Neurology

I. Neurologic Examination

A. Mental Status: Alertness, Orientation (Person, Place, Time, Situation), Language, Cognition

  1. 1. Infants: Observe “cuteness” and ability to dynamically engage caretakers.
  2. 2. Toddlers: Bring toys. Observe and engage in play.
  3. 3. School age: Ask children to draw or describe school or friends.

B. Cranial Nerves (eTable 20.1)

  1. 1. For a quick assessment of cranial nerves for all patients, observe:
    1. a. (II) Visual response to objects in each visual quadrant
    2. b. (III, IV, VI) Conjugate gaze at full lateral and vertical positions, nystagmus, ptosis
    3. c. (VII) Symmetry and expressiveness of face at rest and with emotive activation
    4. d. (VIII) Finger rub, or response to and localization of sound for infants
    5. e. (IX, X, XII) Quality of phonation and articulation; ask about feeding, chewing, swallowing


C. Motor

  1. 1. Muscle bulk: Atrophy or pseudohypertrophy is a red flag.
  2. 2. Tone: Spasticity, rigidity, hypotonia
    1. a. Infants: Observe infant undressed to assess resting posture (varies with age). Active tone: Traction response, axillary stability (slip-through), posture in horizontal suspension. Passive tone (resistance of movements of the joints): Flap hands/feet, scarf sign
    2. b. Red flags: Scissoring, toe-walking, inability to supinate hand, clasped thumb or grasp
  3. 3. Strength:
    1. a. Younger children: Observe ease of normal functions: rising from floor, standing broad jump, running, climbing onto chair or exam table. Note presence of accommodations child is making to execute movements (e.g., shoulder shrug or trunk tilt to raise arm).
    2. b. Older children: Confrontation testing, pronator drift
    3. c. For conventional rating scale, see Box 20.1.
  4. 4. Involuntary movements: Fasciculations, tics, dystonia, chorea, athetosis, myoclonus, tremor

D. Sensory

  1. 1. Primarily important if any concern for spinal cord defect or peripheral nerve injury
  2. 2. Focus initial investigation along three axes for meaningful lesion localization:
    1. a. Distal deficit with preserved (or less impaired) proximal sensation suggests polyneuropathy.
      1. (1) Pain/temperature deficit: Small fiber polyneuropathy/anterior spinal cord
      2. (2) Position/vibration deficit: Large fiber polyneuropathy/posterior spinal cord
    2. b. Lower body more affected than upper body suggests spinal cord injuries.
      1. (1) See Fig. 20.1 for dermatomes.
      2. (2) Ask about continence, assess rectal tone.
    3. c. If difference between left and right, concern for unilateral brain or spinal cord lesion

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FIGURE 20.1
Dermatomes.

From Athreya BH, Silverman BK. Pediatric Physical Diagnosis. Appleton-Century-Crofts; 1985:238–239.

E. Reflexes

  1. 1. Tendon reflexes: Gradation (Box 20.2) and localization (eTable 20.2). Helpful in localizing abnormalities including upper versus lower motor neuron pathology, especially in presence of weakness or asymmetry (eTable 20.3). Compare right to left, upper to lower extremities, and distal to proximal reflexes. Generalized high or low reflexes are of little significance in the setting of normal strength and coordination.
  2. 2. Primitive reflexes: Expected during specific time windows (Table 20.1)



F. Coordination and Gait

  1. 1. Evaluate coordination while watching age-appropriate activities.
  2. 2. Tests for cerebellar function: Rapid alternating movements, finger-to-nose, heel-to-shin, walking, running

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