Good Morning

1. Good Morning Friday, July 19th, 2013

4. Neurologic Exam in Children

5. Neurologic Exam • Components • General Assessment • Mental Status • Cranial Nerves • Motor • Sensation • Reflexes • Cerebellum • Gait

6. General Assessment • Vital Signs • Developmental Stage • General inspection of Patient • Dysmorphic features • Appropriate size, weight, head circumference • Voluntary or purposeful movement • Posture

7. Physical Exam Findings • Skin • Hypopigmented patches, facial hemangiomas, café au lait spots, • Spine • Visualize spine, gluteal folds • Head • Size, sutures, fontanel, swelling

9. Mental Status • Orientation • Language • Memory • Breakfast (short term) • Name of teacher/school (long term) • Counting or Alphabet • Attention, Concentration, Executive Function, Calculations, Praxis • Spell world backwards • Serial 7s • Level of Consciousness • One of the most important parts of the neuro exam • Glascow Coma Scale • Mood, Thought Content

10. Infant Scale 5. Coos, babbles 4. Irritable cries 3. Cries to pain 2. Moans to pain 1. No response 6. Spontaneous, purposeful movement 5. Withdraws to touch 4. Withdraws to pain 3. Decorticate posture to pain (flexion) 2. Decerebrate posture to pain (extension) 1. No response

12. Cranial Nerves • Infants: mainly observational • I olfactory: rarely tested • II optic: • Visual acuity: infant reaching for objects, child recognizing objects/letters/numbers • Visual fields: objects in the periphery • Pupillary light response: direct and consensual • Fundoscopy

13. Fundoscopy

15. Cranial Nerves • III oculomotor: Superior/Inferior/Medial recti, inferior oblique, levatorpalpebraesuperioris, autonomic muscles

16. Cranial Nerves • IV trochlear: superior oblique, pulls down/in

17. Cranial Nerves • VI abducens: lateral rectus, abducts

18. Corneal Light Reflex

19. Abnormal Eye Movements • Nystagmus • Tonic horizontal deviation • Tonic downward gaze deviation • Unilateral dilated, poorly reactive pupil • Unilateral constricted pupil

20. Cranial Nerves • V Trigeminal: • sensation of face, cornea, conjunctiva • Motor function of masseter, temporalis, pterygoids (muscles of mastication) • Lacrimation, taste

21. Cranial Nerves • VII facial: • Symmetry of nasolabial folds • Eyelid muscle strength • Ability to wrinkle forehead • Infants • Closes both eyes when crying • Look for symmetric suck, spillage to one side (V, VII, IX, X, XII) • Taste

22. Cranial Nerves • VII facial nerve palsy

23. Cranial Nerves • VIII Vestibulocochlear: • Infants: alerting reponse to sound, localizes to sound • Children: whisper number or letter • Older children: Webber and Rinne • Vestibular • Poor head control, truncal instability, gait ataxia, N/V, nystagmus (horizontal)

24. Cranial Nerves • Weber Can detect • unilateral sensorineural (inner) • unilateral conductive (middle)

27. Cranial Nerves • IX Glossopharyngeal and X Vagus: • Controls swallowing, soft palate movement, gag reflex • Drooling, pooling saliva can be a sign of dysfunction • Hoarseness can be a sign of CN X dysfunction • Dysarthria (IX, X and XII)

28. Cranial Nerves • XI Spinal Accessory: trapezius and sternocleidomastoids • Elevation of shoulders, turning neck against resistance • XII Hypoglossal: innervates the tongue • Tongue should be midline on protrusion • Deviation to affected side indicates palsy • Atrophy, fasiculations or oromotorapraxia can be a sign of dysfunction or serious illness

30. Motor - Infants • Passive Tone • <28 wga: limbs passively extended • 34 wga: flexion of knee/hip, extended UE • 40 wga: strong flexion in all four extremities • Active Muscle Activity • Posture

31. Ballard Scale

33. Motor - Infants • Active Muscle Activity • Symmetric, smooth, spontaneous movements (34 wga) • Small amplitude, choeo-athetoid movements of hands are normal • Jitteriness, tremulousness can occur, but should not be sustained • Reflexes – stepping reflex • Head Control • Vertical and Ventral Suspension

34. Motor - Infants • Hypotonia • Most common motor abnormality • Hypotonia + preserved mobility + hyperreflexia • Central nervous system origin (Down Syndrome) • Hypotonia + weakness + areflexia • Anterior horn cell disorder • Peripheral nerve or peripheral muscle disorder

35. Motor - Infants • Hypertonia • Less common than hypotonia • Pyramidal tract dysfunction • Passive movement of the muscle  resistance • Associated with hypoxic-ischemic lesions • Difficulty determining spasticity vs. rigidity • Spasticity (meaning to draw or tug) involuntary, velocity-dependent, increased muscle tone that results in resistance to movement • Rigidity - Involuntary, bidirectional, non – velocity-dependent resistance to movement

36. Motor - Infants • Opisthotonus • Arching of the neck and trunk • Decreased cortical inhibition • Associated with bilirubin encephalopathy, tetanus, TBI, CP, meningeal irritation/increased ICP

37. Motor - Children • Observe them at play • Muscle tone • Resistance felt upon passive movement • Hypotonia = decreased resistence + hyperextension • Hypertonia • Spasticity (clasp knife) pyramidal • Rigidity (lead pipe or cog-wheel feel) extrapyramidal

38. Motor - Children • Weakness or Strength • Grades • 0/5: no muscle movement at all • 1/5: visible/palpable contraction, but No Movement • 2/5: movement with gravity eliminated • 3/5: movement against gravity • 4/5: movement against gravity and some externally applied resistance • 5/5: movement against gravity and full resistance

39. Motor - Children • Distal Weakness • Can be symmetric or asymmetric • Seen in peripheral myopathies • Proximal Weakness • Usually symmetric • Seen in myopathyies • Gower’s sign

40. Motor - Children • Pronator Drift • extend UE with palms up, eyes closed • UMN weakness • Arm pronates and falls, can pulls elbow down and in • Cerebellar disease • One arm rises up or oscillates

41. UMN vs LMN • Spasticity +/- weakness • Stiffness +/- mild atrophy • Increased Reflexes/Tone • Spontaneous clonus • Spontaneous spasms • Gait • Slow, stiff, difficult to turn • Heavy legs • Weakness • Foot drop, difficulty w/ stairs • Decreased Reflexes/Tone • Muscle atrophy • Fasciculations • Cramps • Gait • Steppage, waddling

42. LMN signs • http://www.uptodate.com/contents/clinical-features-of-amyotrophic-lateral-sclerosis-and-other-forms-of-motor-neuron-disease?detectedLanguage=en&source=search_result&search=upper+motor+neuron&selectedTitle=1%7E150&provider=noProvider#H11

44. Sensation

45. Sensation • Child • Vibration (128 or 256 Hz tuning fork) • Proprioception (Romberg) • Light Touch (cotton swab) • Temperature and Pin Prick • Two point discrimination, stereognosis, graphesthesia • Infant – difficult to assess • Perioral tactile stimulation  rooting reflex • Spinal cord lesion • Only time pin prick testing is useful in infants

46. Romberg Sign

48. Reflexes - Infant

49. Other reflexes • Babinski reflex • Abdominal reflex • Cremasteric reflex • Perianal reflex

50. Reflexes - Children • Jaw – tap chin with mouth slightly open • Biceps – with elbow flexed, tap at antecubitalfossa • Brachioradialsis - tap above the wrist, on radial aspect  flexion of elbow • Patellar – tap quadriceps tendon below patella  extension of knee • Ankle (Achilles)