40speech
13:41and in this
13:42when child will speak
13:44words will be slurred also nasal speech
13:47will be there it is also associated with
13:50the nasal regurgitation
13:52accumulation of the secretion in throat
13:54and dysphasia in cerebellar disorder
13:57child will have the skinning or stigato
13:59speech
14:00in which child will speak as scanning
14:03the word so child will speak very slowly
14:06in monosyllable or monotonous
14:09example if we will tell the child to
14:11speak the ice cream child will divide
14:13this word in monosyllable
14:17i sir
14:20and
14:20now another disorder of articulation is
14:23dysarthria it is seen in
14:26pseudobulbar palsy
14:28in a cp child
14:30it is because of the lesion in
14:32corticospinal fiber so child will have
14:34the difficulty in opening the mouth
14:37so child will not able to speak
14:40properly because child is having the
14:44closure of the mouth
14:46so child will have the slurred speech
14:50and it is associated with the brisk jojo
14:53extensor plantar response dysphagia
14:56drooling of saliva another part of the
14:58vocal tract which can affect the
15:01speech is the nose so sometimes if the
15:04child is having the palatal paralysis
15:07example seen in the cp child or child is
15:09having cleft palate
15:11then
15:12child will have the hyper nasal speech
15:15we label as a rhinolia aparta it is due
15:18to the defect in
15:20velopharyngeal sphincter muscle
15:23which remain open during the speech
15:25because of the cleft palate or palatal
15:28paralysis so for the assessment of the
15:31nasal speech we have to tell the child
15:33to speak the word
15:35which is produced by the nose example
15:38nag so mummy nana such type of word
15:43child will speak and you have to assist
15:46is it the normal nasal tone or child is
15:49having the hyper nasal or hypo nasal
15:52speech
15:53so hyponasal speech we label as a
15:56rhinolia closer
15:58it is seen in the
15:59when there is a obstruction in nasal
16:01cavity example in septal division nasal
16:05polyp or if the child is having adenoid
16:07hypertrophy
16:09then we have to assess the voice skill
16:11or we can say phonology by the volume
16:14quality and the pitch of the voice which
16:17is produced by the larynx
16:19so whenever there is a disorder of the
16:22larynx
16:23child will have the affected voice
16:25quality example of phonological
16:27disorders are
16:28examples seen in the laryngeal
16:31inflammation laryngitis child will have
16:33the dysphonia painful voice will be
16:36there
16:37volume and quality of the speech will be
16:39affected and child will have the pain
16:42during the
16:43production
16:44we label as a phonia whenever there is a
16:47bilateral vocal cord palsy because of
16:49the involvement of the vegas now which
16:51supply the laryngeal muscle the current
16:54laryngeal now external laryngeal nerve
16:56so in this if the child is having the
16:59adduction palsy
17:00then child will have the normal
17:03respiration but the chances of
17:05aspiration will be there
17:07and
17:08there will be no voice production
17:10if the child is having abduction
17:13policy
17:15then child will have the difficulty in
17:17the respiration also in this
17:19tracheostomy will be required so we
17:21label
17:22aphonia due to the vocal cord policy
17:25bilateral vocal cord policy
17:27if the child is having unilateral vocal
17:29cord policy
17:31in this case hoarseness of voice will be
17:34there
17:35child will speak but the voice quality
17:38and pitch will be affected
17:41so all these are the
17:43speech disorder also and in last and
17:46higher mental function we have to check
17:48if the child is having any release
17:50reflex primitive neonatal reflex due to
17:54the frontal lobe lesion then we have to
17:56mention in the higher mental function
17:59because release reflex normally
18:01disappear by the three to five months of
18:04age if it is present after this age
18:07that means child is having frontal lobe
18:09lesion
18:10so this is all about the higher mental
18:12function
18:13in next video i will cover the
18:16manager irritation sign
18:18so thank you so much

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