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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