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Neurological examination

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Neurological examination Dr. D. Barry Postural Reactions As opposed to primitive reflexes which neonate is born with, these evolve early in infancy Many doctors ... – PowerPoint PPT presentation

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Title: Neurological examination


1
Neurological examination
  • Dr. D. Barry

2
Many Parts in Full Neuro Exam
  • Inspection alertness/GCS
  • Dysmorphia (syndrome?)
  • Cranial Nerves
  • Peripheral Nerves
  • Upper limb
  • Lower limb
  • 4) Co-ordination, Gait, Cerebellar signs
  • Developmental
  • Higher functioning
  • Cognitive Behavioural

3
  • 1) Neonate
  • 2) Infant/toddler
  • Child with Neuro-disability
  • Older Child (age ability - appropriate tests)
    thats the childs ability, not the
    examiners!

4
  • Examination texts/technique should be
    age-appropriate
  • CN II XII gt 5 years
  • ?? with co-operation, sociability etc.

5
1) Neonate
  • Alertness
  • Expose observe
  • Dysmorphism facies
  • OFC plot on centile chart
  • Skeleton, spine, hands feet (deformities)
  • Skin, genitalia, eyes
  • Position, Posture Movement (Muscle bulk etc.)
  • OFC, shape, sutures fontanelle (? VP shunt?)
  • Comment (eyes open/movements? feeding/sucking)
  • Tone position, fisting, head control, floppy?
    etc.
  • Spinal Reflexes knee jerk, clonus etc.
  • Spine / Natal cleft
  • Primitive Reflexes ( moro at end its upsetting)

6
Reflex How to elicit Disappears at
Stepping hold baby vertically walk with feet touching ground gt feet move in stepping motion 2/12
Rooting stroke cheek gt mouth moving to that side 4/12
ATNR rotate infants head to side x 15 secs gt extension of limbs on side turned to with flexion of limbs on side turned away from 4/12
Palmar grasp place index finger in palm of infant gt flexion of fingers/makes fist 4/12
Moro startle response 4-6/12
Galant child held prone, stroke along side of spine on one side gt flexion of trunk on that side 4-8/12
Plantar extensor until 1 yr old
7
Primitive Reflexes
  • Brainstem-mediated
  • Most have fuctional role
  • Disappear with Cortical Inhibition
  • Many books vary on exactly when these reflexes
    are lost, so it can be confusing, therefore at
    least have general rule
  • most gone by 6/12 (with motor dev. voluntary
    movement takes over),
  • All gone by 1 year (roughly)
  • in general, they are lost in a Cephaol-caudal
    direction

8
2) Infant
  • Alertness
  • Dysmorphism (as before)
  • Position, Posture Movement
  • CN Eyes - ? Fixing following
  • Face smiling, crying? Symmetrical?
  • Bulbar feeding making sounds
  • Primitive Reactions Postural Reactions
  • Peripheral Tone, Reflexes
  • Developmental Milestones gross motor, fine motor
    (co-ord) what are they doing watch them
    playing with toys etc.

9
Postural Reactions
  • As opposed to primitive reflexes which neonate is
    born with, these evolve early in infancy
  • Many doctors include them together with primitive
    reflexes, but they have very different underlying
    significance
  • Head-righting reflexes
  • Horizontal suspension (extension of head, spine
    legs) 3-6/12
  • Vertical to horizontal position (? Knees flex
    head corrects) 6/12
  • Parachute reflex support childs trunk lower
    him/her suddenly down towards bed/surface. Child
    will throw out arms to protect him/her-self
    appears 9/12, and persists!

10
3) Child with NeuroDisability
  • Alertness
  • Examination tests depend on level of disability
  • Speak to these children directly, introduce
    yourself
  • do they respond / react?
  • Dysmorphic features (nb OFC)
  • Position, Posture
  • Movements Muscle Bulk
  • External Supports nb. (?Catheter/urine bag/
    splints/ etc.)
  • if in a wheelchair / sitting out ideally Id
    like to examine them in the bed esp for spinal
    lower limb exam expose
  • Peripheral Nerves
  • tone, reflexes /- power
  • CN relative to understanding etc. (as described
    before)

11
4) Older child
  • At gt 5 yrs can comply with most of formal
    neurological exam
  • Need to improvise with younger children engage
    the exam as a game
  • If co-operation vital but difficult (eg. CN)
    - attempt, but if not possible, say so move on

12
May be asked
  • Examine this childs lower limbs
  • Examine this childs gait
  • Examine this patients visual fields / eye
    movements / for squint
  • Demonstrate this childs reflexes
  • Examine this child for signs of cerebellar
    dysfunction
  • Any individual / isolated part of neuro exam

13
General Neuro Inspection
  • Dysmorphic features
  • Facies
  • OFC (eg. Macrocephaly, microcephaly), shape
  • Skeleton, spine (eg. scoliosis, spina bifida),
    hands feet
  • Skin (eg. Neurocutaneous syndromes), genitalia
    eyes
  • Posture
  • Movement
  • Muscle bulk /- fasciculations
  • Supports eg glasses / hearing aids / wheelchair
    etc. etc. etc.

