NBE CME programme for DNB consultants - National Board Of ...

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NBE CME programme for DNB consultantsdisk margins, Papilledema; Macewen’s / Carackpot sign; Cranial nerve deficits; Focal Neurolgocialdeficits; Investigations – MRI / CT; P/A Examination- Visible peristaltic waves, Distension,Tenderness, Palpable Mass, Emptiness in any quadrant, Bowel sounds, Investigations – X-ray/ USG / EndoscopyDifferential Diagnosis – Neonatal — Atresia / Stenosis - Abdominal Distension, Failure topass Meconium; Malrotation - Distension, meconium not passed; Volvulus- Distension, meconiumnot passed; Necrotizing Enterocolitis -Distension, Bilious vomiting, Blood / Mucus PR; MeconiumPlug - Distension, III-defined mass palpable; GE Reflux - Effect of posture and cough; Inbornerrors of metabolism, - Adrenogenital syndrome etc. ; Birth Asphysia - Irregular, slow gaspingbreathing with bradycardia / normal HR; Hyprocephalus - HC > 97 th percentile for GA— Bulging ;Faulty Feeding TechniqueInfancy - Congenital Hypertrophic Pyloric stenosis-Vomiting starting in the 2 nd / 3 rd week of life,Becoming increasingly projectile, Visible gastric peristaltic waves, Palpable pyloric mass; Volvulus-Abdominal distension; Intussusception-Paroxysmal pain causing loud outcries, Red-currant jellystools, Elongated, sausage – shaped in right upper quadrant; GE Reflux; Overfeeding;Gastroenteritis- Fever, Loose Stools, Pain abdomen; CNS Infections-,Bulging fontanelle,Headache, Convulsions; Peritonitis-Fever, pain abdomen; Inborn errors of metabolismChildhood - Gastroenteritis- Fever, loose stools, pain abdomen; Medications; Toxins; Hepatitis-Fever, jaundice, anorexia, pain abdomen; Pneumonia -Fever, Cough, expectoration, Dullpercussion note, Crepitations audible, Consolidation on X-ray; ICSOL- Headache, vomiting,papilloedema, focal signs; Appendicitis- Fever, vomiting, pain abdomen; Peritonitis ; IntestinalObstruction-Hernia /intussusception / peritonitis/foreign bodies/ rumors. ; Intussusceptions;PsychogenicManagement - NonSurgical—Sips of cold, clear fluids; ORT; Drugs-> Metoclopramide,Domperidone, Phenothiazines; Antibiotics for Infecitons. Surgical -CHPS – Ramstedt’soperation(Pyloromyotomy) ; GERD – Nissen’s Fundopication Prosthesis; Appendicitis–Appendicectomy; Hydrocephalus – Shunts; Intussusceptions – Hydrostatic pressure with EnemaExploration; Intestinal Obstruction – ExplorationHemiplegiaHistory - Most importance should be given for a proper and accurate history taking, since it givesthe clue for a correct diagnosis, in CNS cases, unlike other systems where a proper diagnosismay be made even by clinical findings alone. Following points must be stressed in the presentingcomplaints- Was the onset acute, sub acute or gradual? Was it associated or preceded with feverand/ or a seizure? Any severe headache, vomiting or change in consciousness, preceding theonset of hemiplegia. If so, sudden or gradual? Is the condition deteriorating, static or improving?Past history- Any history suggestive of vasculitis, rheumatic fever, trauma or thrombosis or bleedingdisorders. Review of developmental history, antenatal, perinatal, and post natal should always berecorded. Family history and consanguinity must be noted.Clinical Examination - A detailed general examination, including temperature, pulse, BP andanthropometric measurements should be noted. Any facial dysmorphism, cutaneous lesions likecafé au lait spots, angiomas or depigmentation and condition of teeth have to be noted. Look forany mid line defect. Examination of chest, abdomen and palpation of femoral pulse must alwaysbe a part of general physical examination. Note for unusual body order. Palpation of anteriorfontanel, and auscultation for bruits done in erect posture-over both globes, temporal fossae, andmastoid region (six sites).CNS examination - Higher function assessment according to the age of the patient.Cranial nerves-Olfactory-rarely assessed, Optic nerve - Elicit the blink reflex, (in a child>3 mon.old)Fundi examination- optic disc, retinal hemorrhage, chorioretinitis, Look for visual acuity, and field ofvision depending on the age, and sensorium of child. III, IV, VI Cranial nerves- Enophthalmos144
