1. Applied Pediatrics Jose A. Robles, MD Pediatric Neurology

2. HISTORY Chief complaint – actual or approximate time of onset – central problem – foundation upon which differential diagnosis must be constructed – patient own words

3. HISTORY History of Present Illness – should fully describe the chief complaint – Answers 3 important questions : 1.Is the process focal or diffuse ? 2.Is the process acute or insidious ? 3.Is the process static or progressive ?

4. Onset and Course of Neurologic Disease

6. History Prenatal history – Illness of mother – Exposure to radiation / toxic substance Birth History – Apgar score, hospital stay, term ?, preterm? Neonatal History –Illness (jaundice, infection, etc)

7. History Developmental and Past Medical History – time of acquisition or loss of developmental landmarks Family History – Family tree include dead, alive and abortus – delineate genetically determined illness (Autosomal dominant, autosomal recessive, X – linked)

8. Physical Examination Observe Undress Anthropometric measurement Birth: Normal head circumference: 33 –35cms Anterior fontanelle closes : 7 – 20 months Posterior fontanelle closes: 3 months Definition: microcephaly 2 SD below the norm for age, sex, race macrocephaly 2 SD above the norm for age, sex, race

11. Physical Examination Skin lesion Neurofibromatosis Café au lait spots Cutaneous fibromas Autosomal dominant Tuberous sclerosis adenoma sebaceum Depigmented lesions (vitiligo – like lesions) Autosomal dominant Sturge Weber syndrome port wine stain Autosomal dominant

13. Neurologic Examination in Pediatrics

14. NEUROLOGIC MATURATION

15. The dominant posture is one of flexion…

16. Eye opening… is improved reflexly by bringing in the baby from supine to upright (doll’s eye reflex, upright)

17. DEVELOPMENTAL REFLEXES

18. before one can begin to look for the signs of neurological dysfunction Brachial palsy; this is more serious than Erb’s palsy…

19. Weak sucking is strengthened by using automatic palmar grasp to evoke the Babkin Palmomental response Hyperactive neurological dysfunction; the palmar grasp is so strong that the baby lifts free for a longer time; note the backward thrust of the upper limbs simultaneously

20. First one side comes up… then the other (same baby)

21. the pad of the index finger lightly touches the crown of the cheek the baby turns due to the rooting reflex & then the index finger is slipped into the mouth to elicit sucking

22. transient ATNR is physiologicalThe reversed ATNR is physiological

23. starting position for plantar grasp; baby’s toes flexed… the thumbs are deftly applied to the metatarsal heads, symmetrical flexion

24. Neurologic Examination Higher cortical function Test : –AGNOSIA – APRAXIA –APHASIA

25. Neurologic Examination AGNOSIA – inability to understand the significance of sensory stimuli even though the sensory pathways and sensorium are relatively intact 4 necessary conditions – previous skills sufficient – sensorium intact – sensory pathways intact – organic cerebral lesion present EX: finger agnosia, astereognosia, agraphognosia

26. Neurologic Examination APRAXIA – inability of a patient to perform a volitional act even though the motor system and sensorium are relatively intact –4 necessary conditions – previous skills adequate – sensorium intact – motor pathways intact – organic cerebral lesion present EX: constructional apraxia, dressing apraxia, gait apraxia, tongue apraxia

27. Neurologic Examination APHASIA – Expressive – non fluent – Receptive – fluent

29. Neurological Examination Mental status – Consciousness lethargy, delirium, obtundation, stupor, coma – Orientation – Memory immediate recall, recent, remote

30. Neurological Examination Mental status Definition of Terms: – Lethargy : state of minimally reduced wakefulness in which the primary defect is one of attention – Delirium : characterized by disorientation, irritability, delusions or visual hallucinations

31. Neurological Examination Definition of Terms: – Obtundation : mild to moderate blunting of alertness, accompanied by a lessened interest in or response to the environment. Patient have an increase in the number of hours of sleep, often with drowsiness in Delirium : characterized by disorientation, irritability, delusions or visual hallucinations – Stupor : patient can be aroused temporarily only by vigorous and repeated stimulation. Communication is minimal or non - existent

32. Neurological Examination Definition of Terms: – Coma : state of unarousable unresponsiveness; without spontaneous movement and with eyes closed. May respond to noxious stimuli but cannot localize pain

35. CRANIAL NERVE EXAMINATION IN INFANCY

39. Neurological Examination Motor –Strength 0 - No muscle contraction 1 - Flicker or trace of contraction 2 – Active movement with gravity eliminated 3 - Active movement against gravity 4 – Active movement against gravity but not against resistance 5 – Active movement against gravity and resistance – Bulk Normal. Atrophy, hypertrophy – Tone Normal, spastic, hypotonia, flaccid

42. Neurological Examination Sensory – Spinothalamic – pain – Posterior column – vibration, position

43. Neurologic Examination Reflexes – Deep Tendon Reflexes 0 : Areflexia 1-2 : Average 3+ to 4+ : Hyperrefexia – Superficial Reflexes – Pathologic Reflexes Babinski Modified Babinski – Oppenheim – Chaddock – Gordon

44. Segmental Levels of Major Deep Tendon Reflexes

45. Neurologic Examination Cerebellar –Vermis : truncal ataxia – Hemisphere : Limb ataxia Finger to nose Tandem walk Dysdiadocokinesia Head tilt – Nystagmus Meningeal – Kernigs – Brudzinski

48. DIFFERENCES BETWEEN UMN AND LMN LESIONS UMNLMN Strength Bulk Tone DTR, 0 Pathologic reflex + -