Neurological Examination Israel Matoth

Neurological Examination Objective: Determine the functional integrity of central nervous system (CNS) peripheral nervous system (PNS) Detecting and localizing sites of dysfunction

Anamnesis Presenting problem • timing and mode of onset • course Past medical history I. • antenatal • perinatal • neonatal Possible insult:  bleeding,  infection,  hypoxia,  drugs,  trauma - Warning signs:  weight problems  hypoglycemia,  hypocalcaemia,  severe jaundice,  feeding difficulties,  abnormal activity,

Anamnesis II. •Development • Growth • Behavior  Milestones:  delay,  slowing,  cessation,  regression relation to prior illness? Trauma? III. • Family history neuromuscular developmental

Neurological Examination (older children & adolescents) Mental status & language function Cranial nerves Gross motor function Muscle strength Gait and station Balance and coordination Sensory system Deep tendon reflexes

Neurological Examination (the younger child) I. Observation: Level of alertness Interest in people & environment Facies, head shape, body habitués ( dismorphic Features) ברוב הילדים המפותחים תקין בגיל ביה'ס הבדיקה אינה שונה מהמבוגר.* בילדים קטנים יותר חלק גדול מההסתכלות יכול להתבצע בזמן לקיחת האנמנזה כאשר הילד על ההורה או משחק בחפצים * צורת הראש- ‘macrocephaly, microcephaly, crniosynostosisהשטחת הocciput- בילדים עם אחור התפתחותי, כלי דם בולטים ביל"ג התבלטות האוקסיפוט תנוחה – המיפרטית, דיסטונית

Hpertelorism Low-set ears Crniosynostosis Macroglossia Remind Low set Vs. Posterior rotation* Hypertelorism Vs. epicantal folds *Frontal bossing Macroglossia Cleft lip + palate Micrognatia

Neurological Examination (the younger child) Spontaneous movements, position, posture Frog - position Rt. hemiparesis Dystonia

Neurological Examination (the younger child) Spontaneous vocalization, quality & pitch Walk, run, stoop, rise from floor Gower’s Sign

Detailed assessment (playing & drawing): Handedness Mental status + language + fine and gross motor skills Denver Developmental Screening Test - engaging the child in play: keys, toys, dolls…. העדפת צד לפני גיל שנתיים חשודה * 7 mo 11 mo 4 mo.

הליכה TANDEMאחרי גיל 4 שנים

Cranial Nerves III, IV, VI, Catch the otoscope light, follow light, face, toy. Bilateral 3rd nerve palsy 6th nerve palsy יש לציין ניסטגמוס* יש לציין אפסוקלונוס* Extra-ocular movement exam

Cranial Nerves VIII Looking ar direction of sound – 3m

Cranial Nerves VII, IX , X, XII Make face, stick out tongue, blow balloon, say aahh… Peripheral VII n palsy Central VII n palsy Tongue fasiculations

Cerebellar function Pat-a cake games : rapid alternate movement Reach for a toy :  dysmetria

Muscle tone Resistance to passive motion Active motion + motion against resistance ( preschool and older: push- pull games )

Neonates and young infants Shoulder girdle Traction Ventral suspension Heel to ear Scarf-sign

Deep tendon reflexes (shoes off) brisk (+3) up to 6 months, then (+2).  tap on finger: Achilles, patellar  foot ball + ext. : Achilles Openheim (tibia)

Primitive reflexes Moro 0-4m Rooting 0-3m Cross adductor 0-7m Hand grasp 0-3m Toe grasp 0-3m ATNR 2w-6m

Protective Equilibrium Responses Propping 4-6m  persist voluntarily Parachute 8-9m persist voluntarily

(Undress by Parent) Fontanel's and sutures Head circumference (infant +toddler) Growth rate: 2,2,1,1,1,0.5,0.5,0.5,……1y Microcephaly: 2SD below mean Primary (<7m) Secondary

Macrocephaly: >2SD above mean - meglencephly - hdrocephly: •communicating • noncommunicating

Dismorphic features Clinodactily Wasting of hand muscles Short V finger Simian line

neck and back midline Occult Spinal dysraphism

Skin Neurofibromatosis 1 fibromas Café-au-let-spots Axillary freckles hyper pigmentation

Tuberous sclerosis Adenoma sebaceous Café-au-let-spots Shagreen patch Ash-leaf-spot Sub-ependymal-lesions

Sturge Weber Cutaneous hemangioma

Cranial Nerves II ( at the end of exam) Reaction to light, follow objects Cataract Papilledema Optic atrophy