1. Child Neurologic Examination
F.Ahmadabadi MD
Child Neurologist
ARUMS
2014 Oct 22

2. History: Characteristics: Frequency Duration
Static, progressing, or improving
Acute, subacute, or chronic
ROS
Birth history
Gestational age, complications during pregnancy (including infections), maternal drug use, Apgar scores, problems during delivery e.g. meconium, and feeding difficulties

3. History Cont… PMHX: Medications Developmental milestones
immunization status, accidents, chronic medical problems
Medications
when discussing szs, include previous AEDs and response
Developmental milestones
Family history:
Epilepsy, Neurocutaneous syndromes, Migraines, Neurodegenerative disorders

4. General Physical Exam
1. Height, weight, blood pressure, and head circumference. 2. General appearance, including dysmorphology. 3. Skin exam 4. Location of the hair whorl 5. Quality of scalp hair 6. Exam of the midline of the back and neck 7. Presence of unusual body odor 8. Hepatosplenomegaly

5. Principles of Neurologic Examination of the Child
1. Use items such as a tennis ball, small toys (including a toy car), bell 2. Do not wear a white coat. 3. Postpone uncomfortable tasks until the end, such as head circumference, funduscopy, corneal and gag reflexes, and sensory testing. 4. Make the most of every opportunity to examine the child. 5. Examine the younger child in the parent's lap. 6.Always listen to the mother. It is okay to assess the child as sicker than the mother feels.

6. Neurologic Exam
Mental state Humans have an alerting reflex in the vertical position—the same reflex we utilize in newborns when we tilt them upwards so that they open their eyes
Cranial Nerves
fundoscopic examination
    pupils
    extra ocular movements
Motor
Sensory
Reflexes Deep tendon reflexes, Superficial reflexes
Cerebellum
Gait

7. 1.Mental Status Humans have an alerting reflex in the vertical position—the same reflex we utilize in newborns when we tilt them upwards so that they open their eyes
Note these
Patient’s activity as you enter the room, such as chatting, sleeping, posturing, etc.
Stimulus required to awaken patient, such as calling her name, pinching, etc.
Patient’s best mental state seen, such as chatty conversation, sluggish answers, semi-purposeful movements, etc.
Patient’s activity when you stop stimulating her.

8. Consciousness Spell "WORLD" backwards Four Part Command Oriention
Memory

9. 2.Cranial Nerves I (Olfactory) nerve. Not routinely tested
II(Optic)nerve
Fundoscopy:Disk-Hemorrhage
Disc sharpness refers to the sharpness of the distinction between the yellow optic disc and the pink retina.
When the disc is elevated, the vessels may be noted to course downwards as they traverse over the optic disc.
Disc color and retinal vessels.
Spontaneous venous pulsations (SVPs.) While acute papilledema may take 48 hours or more to manifest itself, the first sign is usually loss of SVPs.
PERRL means Pupils Equal, Round, Reactive to Light
Visual acuity.
If the visual acuity can be demonstrated to be normal through a pinhole, glasses, the near card, or the distant chart, then the acuity disturbance it is unlikely to be of primary neurological origin.
Visual fields

10. Comparison of Nl and Abn Retin
Normal Retin
PAPILLEEDEMA
Your Text Here

11. III (oculomotor), IV (trochlear), and VI (abducens).
Cranial Nerves Cont…
III (oculomotor), IV (trochlear), and VI (abducens).
VI Controls the lateral rectus (abducts the eye)
IV Controls the superior oblique (pulls the eye down and in)
III Does all other extraocular movements

12. Cranial Nerves Cont… V. (trigeminal) nerve function includes
Facial sensation
Corneal sensation (the afferent limb of the corneal reflex)
Muscles of mastication (masseter)

13. Cranial Nerves Cont… VII (facial) nerve Facial movements
Taste on anterior 2/3 of tongue
Chordae tympani which dampens loud sounds. Loss of this function causes hyperaccusis

14. Cranial Nerves Cont… VIII (cochlear) nerve IX (glossopharyngeal)
Hearing testing
IX (glossopharyngeal)
X (vagal) nerve Gag reflex
XI (spinal accessory) nerve
Sternocleidomastoid (turns head to the opposite side)
Trapezius (shrugs shoulder)
XII (hypoglossal) nerve
Tongue protrusion forward and to the sides.
Tongue fasciculations seen in anterior horn cell disease.

15. 3.Motor Examination
Pronator Drift. This is a superb and sensitive test for upper motor neuron weakness. First, the child extends his arms palms down. Then, the eyes are closed, and a few seconds later, the child turns his arms palms up. During this turning maneuver, a child with upper motor neuron weakness may pull the elbow down and in.

16. Motor Examination (Cont…)
Screen for upper extremity weakness by testing the triceps and drift
For the lower extremities, the extensor hallicus and ankle dorsiflexors are the best screening tests for upper motor neuron lesions.

17. Motor Examination (Cont…)
Functional motor tests, such as getting up from the ground, using stairs, and gait testing have several uses. 1.They may be the best way to pick up proximal weakness. 2.They may be the only way to gain the cooperation of younger children. 3.Functional tests can often be used as developmental landmarks. These include the parachute

18. Extra pyramidal Movements
Athetosis
Ballismus
Chorea
Dystonia
Tremor

19. Muscle Tone
Distinguish between the peripheral muscle tone (the tone of the extremities) vs. truncal tone (which includes pelvic tilt, posture, tendancy to fall through the examiner’s hands, and jaw tone).

20. Posture and muscle tone
1) Resting posture -observing the infant undressed.). Hypertonia in the extremities decreases after 3 months of age, with the upper extremities then the lower extremities. At the same time, tone in the trunk and neck increases.
2) Passive tone
The scarf sign is where the arm is pulled across the chest and if the elbow passes the midline, then hypotonia is present.
3) Active tone - traction response up to 3 months of age
The infant's hands are held with the examiner's thumbs in the infant's palms, and the fingers around the wrists. The infant is slowly pulled to a sitting position
Normally the elbows flex and the neck raises the head. If hypotonia is present, then the head lags backward, then as the erect position is assumed, the head then drops forward. If hypertonia is present, the head is maintained backwards.
4)Vertical suspension
5)Horizontal (ventral) suspension (Landau reflex)

21. Reflexes
Superficial
Deep(Patella-achillus-…)

22. 4.Primitive reflexes
Moro reflex infant opens his hands, extends and abducts the arms, and then brings them together, followed by a cry Tonic neck response -Abnormal responses occur when this response is sustained or if it occurs differently when the head is turned to the right or left Palmar and plantar grasp reflexes The palmar grasp reflex should disappear by 6 months; the plantar by 9 to 10 months. Parachute response A normal response should be seen at 8 to 9 months and consists of arms extended and hands open. Reflex placing and stepping responses This reflex disappears at about 4 to 5 months of age

23. 5.Gait
Along with Fundoscopy and the Drift, Gait is an essential test in medically stable patients.
Heel walking
(This is particularly difficult in upper motor neuron diseases.) It is easier to observe if done while the child walks towards you.
Toe walking
Easier to observe if done while the child walks away from you.
Tandem walking
Running, including rapid turns, is an even better test.