The Neurologic Exam: Skills for the Pediatric Hospitalist Kendall - - PowerPoint PPT Presentation

The Neurologic Exam: Skills for the Pediatric Hospitalist

Kendall Nash, MD

Assistant Professor, Neurology & Pediatrics UCSF Benioff Children’s Hospital

Objectives

• Learn elements of screening neuro exam
• Practice the screening neuro exam
• Discuss clinical cases

– Exam findings – Localization

Screening pediatric neuro exam

• Mental Status: LOC, attention, language (fluency, following

commands, repetition, naming)

• CNs: pupillary response to light, visual fields, extraocular

movements, facial sensation (light touch), facial expression, palate elevation, shoulder shrug, tongue protrusion

• Motor: appendicular tone, pronator drift, finger/foot taps,

stand from sitting or squatting position, confrontational testing if able

• Sensation – light touch in all extremities
• Coordination – finger-to-nose
• Gait – normal, tandem
• Reflexes – biceps, triceps, patellar, achilles (and check for

ankle clonus)

Goals of the Neuro Exam

• 1. To support the history and help determine if

the patient has a neurologic condition

• 2. To localize the “lesion”

– CNS versus PNS

Human Nervous System

Note: PNS also includes autonomic nerves

Cerebral cortex

Primary Cortical Regions

Brainstem and Cranial Nerves

Corticospinal tract

Spinal Cord and Spinal Nerves

General exam features with special neurologic significance

• Vital signs
• Head size
• Dysmorphic features
• Ophthalmoscopic exam
• Signs of trauma
• Bruits
• Meningismus
• Neurocutaneous stigmata
• Organomegaly
• And don’t forget…age!

Mental Status

Level of consciousness/alertness

• Describe patient’s response to what type of stimulation

– Awake, opened eyes to soft voice, no eye opening or voluntary movements to sternal rub (“coma”)

• Avoid confusing terms (e.g. lethargic, obtunded)

Attention

• Ability to focus on task

– e.g. spelling a word forwards/backgrounds, playing a game, tracking in young child (attending to visual stimulation)

Orientation

• Person, place and time (“oriented x 3”)

Mental Status

Language (basic parts)

• Fluency
• Comprehension

– Tests Wernicke’s area

• Repetition

– Tests Broca’s area

• Naming

Cranial Nerves (functions routinely tested on exam)

• CN II – vision, pupillary response to light
• CN III, IV, VI – extraocular movements
• CN V - facial sensation, mastication
• CN VII - facial expression
• CN VIII – hearing
• CN IX and X – palate elevation, gag, voice production
• CN XI - trapezius, sternocleidomastoid movement
• CN XII - tongue movement

Vision: CN II

Visual acuity

• Each eye using eye chart
• Pre-chiasmal function

Visual fields

• Test each quadrant

– Using object in younger pt – Altered patient: blink to threat

• Post-chiasmal function

Pupil exam

Note pupil size in normal light (check for anisocoria) Direct light response

• Pupil constricts to light

Swinging flashlight test

• Checks for afferent

pupillary defect

– When swinging back to affected eye, pupil dilates (CN II pathology)

17 year-old with subacute onset unilateral decreased visual acuity

Extraocular movements: CN III, IV and VI

CN III supplies all eye muscles except lateral rectus (VI) and superior oblique (IV) Smooth pursuit

• With head motionless, patient follows object in all

directions of gaze

• When gaze is dysconjugate: test each eye separately

Oculocephalic reflex

• Coma exam
• Does not require visual input

15 year-old with headache and diplopia

1 month history of headaches and worsening double vision in obese female teenager Exam: normal mental status, bilateral papilledema, visual acuity 20/20 OU and full visual fields, restricted eye abduction bilaterally

Papilledema (and loss of vessels as they leave disc)

Impaired eye abduction (CN VI)

Facial sensation (CN V)

3 distributions

• Test each side

separately

• Fine touch, pain, temp

Corneal reflex

• Coma exam
• Tests CN V (sensory)

and VII (motor)

Facial movements (CN VII)

Test lower and upper face

• Smile, “show me your

teeth”

• Puff out cheeks
• Close eyes tightly
• Raise eyebrows

*UMN facial weakness spares upper face (forehead, eye closure)

unilateral facial weakness

CN IX and X

Palate elevation

• Check for symmetry
• Uvula turns away from side of the lesion

Gag

• Only tested in altered patients or those with

difficulty swallowing

CN XI and XII

Spinal accessory (XI)

• sternocleidomastoid
• trapezius

Hypoglossal nerve (XII)

