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PNP: Physical Assessment - BK > NEURO > Flashcards

NEURO Flashcards

1
Q

Nervous System Development

A

Environmental influences: nutrition, hormones, O2 levels, maternal life-style, state of health

Neural tube: neural plate, groove, folds tube

Embryonic development of CNS: disruption in any stage causes disorders

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2
Q

5 important components of neurodevelopmental hx

A

health history

behaviorial assessment

psychosocial assessment

school performance

developmental history

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3
Q

Types of neuro exams

A

Neurological eval

Neuropsychological eval = looks at your brain and nervous system affect the way you think and behave

Neurodevelopment evaluation – takes into account developmental levels

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4
Q

Localization of the Problem and History

A
  • If there is a problem with thinking or remembering, the problem may be localized in the hemispheres
  • If there is a problem with coordination the cerebellum may be where the problem is
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5
Q

Problem with arms/legs with bladder control or bowel control the problem is…

A

spinal cord

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6
Q

speech problem

A

left hemisphere

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7
Q

The more problems that the child presents with that do not localize to one area, the more likely the problem involves

A

Psychosocial realms

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8
Q

Mechanism of injury

Episodic history

A

Key to developing an action plan for an acute head injury or acute neurological event

Get as much information as possible from people on the scene of an actual event

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9
Q

Overall inspection of the body

Look for… (5)

A

Neurocutaneous lesions

Muscle atrophy

Weakness in gait

Abnormal positioning

An infant who should not have handedness with marked favoring to one side

Ask about birthmarks

Skin = dermatologic clue to underlying diseases

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10
Q

Ash leaf spot

A

white mark on skin

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11
Q

cafe au lait

A

brown skin macule

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12
Q

Flammeus nevus

A

Flat red capillary skin stains

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13
Q

Large calf muscles (in comparison to thighs) may indicate

A

Muscular dystrophy especially if child has pelvic girdle weakness

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14
Q

Increase in lumbar curve…

A

Lumbar lordosis

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15
Q

Marie Charcot Tooth Syndrome

A
  • Look for thin, stork like legs
    • Neuropathy will be present with distal weakness therefore wasting, stork like legs is a sign of peroneal nerve disease
    • Cuts that do not hurt
      • High arched, toe nail fungus, decreased reflexes
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16
Q

Myopathies present with

A

central weakness

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17
Q

Neuropathy present with

A

distal weakness

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18
Q

Overall inspection

Watch for… (3)

A

Tremors of the hands when moving or tremors of the tongue when not crying

Hypermobility – can be confused with hypotonia (low muscle tone)

Look for asymmetry of the foot – DIASTEMATOMYELIA

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19
Q

What is Diastematomyelia

A

Spinal cord malfunction

Type of spinal dysraphism

Longitudinal split in the spinal cord

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20
Q

Diastematomyelia Epidemiology

A

Split cord malformations are a congenital abnormality and account for ~5% of all congenital spinal defects

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21
Q

Diastematomyelia

Clinical Presentation

A

May be minimally affected or entirely asymptomatic

Presenting symptoms include: leg weakness, low back pain, scoliosis, incontinence

Nevus flammeus along spinal cord – abnormality of gluteal fold

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22
Q

Watch Patient Gait

A

Thumb facing, looks normal, arm swing

Thumbs should face forward

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23
Q

General Cerebral Function (6)

A
  1. age adjusted and developmentally adjusted
  2. Child developmental level in terms of school performance
    1. The examiner must keep the child’s interest to gain full cooperation
  3. Interesting materials
  4. Do one thing at a time
  5. Environment facilitates testing and is not distracting
    1. Use stickers as reinforcement
  6. Positive reinforcement
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24
Q

JOMAC

A

Judgement, problem solving

Orientation to time and space

Memory

Affective disturbances

Calculation disturbances

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25
Q

Preschool Child (what they know)

A
  • Does he recognize common objects – sesame street characters
  • Know names of family members
  • Know where you buy food
  • Name one thing that you keep in the refrig
  • Knows if he has a pet and name
  • Count 3 objects
  • Note behavioral characteristics
  • Draw picture of himself
  • Child can give 3 wishes
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26
Q

