CNS & Abdominal Exam: Clinical Techniques, OmpathStudy

--- Clinical Techniques: CNS & Abdominal Examination Lecturer: Dr. Okanga Unit: Clinical Techniques Year 3 MBChB, Mount Kenya University --- PART 1: CNS HISTORY & PHYSICAL EXAMINATION--- Neurological Terminology -opathy = abnormality; -itis = inflammation (at the level named in prefix) Encephalopathy — brain abnormality; focal/diffuse, metabolic/toxic Encephalitis — brain inflammation; + meninges = Meningoencephalitis Myelopathy/Myelitis — spinal cord abnormality/inflammation Radiculopathy — nerve root; Polyradiculopathy — many roots Plexopathy — brachial or lumbar plexus Mononeuropathy — single nerve; Polyneuropathy — multiple Myopathy/Myositis — muscle abnormality/inflammation Functional — (1) non-structural e.g. migraine; (2) psychiatrically induced e.g. hysterical conversion --- Neurological History Framework Age, sex, handedness, occupation History of present complaint Neurological screening questions Past medical, drug, family, social history Always get history from a bystander in loss of consciousness or memory problems. Commonest causes: neurocardiogenic syncope and epilepsy. --- Presenting Complaint — Key Points Let patient tell their story with minimal interruption Clarify ambiguous symptoms: "Dizziness" → vertigo (spinning) or light-headedness? "Numbness" → weakness or sensory loss? "Blurred vision" → diplopia or dim/hazy? Time course = pathology clue: Onset Pathology --- --- Sudden/acute Vascular Subacute Inflammation, infection, neoplasia Progressive Neoplasia or degenerative Stepwise/stuttering Vascular or inflammation Relapsing-remitting Inflammation (MS) Visual loss — right eye (exam favourite): Time Course Diagnosis --- --- Sudden, 1 min Optic nerve compression (meningioma) 10 min onset, lasted 20 min Optic neuritis Over 4 days, improved over 6 weeks Amaurosis fugax Progressive over 3 months Migrainous Left-sided weakness (face/arm/leg): Time Course Diagnosis --- --- Sudden, lasted 10 min TIA Over 10 min, persists days Tumour Over 4 weeks Subdural haematoma Over 4 months Stroke Since childhood Congenital --- HPI — Additional Components Precipitating/relieving factors — spontaneously reported directly elicited Previous treatments/investigations — helped or caused side effects? Current functional state — what can the patient do now? Screening questions — headaches, fits, faints, blackouts, numbness/tingling/weakness, sphincter disturbance, visual symptoms Always end with: "Is there anything else you wanted to tell me?" --- CNS Examination Sequence Mental status Higher functions Cranial nerves Motor examination Sensory examination Cerebellar examination Gait --- Mental State ExaminationAbnormalities reflect: neurological disease (e.g. frontal lobe/dementia), primary psychiatric illness, or psychiatric illness secondary to neurological disease (e.g. depression post-stroke). Appearance & Behaviour: Unkempt, self-neglect → depression, dementia, alcohol/drugs Slow monotonous speech, downcast facies → depression Fidgety, poor concentration → anxiety Disinhibited/aggressive → frontal lobe disease, Bipolar I Emotional lability → crying/laughing easily Lack of concern despite disability → loss of insight, frontal lobe/conversion disorder Mood: Euphoric → mania Blunted/incongruous → schizophrenia Depressed → depression Hallucination = perception without external stimulus Illusion = misinterpretation of real stimulus (altered consciousness) Delusion = fixed false belief; seen in confusional states and psychosis --- Higher Functions — 7 Tests 1. Orientation & Attention — time, place, person; digit recall (normal = 7 forward, 5 backward) 2. Memory — give name + address; recall after 5 min (short-term). Short-term memory loss in alert patient → bilateral temporal lesion, Korsakoff's psychosis 3. Calculation — serial 7s; doubling 3s → impaired = diffuse encephalopathy 4. Abstract Thought — proverb interpretation; estimates (e.g. weight of elephant). Concrete = encephalopathy; delusional = psychiatric/frontal lobe 5. Spatial Perception — draw clock + copy star Half clock missing → right parietal lobe (visual inattention) Cannot draw → constructional apraxia 6. Visual/Body Perception: Cannot recognise faces → prosopagnosia (bilateral temporoparietal) Ignores one side → hemi-neglect (parietal) Unaware of own weakness → anosognosia Cannot identify object in palm → astereognosis Cannot identify writing on palm → agraphaesthesia 7. Apraxia — cannot perform purposeful task despite no weakness. Test: "Show me how you comb your hair / drink tea / strike a match." Lesion = dominant hemisphere --- Aphasia Wernicke's — poor comprehension, fluent but meaningless speech, no repetition Broca's — preserved comprehension, non-fluent speech, no repetition --- Cranial Nerve ExaminationCN nuclei in the brainstem = anatomical markers for lesion level. If CN is affected opposite to a hemiparesis → lesion is at the level of that CN's nucleus. CN I — Olfactory Test each nostril separately Bilateral anosmia → COVID, trauma, common