Transcript Good Morning - LSU School of Medicine

Good Morning
Friday, July 19th, 2013
Neurologic Exam in Children
Neurologic Exam
• Components
– General Assessment
– Mental Status
– Cranial Nerves
– Motor
– Sensation
– Reflexes
– Cerebellum
– Gait
General Assessment
• Vital Signs
• Developmental Stage
• General inspection of Patient
– Dysmorphic features
– Appropriate size, weight, head circumference
– Voluntary or purposeful movement
– Posture
Physical Exam Findings
• Skin
– Hypopigmented patches, facial hemangiomas,
café au lait spots,
• Spine
– Visualize spine, gluteal folds
• Head
– Size, sutures, fontanel, swelling
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
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
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
Fundoscopy
Cranial Nerves
• III oculomotor: Superior/Inferior/Medial recti,
inferior oblique, levator palpebrae superioris,
autonomic muscles
Cranial Nerves
• IV trochlear: superior oblique, pulls down/in
Cranial Nerves
• VI abducens: lateral rectus, abducts
Corneal Light Reflex
Abnormal Eye Movements
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Nystagmus
Tonic horizontal deviation
Tonic downward gaze deviation
Unilateral dilated, poorly reactive pupil
Unilateral constricted pupil
Cranial Nerves
• V Trigeminal:
– sensation of face, cornea, conjunctiva
– Motor function of masseter, temporalis,
pterygoids (muscles of mastication)
– Lacrimation, taste
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
Cranial Nerves
• VII facial nerve palsy
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)
Cranial Nerves
• Weber Can detect
– unilateral sensorineural (inner)
– unilateral conductive (middle)
Weber without
lateralization
Weber lateralizes
left
Weber lateralizes
right
Normal/bilateral
sensorineural loss
Sensorineural loss
in right
Sensorineural loss in
left
Rinne left BC>AC
Conductive loss in
left
Combined loss :
conductive and
sensorineural loss in
left
Rinne right BC>AC
Combined loss :
conductive and
Conductive loss in
sensorineural loss in right
right
Rinne both ears BC>AC
Combined loss in
right and
conductive loss on
left
Rinne both ears AC>BC
Conductive loss in
both ears
Combined loss in left
and conductive loss
on right
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)
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 oromotor apraxia can be a
sign of dysfunction or serious illness
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
Ballard Scale
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
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
Motor - Infants
• Hypertonia
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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, velocitydependent, increased muscle tone that results in resistance
to movement
• Rigidity - Involuntary, bidirectional, non – velocitydependent resistance to movement
Motor - Infants
• Opisthotonus
– Arching of the neck and trunk
– Decreased cortical inhibition
– Associated with bilirubin encephalopathy, tetanus,
TBI, CP, meningeal irritation/increased ICP
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
Motor - Children
• Weakness or Strength
– Grades
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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
Motor - Children
• Distal Weakness
– Can be symmetric or asymmetric
– Seen in peripheral myopathies
• Proximal Weakness
– Usually symmetric
– Seen in myopathyies
– Gower’s sign
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
UMN
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Spasticity +/- weakness
Stiffness +/- mild atrophy
Increased Reflexes/Tone
Spontaneous clonus
Spontaneous spasms
Gait
– Slow, stiff, difficult to turn
– Heavy legs
vs
LMN
• Weakness
– Foot drop, difficulty w/ stairs
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Decreased Reflexes/Tone
Muscle atrophy
Fasciculations
Cramps
Gait
– Steppage, waddling
LMN signs
• http://www.uptodate.com/contents/clinicalfeatures-of-amyotrophic-lateral-sclerosis-andother-forms-of-motor-neurondisease?detectedLanguage=en&source=searc
h_result&search=upper+motor+neuron&selec
tedTitle=1%7E150&provider=noProvider#H11
Sensation
Sensation
• Child
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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
Romberg Sign
Reflexes - Infant
Other reflexes
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Babinski reflex
Abdominal reflex
Cremasteric reflex
Perianal reflex
Reflexes - Children
• Jaw – tap chin with mouth slightly open
• Biceps – with elbow flexed, tap at antecubital
fossa
• Brachioradialsis - tap above the wrist, on
radial aspect  flexion of elbow
• Patellar – tap quadriceps tendon below patella
 extension of knee
• Ankle (Achilles)
Reflexes - Children
• Absent or diminished
– Can be loss of sensory fibers
– Can be loss of muscle stretch reflex arc
• Exaggerated
– Clonus
– Knee jerk  contralateral hip muscle and plantar
foot flexion
Reflexes
• Grading
– 0 absent
– 1 Decreased (Hypoactive)
– 2 normal
– 3 Increased (Hyperactive)
– 4 Clonus
Cerebellar
• Dysmetria: Difficulty regulating rate and range
of muscle contraction
– Nystagmus
– Intention tremor
– Scanning speech
– Truncal or gait ataxia
– Rebound phenomenon
Gait
• Assess gait, heel walking, toe walking and
tandem gait
• Circumduction (spasticity, hemiparesis)
• Broad-based, ataxic (cerebellar)
• High-steppage gait (peripheral neuropathy)
• Waddling gait (myopathy, DMD)
Noon Conference