Cerebral Function – Affective

A
  • Hyperactivity
  • Decreased attention span
  • Distractibility
  • Disinhibition
  • Emotional liability
  • Impulsivity
  • Hypoactivity
  • Lack of spontaneity
  • Low frustration level
  • Low self-esteem
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27
Q

2 years (13)

A
  • Gains 5-6 lbs and 5 inches HC 2cm
  • Kicks ball forward
  • Removes article of clothing (not hat)
  • Combines two words
  • mild lordosis with protuberant abdomen
  • 8 more teeth to total 14-16
  • Tower of 7 cubes
  • Imitate circular strokes
  • May draw a horizontal line
  • Empties trash can and drawers
  • Parallel play
  • Speech should be understood
  • Rotary chewing refined
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28
Q

3-5 years – preschool

POUNDS, INCHES

Initiative vs. Guilt

A

Gain 4-5 lbs and 2.5-3.5 inches

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29
Q

3 years (15)

A
  • Throws ball overhand
  • Names 4 animal pictures
  • Pedals tricycle
  • Puts on an article of clothing
  • Names one animal picture
  • Jumps up and down
  • Draws a person upon request with sticks
  • State age, sex
  • Involve other in play
  • Can count fingers
  • Hand muscle developed
  • Wants to do things by themselves
  • Learning to shre
  • Likes to help
  • Brushes teeth
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30
Q

4 years (9)

A
  • Lordosis and round abdomen starts to disappear
  • Plays games with other children
  • Says what to do when tired, cold, hungry
  • Says first and last name when asked
  • Copies circle
  • Balances on each foot for 2 seconds
  • Can copy a + with demonstration
  • Finger muscles for tasks
  • Balance on 1 foot for 5 seconds
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31
Q

5 year old (5)

A
  • Dresses without supervision
  • Copies a cross
  • Draws a person
  • Puts object on, under, in front of and behind when asked
  • Hops on one foot 2 or more times
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32
Q

6-12 years

Industry vs. Inferiority

A
  • Mastering skills that will be needed later as an adult
  • Winning approval from other adults, peers
  • Building self-esteem, positive self concept
  • Taking place in a peer group
  • Adopting moral standards
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33
Q

1st Grade

A
  • Print 1st and last name
  • Write #’s 1-10
  • Draws a person with 6 parts
  • Copies a square
  • Heel to toe walk
  • Knows the letters of the alphabet
  • Walk on alternate heels
  • Play sports
  • Friends
  • Peers
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34
Q

CN1 - Olfactory Nerve

A

– 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 1-XII intact unless you test everything

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35
Q

CN 2 - Optic

A
  • Test for vision
  • Vision test after a head trauma. Note and refer if acuity now falls in the abnormal range
  • Note shape of pupil
  • Penny test:
    • Follow it with their eyes.
    • After this, use the cold coin to test for sensation of cold.
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36
Q

CN 2 - Optic

tests

A
  • Examine the Optic Fundi
  • Test Visual Acuity
  • Test Pupillary Reactions to Light
  • Dim the room lights as necessary.
  • Ask the patient to look into the distance.
  • Shine a bright light obliquely into each pupil in turn.
  • Look for both the direct (same eye) and consensual (other eye) reactions.
  • Record pupil size in mm and any asymmetry or irregularity.
  • If abnormal, proceed with the test for accommodation.
  • Test Pupillary Reactions to Accommodation
  • Hold your finger about 10cm from the patient’s nose.
  • Ask them to alternate looking into the distance and at your finger.
  • Observe the pupillary response ineach eye.
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37
Q

Horner’s Syndrome

A
  • Decreased sweating on the affected side of the face
  • Ptosis
  • Sinking of the eyeball into the face
  • Constricted pupil
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38
Q

CN 3, 4, 6

Oculomotor, trochler, abducens

A
  • Inspect eyelids for drooping
  • Inspect pupils size for equality and reaction to light and accommodation
  • Test eye movements in the 6 fields of cardinal gaze.
  • Inspect pupils size for equality and reaction to light and accommodation
  • Test eye movements in the 6 fields of cardinal gaze.
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39
Q