• tongue movement
• tongue deviates toward

lesion

CN Exam in Infant

Motor Exam

Observation

• Involuntary movements; often involved in

lesions of basal ganglia or cerebellum Inspection

• Muscle wasting, fasciculations

Palpation

• Muscle wasting

Motor Exam

Tone testing

• Tested during relaxed wakefulness
• Position is important; head midline
• Increased tone signs: spasticity, rigidity
• Decreased axial tone signs (in younger

children): head lag, decreased resistance on vertical/horizontal suspension

Motor Exam

Functional strength testing

• Often best or only way to assess strength in

children (versus confrontational testing)

• Age-dependent

– Newborns: vigor of movements, palmar grasps, moro, suck, cry – Infants: grabbing objects with both hands, getting up to seated position, pulling up to stand (check for Gower’s) – Child/adult: pronator drift, fast finger/foot taps, squats with arms extended outward

Motor Exam

Confrontational strength testing Upper extremity

• Arm abduction, elbow extension/flexion, wrist

extension/flexion, finger extension/flexion, finger spread Lower extremity

• Hip extension/flexion, knee extension/flexion,

dorsiflexion, plantarflexion, EHL extension/flexion

Localization Tips

Sensory Exam

Fine touch

• Finger or cotton wisp

Pain/temperature (spinothalamic)

• Pin prick, cold alcohol swab

Vibration/joint position sense (dorsal column)

• Tuning fork

Fine touch is adequate for screening exam if no sensory symptoms

Dermatomes

Coordination

Appendicular coordination

• Finger-to-nose: evaluate for dysmetria

(inability to judge distance) Truncal coordination

• Ability to sit up/stand: watch for titubation

Evaluate gait…

Gait

Components:

• Base
• Stride (stance, swing)
• Tandem (more sensitive test for ataxia)

Types of abnormal gait:

• Ataxic – cerebellar or sensory (proprioception)
• Hemiparetic/circumduction – CNS

8 year-old with hemiparetic gait with circumduction

Screening pediatric neuro exam

• Mental Status: LOC, attention, language (following

commands, spontaneous speech, repetition, naming)

• CNs: pupillary response to light, visual fields, extraocular

movements, facial sensation (light touch), facial expression, palate elevation, shoulder shrug, tongue protrusion

• Motor: appendicular tone, pronator drift, finger/foot taps,

stand from sitting or squatting position, confrontational testing if able

• Sensation – light touch in all extremities
• Coordination – finger-to-nose
• Gait – normal, tandem
• Reflexes – biceps, triceps, patellar, achilles (and check for

ankle clonus)

8 year-old boy with subacute-onset left hemiparesis

1 week history of worsening left hemiparesis involving face, arm and leg Exam: UMN pattern of unilateral weakness (extensors > flexors) with increased reflexes, normal sensation Localization?

• CNS; not spinal cord (face involved), unlikely

cortical (sensory spared)

– Corticospinal tract below cortex and above spinal cord  left pontine demyelinating lesion

6 year-old girl with sudden-onset right hemiparesis

Sudden onset right hemiparesis involving face and arm Exam: awake, non-fluent speech, follows simple commands, UMN right facial weakness, distal > proximal/extensor > flexor RUE weakness Localization?

• CNS (expressive aphasia, UMN facial weakness,

extensor > flexor “pyramidal” weakness)

– left motor cortex (language involvement, right-sided weakness) – left MCA stroke

4 year-old with diffuse weakness following viral illness

1 week history of progressive weakness involving arms and legs, dysarthria, and difficulty swallowing Exam: normal vital signs, normal mental status, LMN bifacial weakness, dysarthria, symmetric distal > proximal weakness, decreased sensation to light touch in hands and feet, areflexia Localization?

• PNS (subacute-onset diffuse weakness with

areflexia, LMN facial weakness)

– nerve given motor/sensory involvement; Guillain- Barre syndrome

3 month-old with poor feeding, constipation and weakness

1 week h/o poor feeding, constipation 2 day h/o paucity of extremity movements Exam: normal mental status, sluggish pupillary response, bifacial diplegia, weak suck, diffuse hypotonia, paucity of spontaneous extremity movements – briefly anti-gravity with stimulation, areflexia Localization?

• PNS (subacute onset bulbar and extremity weakness

with areflexia) – Infant botulism (sluggish pupils!)

2 year-old with status epilepticus

Arrived to ED in status epilepticus, received sedating medication to abort the clinical seizure, now lying on gurney with eyes closed Questions: What is his neurologic status? Is he still seizing

• r post-ictal? Are there localizing signs?

Key Points for Exam:

• Describe LOC
• CN exam – pupils, coma maneuvers
• Motor – response to stimulation, check for asymmetry
• Reflexes – check for asymmetry

Appendix

Cranial Nerves