Neurologic examination of the child

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Neurologic examination of the child
Dr. Aviva Mimouni Bloch Pediatric
neurologist Schneider CMCI

• Tami Steinberg
• Pediatric neurologist
• Schneider CMCI

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Aims

• From a symptom
• Localization
• DD
• Evaluation
• Diagnosis

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Main parts

• General appearance
• Dysmorphic features
• Neurocutaneous features

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Main parts

• Consciousness
• Head
• Cranial nerves
• Motor system
• Cerebellar examination
• Sensory
• Developmental assessment
• Behavior

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Observation

• Start while interviewing
• Curiosity, playing.
• Language, dysarthria.
• Facial expression, tics, movements
• Behavior, attention, relation with parents

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Observation

• Dysmorphic features

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Observation

• Weight, length FTT, IUGR, Obesity
• Clues to hormonal abnormalities
• Abnormalities of midline clues to spinal
  dysraphism

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Skin

• Skin and nervous system originate from ectoderm
• Neurocutaneous syndromes
• Hemangiomata
• Café au lait spots
• Hypopigmented patches

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General PE

• Cardiac murmurs, bradycardia
• Organomegaly Lysosomal, peroxisomal

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Head and skull

• General appearance, Symmetry, dysmorphism
• Sutures ridging, craniosynostosis
• Fontanelles
• Hydrocephalus Fontanelle,Frontal bossing,
  veins, Sunset eyes
• Head circumference- micro, macro, curve
• Head murmurs - AVM

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Sutures and fontanelles
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Meningeal signs
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Cranial nerves

• Cranial nerve I
• Cranial nerve II
•     visual acuity
•     visual field
•     colour vision
•     optic disc appearance

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Normal fundus
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Papilledema
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Cranial nerves

• Cranial nerve III, IV, VI
•     eye movement
•     ptosis (III nerve), and pupil reaction to
  light (II III nerve)
• Cranial nerve V
•     jaw power
•     sensation of face
•     corneal and jaw reflexes

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Lateral rectus palsy

• Can be caused by increased ICP.

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CRANIAL NERVES

• VII - FACIAL
• OBSERVE FOR FACIAL ASYMMETRY
• FOREHEAD WRINKLING, EYELID CLOSURE,
  WHISTLE/PUCKER
• VIII - VESTIBULOCOCHLEAR
• ACUITY

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Facial nerve palsy

• The patient can not move the forehead
  upward,close the eye forcefully,or elevate the
  corner of the mouth.
• Taste sensation is lost over the anterior two
  thirds of the tongue.

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Facial nerve palsy
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Cranial nerves

• Cranial nerve IX
•     gag reflex
• Cranial nerve X
•     soft palate elevation and deviation
•     gag reflex
• Cranial nerve XI
•     shoulder elevation (trapezius and
  sternomastoid)
• Cranial nerve XII
•      tongue function wasting / fasciculation

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Spinal accessory nerve.

• Provides innervation for the trapezius and SCM
  muscles.
• Comprises some fibers from C1 and C2, lesions in
  the area of the foramen magnum most commonly
  cause difficulties of cranial nerve XI.

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Gross motor function

• Most children above 4 ys usually cooperate
• Walk, jump, tiptoe, heelwalk, tandem walk
• Romberg
• Cerebellar

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Motor examination

• Muscle bulk
• Muscle strength
• Muscle tone
• Posture
• Walking
• Deep tendon reflexes
• Primitive reflexes
• Abnormal reflexes

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Muscle power

• 0 no contraction
• 1 flicker or trace of contraction
• 2 active movement,with gravity eliminated
• 3 active movement against gravity
• 4 active movement against gravity and resistance
• 5 normal power

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STRENGTH EXAM

• UPPER AND LOWER EXTREMITIES
• DISTAL AND PROXIMAL MUSCLES
• SUBTLE WEAKNESS
• TOE WALK, HEEL WALK
• OUT OF CHAIR
• Special attention to functional assymetry

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Muscle Tone

• Do not confuse tone and strength
• Tone resistance to passive movement
• Shoulder girdle hypotonia baby falls when you
  put your hands under his armpits
• Normal tone changes with age eg premies

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Spasticity

• ???? ?"? ????? ?- Upper motor neuron
• ??????? ??????? ?? ????? ?????? "???? ?????"
  clasp knife
• ???? ????????? ?? ????? ??????? ??????????? ??
  ???????
• ??"? ?? ????????, ???????, ?????? ??????,
  ??????? ?????? ????? LMN ??? ??? ????? (disuse
  atrophy)
• Clonus ?????? ???????. ???????? 5-10 ??????
  ???? ??????
• ?? ?????? ??????? "????? ??????"
• ????????????

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Babinski reflex

• ????? ???? ?????? ?? ?? ????
• "?????"
• ???????? ?????
• fanning ?? ??? ???????
• ????? ?? ??? ???????? ?????? ????????
• "?????" ????? ?????? ???????? ?? ??? 10-12 ?'

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????? ?? ???? - Hypotonia

• ????? ????
• ????? ????? ????? ????????
• ????? ?????? ?? ??? ???????, ??????, ?"?, ?????
  ???????? ?? ????
• Floppy infant ???? ???? ???, ????, ???? ?????
  ?? ??????
• Frog position ?? ???
• ????? ???? ??????? ?? ????
• 28wk ????, 32wk - ?? ??? ??????. Term ????
  ???????

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??????? ?????? ?????? ???????

• Biceps C5-C6
• Brachioradialis C5-C6
• Triceps C7-C8

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??????? ?????? ?????????

• Patellar 4-5L
• Achilles 1-2S
• ???? ?????? ??? ???? !

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?????? ??????????
????? ??? ?????? ????? ??? ????? ??...
Palmar grasp 28 wk 32 wk 2-3 mo
Rooting 32 wk 36 wk ???? ???? ????
Moro 28-32 wk 37 wk 5-6 mo
Tonic neck 35 wk 1 mo 6 mo
Parachute 7-8 mo 10-11 mo ??? ?????
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Moro reflex
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Tonic neck reflex
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??? UMN ??? LMN
LMN UMN
DTR ? ?
??? ?????? ? ?
????? ?????? ? ?
??? ???? ???? ?
??????????? -
??????? ?????? -
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Cerebellar functions

• ????? ???????????? ?????? ?? ????? ?????? ?????
• Trunca ataxial
• ????? ???, ???? ????? ?? ?????
• ???? ?????? ? cerebellar vermis
• Limb ataxia
• ????? ?????? ????? intention tremor
• ????? ? cerebellar hemispheres
• ????? ?"? ????-??, tandem walking

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Cerebellar functions
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Cerebellar dysfunction.

• Ataxia .
• Hypotonia.
• Action tremor (intention).
• Dysdiadochokinesis.
• Dysmetria
• Dysarthria

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????? ?????? ????????

• ??? - ?????
• ??? ?"? ???? (?? ???!)
• ??? ????
• ???????? ?"? ????
• ????? proprioception - ???? ????? ?????

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????????

• ??? ?????? ??? ????? ?? ??? ????
• ????? ?? ?? ???? ?????? ????? ?????
• ????? ??? ??????? V (?????????)

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Cerebellar signs

• intention tremor
• past-pointing (dysmetria, limb ataxia)- pointing
  beyond the finger in the finger-nose test
• dysdiadochokinesis - this feature is shown when
  the patient is slow and uneven in attempting fast
  hand movements, e.g. tapping the right hand fast
  on the back of the left hand
• nystagmus - coarse and slow worst on looking to
  the side of the lesion
• Ataxia
• rhombergism
• hypotonia and pendular reflexes