Download Brainstem auditory evoked response

NEUROLOGIC
EXAMINATION
• 1)OBSERVATİON
• 2)SCREENING GROSS MOTOR
FUNCTION
• 3)DEEP TENDON REFLEXES (MUSCLE
STRECH REFLEXES) AND OTHER REF.
• 4)CEREBELLAR FUNCTION
• 5)CRANIAL NERVE EXAMINATION
• 6)SENSORY SYSTEM
• 7)SCELETAL MUSCLES
1-OBSERVATION
• Intellectual skills with understanding and
controbition child’s language skills
• Dysarthria, nasal speech, dysphonia, articulation
problems.
• Facial movements:head nodding, lip tremors, eye
blinking,
• Movement disorders:chorea or tic, neck, limp and
trunk movement
• Child’s behaviour
• Parent-child interaction
2-SCREENING GROSS
MOTOR FUNCTION
•
•
•
•
•
To hop in place on each foot
Toe walk
Heel walk
Rise from a squatting position
To stand with the feet close together, eyes
closed
• Finger to nose movements with the eyes
closed
3-DEEP TENDON REFLEXES
• With a reflex hammer while the child is sitting
quickly
• Biceps
C5-6
• Brachiaradialis C5-6
• Triceps
C6-8
• Patellar
L2-4
• Achilles
S1-2
mediated at spesific spinal
segment on levels
3-DEEP TENDON REFLEXES
2
• Hyperactive reflexes} result for corticospi• Clonic response
} nal dysfunction
• Hyporeflexia ; associated with lower motor
unit involvement, anterior horn cell
disease, Peripheral neuropathy (+ sensory
involvment) Myopathy ; may be normal in
the early course of disease
• May be occasionaly be found with central
depression= CENTRAL HYPOTONIA
3-DEEP TENDON REFLEXES
3
• Cerebellar disease generaly decreased muscle
tone and may decreased reflex
• OTHER REFLEXES: -planter toe sign is normal
in children
- Impairment of corticospinal function leads to
extansor responses. Babinsky Reflex: Firm,
steady, slow stroking from posterior to anterior of
the lateral margin of the sole with an object such
as a key or smooth broken tongue blade =
SHOULD NOT BE PAINFUL
3-DEEP TENDON REFLEXES
4
• Hoffmann reflex:Flicking the patient’s nail
(second or third) dawnward with the
examiner’s nail results in flexion of the
distal phalanx of the thumb
• No response or muted response may occur
normal children
• A brisk or a symmetric response occurs in
the presence of corticospinal tractus
involvement
• ABDOMINAL REFLEXES:Stroking the
abdomen from lateral to medial strokes
beginning just above the umblicus.
• Unilateral absence of acquaired corticospinal
dysfunction
• CREMASTERIC REFLEX: Stroking the inner
aspects of the thigh in a caudo-proximal
direction and observing the contraction of the
scrotum= NORMAL
• Absence or asymmetry also indicates
corticospinal involvement
4-CEREBELLAR FUNCTION
• Head tilt: may be associated with tumors of the
cerebellum, herniation of cerebellar tonsils
through the foramen magnum seconder to
increased intracranial pressure
• Tremor: occurs with action
• Handpatting: alternating pronation and
supination of the hand assesing
dysdiadochonesis
• Repetetive finger tapping= thumb to finger
• Fast tapping
• Finger to nose
• Finger to finger (examiner’s) to nose
5-CRANIIAL NERVE
EXAMINATION
CN I (OLFACTORY)
• Rarely imparied in childhood.Evaluated by
having the child pleasant aromas through
each individual nostrila (chocolate,vanilla
etc...)
• Anosmia= URI, head trauma (often
occipitale), neoplasm in the inferior frontal
lobe
• Unilateral is more worrisome
Olfactor nerve
CN II (OPTIC)
• Gross vision= E test, sizes, shapes,
• Visual field= object moved from temporal
to nasal
• Examination of optic disc= papilledema,
hemorragiae
• Pupils= diameter, regulary of contour,
responsivity of the pupilla to light,
opticofacial reflex, opticokinetic reflex
CN III,IV,VI
extraocular muscle paralysis
• Paretic muscle
CN nerve Eye deviation
•
•
•
•
III
III
VI
IV
Inf oblique
Inf rectus
Lat rectus
Sup oblique
outward
• Sup rectus
III
down and out
up and in
medial
upward and
down and in
CN III,IV,VI 2
• Extraocular muscle dysfunction is
associated with many conditions that affect
• Brainstem
• Nerves
• Neuromuscular junction
• Muscles
CN V (TRIGEMINAL)
• Has both motor and sensory functions.
• Motor division innervated: masatter, pterygoid
and temporal muscles.
• Temporal muscle atrophy manifests as scalping
of the temporal fossa.
• The masatter muscle bulk may be palpated while
the patient firmly closes the jaw.
• Pterigoid muscle strenght is evaluated by having
the patient open the mouth and slide the jaw from
side to other side while examiner results
movement
CN V –2
• Trigeminal nerve is also responsible for
sensations of the face and the anterior half
of the scalp
• Corneal reflex= diminished or absent
following:
• Trauma
• Cerebellopontin angle Tm
• Brainstem Tm
CN VII (FACIAL )
• Taste sensation over the anterior 2/3 of the
tongue
• Secretory fibers innervate the lacrimal and
salivary gland
• Innervate of all facial muscles
• Complete motor dysfunction on one side of the
face ensues when the cranial nerve VII pathway
is disrupted in the nucleus, pons or peripheral
nerve.
CN VII – 2
• The patient is unable to move the forehead
upward, close the eye forcefully or elevate the
corner of the mouth on side of the affected nerve.