14
1) Cranial Nerves
  • I - olfactory
  • Eyes vision movements
  • II optic visual acuity, fields, fundoscopy,
  • III - oculomotor
  • IV trochlear
  • VI abducens (false localising)
  • Face (motor sensory)
  • V facial muscles of facial expression
  • VII trigeminal sensory to face ( tongue)
  • VIII vestibule-cochlear hearing
  • Bulbar (speech swallow)
  • IX glossopharyngeal
  • X vagal
  • XI accessory
  • XII hypoglossus

15
  • Examine relative to childs understanding
  • May need to improvise
  • Remember what your testing
  • Eyes (vision, movement, pupils)
  • Face
  • Hearing
  • Speech (making sounds) Swallow

16
Eyes CN II, III, IV, VI
  • Pupils round, regular, reactive, equal?
  • Visual Acuity ? Any books around / Snellen chart
  • Visual Fields confrontation perimetry
  • For younger child distraction test with 2
    examiners or engage the childs gaze, shine a
    light / toy at periphery move it around until it
    catches their attention
  • If abnormal, do formal testing
  • Red-pin test (scotoma) seldom necessary
  • Fundoscopy do at end, dim lights/pull curtains
  • Get child to fix on something interesting
  • Eye Movements ptosis ? Nystagmus ? squint
  • Hold childs head still
  • follow my finger
  • ? Ask re double vision if old enough

17
Squint (Strabismus)
  • Remove glasses
  • Observe position of eyes
  • Corneal reflections (of a light 30 cm away)
  • Cover test (manifest vs. latent)
  • Cover/uncover manifest squint
  • Alternate cover test latent squint
  • Eye Movments (paralytic vs. concomitant)
  • Offer to do visual acuity (each eye separately)

18
Squint may be
  • Paralytic or Concomitant
  • Divergent or Convergent
  • Horizontal or Vertical
  • Hypertropic or Hypotropic
  • Permanent or Intermittent
  • Pseudo-squint (epicanthic folds etc.)

19
Squint (Strabismus)
  • Paralytic
  • ??deviation with direction of gaze
  • Divergent (CN III)
  • Convergent (CN IV, VI)
  • ie. Muscle / nerve dx
  • CN VI palsy is assn with ? ICP esp if squint
    recent!
  • Concomitant (non-paralytic)
  • Angle of deviation constant in all directions of
    gaze
  • ie. Eye disease /
  • refractive errors /
  • ? binocular vision

20
Cover/Uncover test
  • If Normal, (ie. no squint normal binocular
    vision), both eyes maintain steady fixation on
    distant object
  • gt no deviation when either eye covered
  • focus on distant object
  • Cover uncover each eye in turn
  • Watch eye movements
  • If deviation of one eye when one/other is covered
    gt squint!
  • But which eye?

21
Practice on each other!!!Think it out!
  • Manifest Squint
  • Squinting eye turns in, normal eye maintains
    fixation distant object
  • Which is which?
  • Cover one eye, if the uncovered eye moves to take
    up fixation it has the manifest squint!
  • (see diagram)
  • Latent Squint
  • Both eyes fix at object
  • Cover one eye, if it deviates it has latent
    squint
  • ie. Deviates when you cover it! Resumes fixation
    when you uncover it!

22
Face (CN V, VI)
  • Trigeminal (CN V)
  • Sensory 3 divisions ophthalmic / maxillary /
    mandibular
  • Close eyse, when you feel something, point to
    side you feel it on
  • Compare sides
  • Motor Muscles of mastication
  • ? Bite wooden spatula resist you removing it
  • Reflexes corneal jaw jerk (seldom done)
  • Facial (CN VII) facial expression
  • Do these with the child, so they can see it!
  • raise your eyebrows
  • shut them tight dont let me open
  • smile, show me your teeth

23
Vestibulo-cochlear (VIII)
  • Hearing
  • Examine external auditory meatus
  • ? Speech normal ?
  • Conductive or Sensorineural?
  • Rinne Weber
  • Balance
  • (often tested with cerebellar signs/gait)

