Neurologic Examination in Pediatrics PDF

Pediatrics NEUROLOGIC EXAMINATION IN PEDIATRICS Dr. Joan Roque-Viado – January 29, 2024 SEM 2 PRELIMS – TRANS 5 OUTLINE Examination must be tailored to the age-specific...

Pediatrics NEUROLOGIC EXAMINATION IN PEDIATRICS Dr. Joan Roque-Viado – January 29, 2024 SEM 2 PRELIMS – TRANS 5 OUTLINE Examination must be tailored to the age-specific expectations of the developing nervous system. I. Pediatric Neurological Examination a. Main Points Many neurological deficits can be detected by watching the b. Elements of a Complete Neurological Assessment child walk, talk, and play. II. History a. Parts of the Pediatric History B. Elements of a Complete Neurological Assessment b. Is there a neurologic problem? c. Temporal profile and localization of important Focused clinical history pathologies affecting the brain Physical Examination Physical examination III. Physical Examination Compete neurological examination a. Skull Presumptive diagnosis/Differential diagnosis and plan for b. Mental Status laboratory evaluation c. Cranial Nerves In some cases developmental screening tests are also d. Motor Examination helpful e. Gait and meningeal Signs f. Sensory Examination II. History g. Cerebellar Examination IV. References Answers: a. Is there a neurologic problem? Legends For example, headache. Is the headache really a [In dark blue color] From the book; Batch Naregget Lecture neurologic problem or a systemic problem? Is it notes; board-sensitive notes; other references secondary to a tumor? Migraine? Or Dehydration l General info (from 2024 trans, Doc’s ppt) metabolic imbalance? b. Where is the lesion? I. Pediatric Neurologic Examination Does it belong in the CNS or PNS? Is it an upper The neurological examination provides essential data motor neuron problem or a lower motor neuron regarding anatomical localization. problem? (Dependent on PE) The absence of an abnormality is often equal in importance c. What is the lesion? to the presence of an abnormality. On the premise that is has something to do with the A complete neurological examination reassures the family age group of the patient and history and child that their concerns have been taken seriously. Documenting the examination over time is essential in Parts of Clarifying the History of the Current Illness is to evaluating neurological disorders that evolve over time Answer Four Basic Questions: “The neurological examination is the window through which 1. Is the process acute or insidious? the clinician views the nervous system. Acute process: Ex. Sudden severe of your life. This Must have good knowledge of embryology is more likely vascular, either ruptured AV Brain is the first and last organ to mature. malformation in pediatrics or a ruptured aneurysm in adults. “The examination must be adapted to the You will not have acute, sudden severe headache if child, his/her temperament, and you’re entertaining a brain tumor because a brain developmental level.” tumor presents with a chronic progressive headache The neurological examination provides essential data Severe headache during the first 24 hours is an o A detailed history is the cornerstone of neurologic acute process and is probably secondary to a assessment. vascular problem, either ruptured aneurysm in adult, o Lahat ng examination sa pediatrics are age-specific. or ruptured AV malformation in pediatric. Hindi pwedeng gagawin sa 6months old na conscious, So, you have to know the course of your differential coherent and oriented. diagnoses. o Have knowledge on normal growth and development 2. Is it focal or generalized? o Examination should be adapted from child’s Does it involve one side or all the sides? temperament and developmental level. o Kung 7 years old, buhat-buhat ng nanay or nasa 3. Is it progressive or static? stretcher at tulog, ibig sabihin may decreased Is there a progressive deterioration since the onset sensorium. of symptoms 2 months ago or is the symptoms the o So, 1 year old or 2 years old na happy nakatingin sayo same even from last year? baka walang neurologic problem yun Progressive lesions: Degenerative, demyelinating, brain tumor A. Main Points In neurodegenerative diseases, it’s usually chronic progressive. Example in adrenoleukodystrophy, it Pediatric neurological examination must be conducted and causes progressive weakness over time. interpreted in the context of expected neurodevelopmental milestones. Static lesions: Ex. Cerebral palsy 4. At what age did the problem begin? It will be different in infant, toddler, preschool children, but it will be the same in older children, teenager and adult. PEDIA – Neurologic Examination in Pediatrics | TG9 1  HPI should provide chronological outline of patient’s symptoms, with attention paid to location, quality, intensity, duration, associated features, and alleviating or exacerbating factors. Severity and extent of the problem. Then, determine the cause. Do lab exams. And of course, treatment and prognosis A. Parts of the Pediatric History a. General data b. Chief complaint c. History of present illness d. Past personal history/Birth and Maternal history e. Prenatal – gestational history f. Natal – birth history g. Neonatal history Figure 2. Parts of the brain. From doc’s ppt. h. Past medical history Temporal profile of neurological disease i. Feeding history/nutritional history j. Developmental history Acute: seconds, minutes, hours k. Immunization history Subacute: hours, days l. Family history Chronic: days, months m. Social and economic history/socio-economic history Paroxysmal: episodes of illness with returns to baseline n. Environmental history C. Temporal profile and localization of important o. Review of systems (ROS) pathologies affecting the brain B. Is there neurologic problem? Acute Vascular/infarct – focal Hypoxic – diffuse Trauma - focal or diffuse Acute: seconds, minutes, hours The most common cause of sudden severe headache. Acute onset, a few hours or an hour prior to consult is more of a ruptured