Exam 3 Flashcards
Localization of the problem -
[Problem] Thinking/remembering
[Localization]
the hemispheres
Localization of the problem -
[Problem] Coordination
[Localization]
cerebellum
Localization of the problem -
[Problem] Arms/legs, with bladder or bowel control problem
[Localization]
spinal cord
Localization of the problem -
[Problem] Speech
[Localization]
left hemisphere
Ash leaf spot
- white mark on skin
- a lot of them (~40) could indicate tuberous sclerosis
Cafe au lait spot
- brown skin macule
- in the axillae (5+) could make the diagnosis of neurofibromatosis
Flammeus nevus
- flat red capillary skin stains
- Sturge-Weber: 1/2 of face
Marie Charcot Tooth syndrome
- Look for thin, stork-like legs
- Neuropathy will present with distal weakness therefore wasting, stork-like legs is a sign of peroneal nerve disease
- Cuts that don’t hurt
Myopathy presentation
Muscle weakness
Neuropathy presentation
Distal weakness; peripheral signs:
- claw toes, high arches
Diastematomyelia
- Split cord malformation (type of spinal dysraphism) is a longitudinal split in the spinal cord.
- Nevus flammeus along the spinal cord on the thoracic lumbar region
- Epidemiology: split cord malformations are a congenital abnormality and account for ~5% of all congenital spinal defects.
- Clinical presentation: may be minimally affected or entirely asymptomatic.
- Presenting symptoms include: leg weakness, low back pain, scoliosis, incontinence
Cerebral function - JOMAC
[J]udgment, problem solving [O]rientation to time and space [M]emory [A]ffective disturbances [C]alculation disturbances
Horner’s syndrome
- decreased sweating on the affected side of the face
- ptosis
- sinking of the eyeball into the face
- constricted pupil
- common in post-op follow up
Cranial Nerve 1
Olfactory nerve
- important to test for smell after a direct blow to the forehead above the nasal bridge which might involve a fracture of the cribriform plate
- not done often
- do not use “I-XII intact” unless you test everything
Cranial Nerve 2
Optic nerve
- Test for vision (visual acuity)
- Look for both the direct and consensual reactions
Cranial Nerve 3
Oculomotor nerve
- looks inward
- Paralysis of CN 3 results in inability for eye to adduct
Cranial Nerve 4
Trochlear nerve
Cranial Nerve 5
Trigeminal nerve
- Inspect face for muscle atrophy and tremors
- Palpate the jaw muscles as child makes a “monster face” clenching their jaws together
Cranial Nerve 6
Abducens nerve
- Dysfunction of the 6th CN can result from lesions occurring anywhere along its course between the 6th nerve nucleus in the dorsal pons and the lateral rectus muscle within the orbit.
- The 6th nerve has the longest subarachnoid course of all cranial nerves and innervates the ipsilateral lateral rectus (LR) which abducts the eye
- It has the LONGEST PATH of all the cranial nerves; anything along its path is going to cause a problem.
Cranial Nerve 7
Facial nerve
- When monster face is over, do a happy face (smile/frown, puff cheeks)
Horizontal nystagmus
- Seen with labrynthine, cerebellar, or brainstem pathology
- Medication toxicity
Vertical nystagmus
- Seen with cerebellar or brainstem pathology
- Medication toxicity
Central vs. Peripheral CN 7 palsy
In peripheral, unable to raise eyebrow + close eyelid on affected side.
Cranial Nerve 8
Acoustic nerve
- screen for hearing from 500 to 6,000 or 8,000 decibels to screen for higher frequency hearing loss that is found with mild sensorineural damage
- we tend to screen between 6-8 months; you expect them to turn their head toward the sound
Weber test
- placing a vibrating tuning fork on the middle of forehead
- does patient hear it equally or feels/hears it best on one side?
- normal = same on both sides.
