Transcript Applied Pediatrics Jose A. Robles, MD Pediatric Neurology HISTORY

Applied Pediatrics
Jose A. Robles, MD
Pediatric Neurology
HISTORY
Chief complaint
– actual or approximate time of onset
– central problem
– foundation upon which differential
diagnosis must be constructed
– patient own words
HISTORY
History of Present Illness
–
–
should fully describe the chief complaint
Answers 3 important questions:
1. Is the process focal or diffuse ?
2. Is the process acute or insidious ?
3. Is the process static or progressive ?
Onset and Course of Neurologic Disease
History
Prenatal history
– Illness of mother
– Exposure to radiation / toxic substance
Birth History
– Apgar score, hospital stay, term ? ,
preterm?
Neonatal History
– Illness (jaundice, infection , etc)
History
Developmental and Past Medical History
– time of acquisition or loss of developmental
landmarks
Family History
– Family tree include dead, alive and abortus
– delineate genetically determined illness
(Autosomal dominant, autosomal recessive , X –
linked)
Physical Examination
Observe
Undress
Anthropometric measurement
Birth: Normal head circumference: 33 –35cms
Anterior fontanelle closes : 7 – 20 months
Posterior fontanelle closes: 3 months
Definition:
microcephaly 2 SD below the norm for age, sex,
race
macrocephaly 2 SD above the norm for age, sex,
race
Physical Examination
Skin lesion
Neurofibromatosis
• Café au lait spots
• Cutaneous fibromas
• Autosomal dominant
Tuberous sclerosis
• adenoma sebaceum
• Depigmented lesions (vitiligo – like lesions)
• Autosomal dominant
Sturge Weber syndrome
• port wine stain
• Autosomal dominant
Neurologic Examination
in Pediatrics
NEUROLOGIC MATURATION
The dominant posture
is one of flexion…
Eye opening…
is improved reflexly by bringing
in the baby from supine to
upright (doll’s eye reflex, upright)
DEVELOPMENTAL REFLEXES
before one can begin to look for
the signs of neurological
dysfunction
Brachial palsy; this is more serious
than Erb’s palsy…
Weak sucking is strengthened by using
automatic palmar grasp to evoke the Babkin
Palmomental response
Hyperactive neurological
dysfunction; the palmar grasp
is so strong that the baby lifts
free for a longer time; note the
backward thrust of the upper
limbs simultaneously
First one side comes up…
then the other (same baby)
the pad of the index finger
lightly touches the crown of
the cheek
the baby turns due to the rooting reflex
& then the index finger is slipped into
the mouth to elicit sucking
transient ATNR is physiological
The reversed ATNR is physiological
starting position for
plantar grasp; baby’s
toes flexed…
the thumbs are deftly
applied to the
metatarsal heads,
symmetrical flexion
Neurologic Examination
• Higher cortical function Test :
– AGNOSIA
– APRAXIA
– APHASIA
Neurologic Examination
• AGNOSIA
– inability to understand the significance of sensory
stimuli even though the sensory pathways and
sensorium are relatively intact
• 4 necessary conditions
– previous skills sufficient
– sensorium intact
– sensory pathways intact
– organic cerebral lesion present
EX: finger agnosia, astereognosia, agraphognosia
Neurologic Examination
• APRAXIA
– inability of a patient to perform a volitional act even
though the motor system and sensorium are relatively
intact
– 4 necessary conditions
– previous skills adequate
– sensorium intact
– motor pathways intact
– organic cerebral lesion present
EX: constructional apraxia, dressing apraxia, gait apraxia,
tongue apraxia
Neurologic Examination
• APHASIA
– Expressive – non fluent
– Receptive – fluent
Neurological Examination
• Mental status
– Consciousness
• lethargy, delirium, obtundation,
stupor, coma
– Orientation
– Memory
• immediate recall, recent, remote
Neurological Examination
• Mental status
• Definition of Terms:
– Lethargy : state of minimally reduced
wakefulness in which the primary defect is
one of attention
– Delirium : characterized by disorientation,
irritability, delusions or visual hallucinations
Neurological Examination
• Definition of Terms:
– Obtundation : mild to moderate blunting of
alertness, accompanied by a lessened interest in
or response to the environment. Patient have an
increase in the number of hours of sleep, often
with drowsiness in Delirium : characterized by
disorientation, irritability, delusions or visual
hallucinations
– Stupor : patient can be aroused temporarily only
by vigorous and repeated stimulation.
Communication is minimal or non - existent
Neurological Examination
• Definition of Terms:
– Coma : state of unarousable
unresponsiveness; without spontaneous
movement and with eyes closed. May
respond to noxious stimuli but cannot
localize pain
CRANIAL NERVE EXAMINATION IN INFANCY
Neurological Examination
• Motor
– Strength
•
•
•
•
•
•
0 - No muscle contraction
1 - Flicker or trace of contraction
2 – Active movement with gravity eliminated
3 - Active movement against gravity
4 – Active movement against gravity but not against resistance
5 – Active movement against gravity and resistance
– Bulk
• Normal. Atrophy, hypertrophy
– Tone
• Normal, spastic, hypotonia, flaccid
Neurological Examination
• Sensory
– Spinothalamic – pain
– Posterior column – vibration, position
Neurologic Examination
• Reflexes
– Deep Tendon Reflexes
•
0 : Areflexia
• 1-2 : Average
• 3+ to 4+ : Hyperrefexia
– Superficial Reflexes
– Pathologic Reflexes
• Babinski
• Modified Babinski
– Oppenheim
– Chaddock
– Gordon
Segmental Levels of Major Deep Tendon Reflexes
Neurologic Examination
• Cerebellar
– Vermis : truncal ataxia
– Hemisphere :
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•
•
•
•
Limb ataxia
Finger to nose
Tandem walk
Dysdiadocokinesia
Head tilt
– Nystagmus
• Meningeal
– Kernigs
– Brudzinski
DIFFERENCES BETWEEN
UMN AND LMN LESIONS
UMN
Strength
Bulk
Tone
DTR
Pathologic reflex +
LMN
,0
-