vascular problem. It can be vascular aneurysm or in pediatrics the most common is AV malformations. Nowadays, there is an increasing episode of children or adolescents having stroke secondary to infarct. Figure 1. Outline of the human motor system. From doc’s ppt. Figure 3. Onset of acute neurological disorders within the first Signs and Symptoms of the CNS day of illness. From doc’s ppt. History of Present Illness Subacute o Duration of symptoms: Inflammatory/infectious – focal or diffuse § Constant/episodic Immune – focal or multifocal § Static, progressive, or resolving Toxic/metabolic – diffuse o The history may suggest localization to a specific anatomical region: central or peripheral Headache Changes in sensorium Weakness Changes in vision? Hearing? Response? PEDIA – Neurologic Examination in Pediatrics | TG9 2  Figure 7. Pattern of metabolic conditions presenting chronically. Figure 4. Subacute onset of neurological impairment. From From doc’s ppt. doc’s ppt. Paroxysmal Seizure – focal or diffuse Vascular/syncope – diffuse Pain/headache – focal or diffuse Typical prototype of this type of history are patients with epilepsy or patients with vascular syncope, fainting spells and some patients with history of migraine headaches. Attacks are acute recurrence usually a history of more than 3 months C. Where is the lesion? The neurological examination is the window through which Figure 5. Toxic condition. From doc’s ppt. the clinician views the nervous system. Chronic General Tips Days, months, more than 2 weeks Use items such as tennis ball, small toys (including a toy Congenital – focal or diffuse car), bell, and an object that will attract the child’s attention. o Insult occurs intrautero postpone uncomfortable tasks until the end, such as head o Focal – there can be a bleed because patient is circumference, fundoscopy, corneal and gag reflexes, and premature in the germinal matrix and can present sensory testing with focal weakness or hemi/paraparesis make the most of every opportunity to examine the child. o Diffuse – can present with chronic history of See how he or she plays, it there a preferential movement, spasticity and movement problems like cerebral is the patient using left and right at the same time, moving palsy taking into account handedness and motor deficits. Degenerative – diffuse or system-related Examine the younger child in the patient’s lap Neoplastic – focal Give the child a toy to establish rapport o Ex. Brain tumor – progressive headache more than Doing the neurologic examination starts as the patient enters weeks presenting with sudden onset of focal the clinic. For example, a five-year old walking and out and about, you can check if the child has gait problems (gait seizure/weakness in 1 extremity imbalance, problem in walking) o Ex. Three months prior to consult, patient presents of headache, relieved by paracetamol then 2 Assessing the child with the neurologic illness we test for: months ago there is increase severity of headache General physical examination and a week prior to consult the patient is being Mental status awakened by the headache. Cranial nerves Motor skills Sensory Balance and coordination Reflexes Figure 6. Metabolic conditions. From doc’s ppt. Figure 8. Tools used during examination. From doc’s ppt. PEDIA – Neurologic Examination in Pediatrics | TG9 3  A. Skull Microcephaly, macrocephaly, craniosynostosis (or premature closure of the cranial sutures) Prominence of the scalp veins – increased ICP Flattening of the occiput – hypotonia Prominence of the occiput – Dandy-Walker syndrome Ridging of the cranial sutures – craniosynostosis Macewen (cracked pot) sign – sutures are separated, may indicate increased ICP B. Mental Status Or state, general behavior and appearance, the child’s level of awareness and interaction with the environment, speech, mood and affective response, content of thought, intellectual capacity and sensorium Sensorium: o Consciousness o Attention span o Orientation to time, place, person o Recent and remote memory o Fund of information Figure 14. UMN versus LMN (Doc Viado’s ppt) o Insight o Judgment Upper motor neuron signs o Planning o Weakness o Calculation o Increased tone (spasticity) Observe: o Hyperreflexia o Behavior o Very little atrophy (atrophy of disuse) o Degree of awareness and alertness o Primitive reflexes (Babinski reflex) o Eye contact o Ability to maintain attention/concentration Lower motor neuron signs o Ability to recall immediate, recent, and remote events o Weakness o Abstract reasoning o Atrophy muscle wasting Assess: o Reduced or normal tone (flaccidity) o Knowledge of general information o Hyporeflexia o Reading o Fasciculations o Spelling and math o Personality Table 1. UMN AND LMN Lesion o Other emotional factors Sign UMN Lesion LMN Lesion Assess by watching the infant interact with the parent, or by asking the older child to follow directions pr answer weakness present present questions appropriately Older child Atrophy absent present o observed for clear speech and making sense while reflexes increased decreased talking tone increased decreased This is done by observing the child during normal fasciculations absent present interactions and you report it by describing them. Babinski reflex present absent Table 1. States of Decreased Consciousness III. Physical Examination Lethargy Difficulty to maintain aroused state Facial dysmorphism Obtundation Responsive to stimulation other than pain Head shape Abnormalities of skin pigmentation Stupor Responsive to pain Color and texture of hair Coma Unresponsive to pain Concomitant diseases Height, weight, blood pressure, and head circumference (normal for age) Age aside, the neurologic examination should include an Hair: whorl, eyebrows, nails assessment of the patient’s mental status in term of both level Dimpling/tuft of hair: sacral (spinal dysraphism) of arousal and interaction with the environment Unusual odors: urine (MSUD) inborn error of metabolism Premature infants born at