24
Bulbar
  • Glossopharyngeal (IX) Vagus (X)
  • Dysarthria, nasal speech, difficulty swallowing
    ?drooling
  • Say ahhh ? Palate elevates (IX X)
  • ? Uvula deviation (deviates away from affected
    side)
  • Gag reflex (do not elicit in conscious child)
  • Accessory (XI)
  • Shrug shoulders
  • Turn chin over to. (against your resistance)
  • Hypoglossal (XII)
  • Tongue ? fasciculations?
  • Stick out tongue (deviates to affected side)

25
Cranial Nerves Summary
  • Comment on pupils, eye position reactivity
  • Visual fields
  • Eye movements
  • Im going to leave acuity, fundoscopy to the
    end if thats ok
  • Comment on facial symmetry
  • raise eye brows
  • shut your eyes, dont let me open them
  • smile show me your teeth
  • Do you feel this? (cotton ball etc), ok, now
    close your eyes point with your hand to which
    side you feel this on
  • blow out your cheeks like this / bite down on
    this spatula
  • Im also going to come back to hearing
    assessment when Ive completed other cranial
    nerves
  • Comment on speech swallow / drooling etc.
  • open your mouth, say ahh comment on palate,
    uvula,
  • tongue rest . .stick out your tongue
  • Shrug up shoulders (against resistance) turn
    chin against resistance
  • Pupil reactivity, Fundoscopy - offer to do
    acuity hearing

26
2) Peripheral Nerve Examination
  • Tone
  • Power
  • Reflexes
  • Co-ordination
  • Sensation

27
Tone
  • Resistance to Passive Movement
  • Child should be relaxed (ie distract them with
    chat)
  • Note difference hypotonia vs. joint flexiblity
  • Clonus rhythmic series of involuntary muscle
    contraction evoked by stretching the muscle

28
? Tone
  • Spasticity
  • rapid build-up of
  • resistance during first
  • few degrees of passive
  • movement,
  • then resistance lessens
  • Much more common in paeds!
  • UMN eg. CP
  • Rigidity
  • sustained resistance
  • passive movement
  • Extrapyramidal / Basal ganglia

29
Power
  • Know grades
  • Compare side to side
  • Muscle groups

30
Power
  • 0 no contraction
  • 1 flicker of contraction
  • 2 active movement (gravity eliminated)
  • 3 anti-gravity movement
  • 4 movement against resistance (but weaker)
  • 5 Normal power

31
Reflexes
  • Know how to elicit reflexes!!!!!
  • Child must be still relaxed
  • Therefore use distraction (conversation)
  • Absent (?or not elicited)
  • Normal
  • Increased/Brisk

32
Tendon Reflexes
  • Triceps C7, 8
  • Biceps C5, 6
  • Supinator C5, 6
  • Knee L3, 4
  • Ankle S1, 2

33
please examine this childs upper limbs
34
Upper Limbs Inspect
  • Ideally undress child to waist
  • Stand with arms outstretched, fingers wide
  • Wasting
  • Fasciculations
  • Spontaneous purposeful movements
  • Involuntary movements
  • Asymmetry
  • ? handedness

35
Upper limbs Tone
  • is there any pain, is it ok if I move your arm
    well do it together, ok?
  • Wrist, elbow, /- shoulder passively move

36
Upper Limbs Power
  • Shoulders abduction C5 adduction C6,7
  • Elbows flexion C5,6 extension C7,8
  • Wrist Flexion/extension C6,7,8
  • Fingers abduction/adduction T1
  • Isolate muscle groups
  • Compare side to side

37
Upper Limb Reflexes
  • Distract child with conversation
  • Lie arm semi-flexed over body
  • Biceps C5,6
  • Triceps C7,8
  • Supinator C5,6

38
Finger jerk (C7,8, T1)
  • If ? Brisk reflexes
  • Childs hand relaxed, palm down
  • Place your fingers (facing up) under childs
    fingers
  • Tap (with hammer) your fingers
  • Childs fingers flex briskly!

