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) Hypoglossal nerve (XII) • sternocleidomastoid • tongue movement • trapezius • 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!)