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Download Applied Pediatrics Jose A. Robles, MD Pediatric Neurology HISTORY
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Applied Pediatrics Jose A. Robles, MD Pediatric Neurology HISTORY Chief complaint – actual or approximate time of onset – central problem – foundation upon which differential diagnosis must be constructed – patient own words HISTORY History of Present Illness – – should fully describe the chief complaint Answers 3 important questions: 1. Is the process focal or diffuse ? 2. Is the process acute or insidious ? 3. Is the process static or progressive ? Onset and Course of Neurologic Disease History Prenatal history – Illness of mother – Exposure to radiation / toxic substance Birth History – Apgar score, hospital stay, term ? , preterm? Neonatal History – Illness (jaundice, infection , etc) History Developmental and Past Medical History – time of acquisition or loss of developmental landmarks Family History – Family tree include dead, alive and abortus – delineate genetically determined illness (Autosomal dominant, autosomal recessive , X – linked) Physical Examination Observe Undress Anthropometric measurement Birth: Normal head circumference: 33 –35cms Anterior fontanelle closes : 7 – 20 months Posterior fontanelle closes: 3 months Definition: microcephaly 2 SD below the norm for age, sex, race macrocephaly 2 SD above the norm for age, sex, race Physical Examination Skin lesion Neurofibromatosis • Café au lait spots • Cutaneous fibromas • Autosomal dominant Tuberous sclerosis • adenoma sebaceum • Depigmented lesions (vitiligo – like lesions) • Autosomal dominant Sturge Weber syndrome • port wine stain • Autosomal dominant Neurologic Examination in Pediatrics NEUROLOGIC MATURATION The dominant posture is one of flexion… Eye opening… is improved reflexly by bringing in the baby from supine to upright (doll’s eye reflex, upright) DEVELOPMENTAL REFLEXES before one can begin to look for the signs of neurological dysfunction Brachial palsy; this is more serious than Erb’s palsy… Weak sucking is strengthened by using automatic palmar grasp to evoke the Babkin Palmomental response Hyperactive neurological dysfunction; the palmar grasp is so strong that the baby lifts free for a longer time; note the backward thrust of the upper limbs simultaneously First one side comes up… then the other (same baby) the pad of the index finger lightly touches the crown of the cheek the baby turns due to the rooting reflex & then the index finger is slipped into the mouth to elicit sucking transient ATNR is physiological The reversed ATNR is physiological starting position for plantar grasp; baby’s toes flexed… the thumbs are deftly applied to the metatarsal heads, symmetrical flexion Neurologic Examination • Higher cortical function Test : – AGNOSIA – APRAXIA – APHASIA Neurologic Examination • AGNOSIA – inability to understand the significance of sensory stimuli even though the sensory pathways and sensorium are relatively intact • 4 necessary conditions – previous skills sufficient – sensorium intact – sensory pathways intact – organic cerebral lesion present EX: finger agnosia, astereognosia, agraphognosia Neurologic Examination • APRAXIA – inability of a patient to perform a volitional act even though the motor system and sensorium are relatively intact – 4 necessary conditions – previous skills adequate – sensorium intact – motor pathways intact – organic cerebral lesion present EX: constructional apraxia, dressing apraxia, gait apraxia, tongue apraxia Neurologic Examination • APHASIA – Expressive – non fluent – Receptive – fluent Neurological Examination • Mental status – Consciousness • lethargy, delirium, obtundation, stupor, coma – Orientation – Memory • immediate recall, recent, remote Neurological Examination • Mental status • Definition of Terms: – Lethargy : state of minimally reduced wakefulness in which the primary defect is one of attention – Delirium : characterized by disorientation, irritability, delusions or visual hallucinations Neurological Examination • Definition of Terms: – Obtundation : mild to moderate blunting of alertness, accompanied by a lessened interest in or response to the environment. Patient have an increase in the number of hours of sleep, often with drowsiness in Delirium : characterized by disorientation, irritability, delusions or visual hallucinations – Stupor : patient can be aroused temporarily only by vigorous and repeated stimulation. Communication is minimal or non - existent Neurological Examination • Definition of Terms: – Coma : state of unarousable unresponsiveness; without spontaneous movement and with eyes closed. May respond to noxious stimuli but cannot localize pain CRANIAL NERVE EXAMINATION IN INFANCY Neurological Examination • Motor – Strength • • • • • • 0 - No muscle contraction 1 - Flicker or trace of contraction 2 – Active movement with gravity eliminated 3 - Active movement against gravity 4 – Active movement against gravity but not against resistance 5 – Active movement against gravity and resistance – Bulk • Normal. Atrophy, hypertrophy – Tone • Normal, spastic, hypotonia, flaccid Neurological Examination • Sensory – Spinothalamic – pain – Posterior column – vibration, position Neurologic Examination • Reflexes – Deep Tendon Reflexes • 0 : Areflexia • 1-2 : Average • 3+ to 4+ : Hyperrefexia – Superficial Reflexes – Pathologic Reflexes • Babinski • Modified Babinski – Oppenheim – Chaddock – Gordon Segmental Levels of Major Deep Tendon Reflexes Neurologic Examination • Cerebellar – Vermis : truncal ataxia – Hemisphere : • • • • • Limb ataxia Finger to nose Tandem walk Dysdiadocokinesia Head tilt – Nystagmus • Meningeal – Kernigs – Brudzinski DIFFERENCES BETWEEN UMN AND LMN LESIONS UMN Strength Bulk Tone DTR Pathologic reflex + LMN ,0 -