39
Hoffmans sign
  • If ? Brisk reflexes
  • Stabilise childs middle phalanx (with your thumb
    index finger)
  • Flick DIP
  • Thumb flexes test (hyper-reflexia)

40
Upper Limbs Co-ordination
  • Composite function motor, sensory cerebellar
    systems
  • Ask handedness!
  • Finger-nose test
  • Dysdiadochokinesis
  • Writing
  • Drawing

41
Upper Limb Sensation
  • Light touch cotton wool
  • Superficial Pain pin prick
  • Deep Pain tendon reflexes
  • Temperature warm-cold
  • Proprioception joint position
  • Vibration tuning fork
  • 2 point discrimination (seldom done)

42
Dermatomes
43
dermatomes
44
please examine this childs lower limbs
45
Lower Limbs Inspection
  • Ideally undress child from waist down, but expose
    leg is accepted
  • Comment on
  • Wasting
  • Fasciculations
  • Spontaneous purposeful movements
  • Involuntary movements
  • Asymmetry

46
Lower Limbs Tone
  • is there any pain in your legs?
  • Distract child (conversation)
  • Lightly lift leg passive movement of hips,
    knees feet
  • /- flex knee abduct hip (with pelvis
    stabilised) ? ? tone (if ankle raises also)
  • Compare sides ? Asymmetry
  • Clonus on dorsiflexion of ankle
  • (gt3 sustained contractions)

47
Lower Limb Power
  • Infants movements? Against pressure?
  • Toddler pre-school Gait
  • School-going individual muscle groups
  • (next slide)

48
Lower Limbs Power
  • Hip flexion (L1,2) Extension (L5, S1)
  • abduction adduction
  • Knee extension (L3,4) Flexion (S1)
  • Plantar flexion (L4,5) Extension (S1,2)
  • Foot inversion (L4,5) Eversion (L5, S1)
  • Hallux flexion (L5)
  • Pelvic Gridle power
  • stand up from kneeling position with arms folded
  • stand up from lying position (? Gowers sign ?)

49
Lower Limb Reflexes
  • Head in central position
  • Distraction (Jendrassiks maneouvre)
  • Knee jerk (L3,4)
  • Dangle over bed or your arm
  • Ankle jerk (S1,2)
  • Flex ankle over opposite shin
  • Babinski stroke along lat aspect of sole
  • Withdrawal unequivocal
  • ie hallux dorsiflexion splaying of toes
    (UMN)
  • - (normal) ie down-going plantars

50
Lower Limb Co-ordination
  • Gait
  • /- stairs, running, hopping
  • Heel form opposite knee to ankle

51
Lower Limb Sensation
  • Modalities Dermatomes (as per upper limb
    assessment)

52
please examine this childs cerebellar function
/ gait / co-ordination
53
Cerebellar signs
  • S speech
  • P past-pointing
  • I intention tremor
  • N nystagmus
  • D dysdiadochokinesis
  • A ataxic gait
  • R Rombergs sign

54
Gait!
  • Observe walking firstly
  • Qs Walk on heels
  • Tip-toes
  • Run
  • Stand on one leg (x 5 secs) 3 yrs
  • Hop 4 yrs
  • Walk straight line x 20 steps 5 yrs
  • Tandem (heel-toe) walking 7 yrs
  • Crouch down (distal muscles)
  • stand up (proximal muscles)

55
Gait abnormalities
  • Broad-based
  • appropriate when learning to walk
  • Hypotonia of legs / pelvic girdle
  • Cerebellar dysfunction
  • Hip joint problems
  • Narrow gait (?scissoring)
  • Adductor spasm (mild diplegia)
  • Hemiplegic gait (wide swing)
  • Waddling gait
  • poximal muscle weakness
  • High-stepping gait
  • Sensory neuropathy
  • Distal weakness eg. foot-drop

56
Spinal Cord
  • Adult to L1 (lower border)
  • Infant to L3
  • Vertebral column growth gt spinal cord
  • Exaimine spine ? Spina bifida?
  • Bowel Bladder
  • Pelvic girlde / posture
  • Lower limbs (as before)

57
Upon completing your neuro examination, try to
elicit a pattern
  • Which cranial nerves (if any)?
  • Which peripheral modalities (tone/weakness/parasth
    esia etc)?
  • Unilateral (which side) vs. symmetrical?
  • Upper or lower limbs or all 4?
  • UMN vs LMN etc. etc.
  • Composite/integrated functioning
    co-ordination/gait etc.
  • Ultimately can you piece together your clinical
    findings
  • locate the lesion!
  • Make comment on any difficulties/obstacles to
    completeness of your examination
  • Any further testing you think appropriate
  • Eg. Formal visual or hearing assessment
  • Eg. Developmental / cognitive / psychiatric
    assessments

58
Neuro Tutorial
  • Ill ask you to assess
  • 1) Upper limb/Lower limb
  • Cranial Nerves
  • Cerebellar / Co-ordination
  • Neuro exam of neonate
  • Infant/toddler exam
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