• Central (supranuclear) facial nerve impairment
produces only paresis of the muscles involving
the lower face, with resultant drooping of the
angle of the mouth, disapperance of diminution
of the nasal labial fold.
• Taste sensation = place salty, sweet, acid, sour
and bitter material
CN VIII (AUDITORY)
• VESTIBULER COMPONENT:Caloric
testing (nausea, ataxia, vertigo,
unexplained vomiting, ice water)
• AUDITORY COMPONENT: whispered
language, party noisemaker, ticking of
watch, tuning pork
• Brainstem auditory evoked potentials
provide the necessary information.
Brainstem auditory evoked response
CN IX,X
(GLOSSOPHARYNGEAL AND
VAGUS)
• Examination of the larynx, pharynx and
palate
• Unilateral paresis of the soft palate
• Bilateral paresis – voice becomes nasal
- regurgitation of fluids during drinking
CN XI (SPINAL ACCESSORY)
• Innervation for trapezius and SCM muscles
• Trapezius: shrug the sholders against
resistance placed by the examiner
• SCM: Examining the resistance against the
child head while, attempts rotation to one
side
CN XII (HYPOGLOSSAL)
• The tongue muscle is primary responsibly
of cranial nerve XII
• Atrophy and fasculation of tongue occur
when ipsilateral hypoglossal nucleus or
hypoglossal nerve involved.
• The protruted tongue deviates toward the
involved side. Speech may be muffled or
dysarthric.
Hypoglossal,facial nerve
paralisis
6 - SENSORY SYSTEM
• Vibration sense
• Joint and position sense
• The ability to localize the area of contact of
a tactile stimulus (TOPAGONOSIS) is
monitored by touching the patient whose
eyes are closed on the face, arm, hand, leg
or foot. The child is asked to point to or
verbally identify the area= The loss of
ability to localize the stimulus is associated
with cortical, parietal lobe dysfunction
6 - SENSORY SYSTEM-2
• DISTINCTION : The patient is touched on two
parts of the body simultaneosly= Failure of the
child to perceive both stimuli
• TOUCH
• PAIN
• STEREOGNOSIS=Recognition of familiar
object by touch, ASTERIOGNOSIS: Lesion of
parietal lobe
• GRAPHESTESIA=Ability to recognize numbers,
letters traced on the skin.
7-SKELETAL MUSCLES
• Tone, bulk and strenght of skeletal muscle
• STRENGHT=Testing the child’s ability to
counteract resistance imposed by the
examiner on proximal and distal muscle
groups or individual muscle.
• BULK=Gentle palpation and observation
• Atrophy, fassiculation=ant horn cell dis.
• Hypertrophy= Duchenne/Becker musculer
dystrophy...
7-SKELETAL MUSCLES-2
• TONE= Resistance to passive movement,
cerebellar dis. Ant. horn cell dis.
• 0 No muscle contraction
• 1 Trace of muscle contraction
• 2 Active movement at joint ( not gravity)
• 3 Active movement at joint (against grav.)
• 4 Active movement againist resistance
• 5 Normal
PRIMITIVE REFLEXES
Develop during intrauterine life and gradually
supressed as the higher cortical centers become
functional
SEGMENTAL MEDULLARY REFLEXES
Become functional during the last trimester of gestation
Respiratory activity
Cardiovascular reflex
Sneezing reflex (trigeminal nerve)
Swallowing reflex (trigenimal and glassopharyngeal nerve)
Sucking reflex ( afferent fibers of trigeminal and
glossopharyngeal nerves, efferent fibers of facial,
glassopharyngeal and hypoglossal nerves)
FLEXION REFLEX
Elicited with the unpleasant stimulation of the skin of the
lower extremity
Dorsiflexion of the great toe and flexion of the ankle,knee
and hip
Immature fetuses
Seen also in infants, whose higher cortical centers have
been damaged
Reflex stepping is present in healthy newborn when the
infant is supported in the standing pasition → dissapears
in the 4th – 5 th mnt of life
MORO REFLEX
By a sudden dropping of the head in relation to the trunk
Infant opens the hands extends and abducts the upper
extremities, then draws them together
Fades out 3-5 months of age
Persistence beyond 6 months
Neurologic dysfunction
Absence during the first few weeks
TONIC NECK RESPONSE
Rotating the infants head to one side → extension of the
arm and leg on the side toward which the face rotated and
flexion of the limbs on the opposite side
Asymetric response is abnormal
Can be elicited as long as 6-7 months of age
RIGHTING REFLEX
With the infant in the supine position, the examiner turns
the head to one side,healthy infant rotates the shoulder in
the same direction followed by the trunk and finally the
pelvis
The shoulders, trunk and pelvis rotation simultaneously in
which the infant can be rolled over →ABNORMAL
PALMAR AND PLANTAR GRASP REFLEXES
Elicited by pressure on the palm or sole
Planted is weaker than the palmar reflex
Palmar grasp reflex
→ Absence before 2 or 3 mnt
Persistence beyond the age
Consistent asymetry
Abnormal
VERTICAL SUSPENSION
Suspending the child with the examiner’s hand under
axillae→marked extension or scissoring→indication of
spasticiy
LANDAU REFLEX
Lifting the infant with one hand under trunk, face
downward → a reflex extension of the vertebral column
With hypotonia→ irfant’s body tends to collapse into an
inverted U shape
PARACHUTE RESPONSE
Child suspended horizontally, projected →suddenly
toward the floor→ consequent extension of the arms and
spreadig of the fingers
Minimal assymetry→consequence of bacterial meningitis
REFLEX PLACING and STEPPING RESPONSES
Disappears 4-5 months of age