NBE CME programme for DNB consultantsptosis, meosis, lack of sweating, on the ipsilateral side of face.. See the papillary reflex, If ptosis ispresent, look for ‘Marcys Gunn sign,’ Test the movements of all extraocular muscles. If the child isunconscious see the ‘doll’s eye movement. Examine for internuclear ophthalmoplegia by lookingfor defective adduction of the medial rectus and nystagmus of the abducting eye. See for nystagmus,and if present stage it (stage 1,2,3). V Nerve- Look for deviation of jaw.. corneal and conjunctivalreflexes. Test sensation of face. VII Nerve- Is the facial nerve affected. If so, ipsilateral or contralateralto the side of hemiplegia..Look for’emotional ‘facial weakness. Confirm whether UMN or LMN typeof involvement.. Look at the naso labial fold and wrinkling of fore head. Is the taste salivation and/or tear production affected? Look for the strength of orbicularis occuli. Elicit ’Mc Carthy reflex’ VIII(Cochlear and Vestibular). Rinne’s test for defective hearing. Test for vertigoIX and X - Any nasal regurgitation or change in voice? Movement of palate. XI Nerve- Test the sternomastoid and trapezius muscles XII Nerve- Look for deviation of tongue when protruded,fasciculations when the tongue is inside the mouth, and/ or atrophy.Motor system- Look for abnormal movements. Muscle power (0-5- MRC scale). Tone, pronatorsign for upper extremities and Barre sign. for lower limbs, depending on the age of the child.. Lookfor coordination by applying specific tests for cerebellar function- Finger nose test,’ tapping in acircle (one cm.diameter) test’, look for rebound phenomenon.Sensory system in older child - Temperature, light touch, crude touch, based on a dermatomaldistribution. Examine for position and vibration sense, and elicit Roberg’s sign.Reflexs- Elicit superficial and major tendon reflexes, knowing its root value, and cutaneous nerveinvolved..Elicit plantar reflex and ankle clonusInfants - Posture and muscle tone, primitive reflexes- Moro reflex, Tonic neck reflex, Righting-reflex,palmar and plantar grasp reflexes, Vertical suspension, and Landau reflexInvestigations-Besides, routine CBC, Mantoux and X Ray chest, the following investigations shouldbe done- CSF examination. Electrolyte estimation (Na, K, Cl2 ) ; PT, APTT.Antiphospholipid antibodies (in SLE), ANA ; Estimation of antithrombin III level, protein C, S, andfactor V Leiden. ECG, ECHO, EEG, NCV, and CT brain; Cerebral angiogram, or MR angiography(MRA)/ Functional MRI Evoked potentials VERs/BAERs and, SSEPs) ; Radiography of Spine andMyelographyDiffusion-Weighted Magnetic Resonance Imaging in acute stroke conditions; Magnetic ResonanceSpectroscopy (MRS), when cerebral metabolites are of significance ; Positron-emission tomography(PET), esp. in children for surgical programmes.. Single – photon – emission computerizedtomography (SPECT) for conditions where regional blood flow study is important.Differential Diagnosis-The following conditions should be kept in mind to arrive at a provisionaldiagnosis. Of the following, only 3 most probable conditions judged by history and clinical signsmust be discussed in differential diagnosis- Hemiplegic cerebral palsy, Infantile hemiplegia (to beconsidered only in a child up to 6 years),Vascular causes, including IEM (haemarrahage, thrombosis,vasculitis, trauma, hemiplegic migraine),Infective causes- bacterial, viral, fungal (Meningitis,encephalitis, TBM),Demyelintng- Acute Desseminated Encephalo Myelitis (ADEM), Todd’s paralysisalso may be considered, if hemiplegia follows a prolonged seizure, Space occupying lesionsNon-surgical management - Depends on etiology. Measures to reduce cerebral edema, correctionof fluid and electrolytes imbalance, if any has to be done. Long term management like physiotherapy,speech therapy, and rehabilitative measures may be required in some cases. Referral to a childdevelopment center (CDC) is advisable for selective patients.Surgical management - Surgical management will be required in space occupying lesions andselective cases of spastic cerebral palsy.Any other - Site of the lesion, (Localisation) must be discussed before considering the differentialdiagnosis..145
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NBE CME programme for DNB consultants - National Board Of ...

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