- Unilateral neurosensory hearing loss: best in the normal ear
- Unilateral conductive hearing loss: best in the abnormal ear
Chaddock sign
- Stroke with a blunt point around the side of the foot, from external malleolus to the small toe
- In a positive test, there is dorsiflexion of the great toe
Oppenheimer sign
- Firmly press down on the shin and run the thumb and the knuckles down along the anterior medial tibia toward the foot
- In a positive test, there is dorsiflexion of the great toe
Motor screening of the 9-month old visit
- Roll to both sides
- Sit well without support
- Demonstrate motor symmetry without established handedness
- Should be grasping and transferring objects hand to hand
Motor screening of the 18-month old visit
- Sit, stand, and walk independently
- Grasp and manipulate small objects
- Mild motor delays undetected at the 9-month screening visit may be apparent at 18 months
Motor screening of the 30-month old visit
- Most motor delays will have already been identified during previous visits.
- Subtle gross motor, fine motor, speech, and oral motor impairments may emerge at this visit.
- Progressive neuromuscular disorders may begin to emerge at this time and manifest as a loss of previously attained gross or fine motor skills.
Motor screening of the 48-month old visit
- Early elementary school skills, with emerging fine motor, handwriting, gross motor, communication, and feeding abilities that promote participation with peers in group activities
- Concerns about motor development is concerning
- Loss of skills - progressive disorder
Gower’s
- Gower’s maneuver
- Climbing up legs to get up
Duchenne Muscular Dystrophy
- affects boys
- difficulty climbing stairs, running, jumping from a standing position, frequent falls
- slow motor milestones: 18 months starts walking, age 2-3 years “somewhat clumsy,” age 3-5 years “difficulty keeping up with peers”
Duchenne Muscular Dystrophy - Clinical Manifestations
- Weakness
- Consistent in pattern
- Proximal muscles weaken before distal
- Legs weaken before arms
- Extensors weaken before Flexors
(remember “E” comes before “F”!!!)
Duchenne Muscular Dystrophy - Progression
- Toe walking
- Calf pseudohypertrophy: calf is as large as thigh
- Positive Gower’s maneuver
- Lumbar lordosis
- Multifocal contractures
- “Trendelenberg” gait
- Fatigue (need to sit down after a period of time)
Pronator drift
- ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, eyes closed
- instruct the patient to keep the arms still while you tap them briskly downward
- the patient will not be able to maintain extension and supination (and drift into pronation) with upper motor neuron disease
Epidural Hematoma
- Blood is between the dural surface and the skull and is usually the result of a tearing of the meningeal artery
- more common in older children than in toddlers/infants, because before age 2 the middle meningeal artery is not yet embedded in the bony surface of the skull
- may NOT have loss of consciousness
- S+S: headache, decreased LOC, fever, dilation of the pupil on the affected side of the brain
Basilar skull fracture
S+S:
- blood behind the tympanic membrane
- nerve palsies (paralysis)
- deafness, or ringing in the ears
- dizziness; nausea, vomiting
- Battle’s sign: bruising over the temporal area
- Raccoon sign: bruising around the eyes
Meningitis
Presentation of Meningitis: (In newborns) - fever - nonspecific symptoms (e.g., poor feeding, vomiting, diarrhea, rash) - bulging fontanel - irritable, restless, lethargic
(Older children)
- Sudden fever
- Headache
- Nausea, vomiting
- Confusion, stiff neck, photophobia
Meningitis can cause seizures, and decreased level of awareness.
*Patients with VP shunt have a higher risk, and may be afebrile.
Brudzinski sign
- Flexion of neck causes flexion of hips and knees
- Test for nuchal rigidity with head off table in your hands
- Gently flex the head at the neck until the chin touches the chest
- Positive: when both knees and hips are flexed in response to passive flexion of the neck towards the chest. Reflex is due to exudate around the roots in the lumbar region
Kernig’s sign
- Associated with meningeal irritation and hamstring spasm
- Flex hip and knee, then straighten knee
- Excessive pain and resistance bilaterally suggests meningeal irritation
Genu varum
Bow legged
- seen until child has been walking for 1 year
Genu valgum
Knock knees
- Abnormal if child has been walking less than 1 year
Galeazzi sign
- shorter appearance of involved lower extremity when hips and knees are in 90 degrees of flexion
- classic identifying sign for unilateral hip dislocation