Abducens

A
  • Dysfunction of the sixth cranial (abducens) nerve can result from lesions occurring anywhere along its course between the sixth nerve nucleus in the dorsal pons and the lateral rectus muscle within the orbit.
  • The sixth nerve has the longest subarachnoid course of all cranial nerves and innervates the ipsilateral lateral rectus (LR) which abducts the eye
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40
Q

Increased ICP

Abducens

A
  • Can result in downward displacement of the brainstem, causing stretching of the sixth cranial nerves which are tethered in Dorello’s canal.
  • Can occur secondary to a variety of different causes

– Shunt failure
– Pseudotumor cerebri
– Posterior fossa tumors
– Neurosurgical trauma
– Venous sinus thrombosis – Meningitis
– Lyme disease.

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41
Q

Mimics of 6th Nerve Palsy

A

Thyroid eye diseases

Myasthenia gravis

Duane’s syndrome

Spasm of the near reflex

Delayed break in fusion

Old blowout fracture of the orbit

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42
Q

Papilledema

A

Optic nerve with mild swelling

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43
Q

Grade I papilledema

A

Pathologic C shaped halo of edema surrounding the optic disk

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44
Q

Grade II papilledema

A

The halo of edema now surrounds the optic disk

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45
Q

Grade IV papilledema

A

With more severe swelling in addition to a circumferential halo, the edema covers major blood vessels as they leave the optic disk (grade III) and vessels on the disk (grade IV)

The subretinal hemorrhage is present at 7 o clock

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46
Q

Nystagmus

Vertical, horizontal, medication

A

note direction, speed

  • Horizontal nystagmus may be seen with labyrinthine, cerebellar, or brainstem pathology.
  • Vertical nystagmus may be seen with cerebellar or brainstem pathology.
  • Medication toxicity may cause both horizontal and vertical nystagmus
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47
Q

Abnormal pupils

A

Small, pinpoint, fixed, dilated, unequal

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48
Q

CN 3

A

Paralysis

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49
Q

Horizontal Nystagmus

A

Labyrinthine

Cerebellar

Brainstem pathology

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50
Q

Vertical nystagmus

A

Cellebellar or brainstem pathology

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51
Q

Medication toxicity

A

May cause both horizontal and vertical nystagmus

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52
Q

CN 5 or Trigeminal

A
  • Inspect face for muscle atrophy and tremors
  • Palpate the jaw muscles as child makes a “monster face” clenching their jaws together. show upper and lower teeth
  • Test for touch and temperature sentation on either side of the face
  • Corneal reflex is deferred
53
Q

CN7 - Facial Nerve

A

While the child is doing the monster clenched teeth face for the trigeminal nerve, look for facial symmetry

When the monster face is over do a happy face

Smile and frown

Close eyes tight

Puff cheeks

54
Q

CN 7-facial nerve

Central

A

Patient can elevate both eyebrows

Close both eyes

Loss of nasolabial folds

55
Q

CN 7 - facial

Peripheral

A

Unable to elevate eyebrow on right

Right eye does not close and eyeball turns UP (Bell’s phenomenon)

56
Q

CN 8 - Acoustic

A
  • In the younger child, use of a tuning fork to determine which ear the sound is louder on can be very difficult
    • Screen for hearing from 500-6000 or 8000 decibels to screen for higher frequency hearing loss that is found with mild sensorineural damage
  • Equilibrium is also determine by the 8th CN
    • Use of audioscope or audiometer for a routine hearing screen can test the 8th CN
57
Q

Weber Test

A
  • Placing a vibrating tuning fork on the middle of the forehead
  • Does patient hear it equally or feels or hears it best on one side or the other
  • Normal - same on both sides.
  • Unilateral neurosensory hearing loss - best in
  • the normal ear
  • Patient with unilateral conductive hearing loss - best in the abnormal ear.
58
Q

Rinne Test

A
  • Comparing bone condution
    • Placing the tuning fork on the mastoic process behind the ear
  • Air conduction
    • Assessed by holding the tuning for in air near the front of the ear
  • AC is GREATER than BC
59
Q

Hearing Screening

CONDUCIVE hearing loss

A

Eustachian tube dysfunction

Ear fluid

Hole in eardrum

Fixed middle ear bone

60
Q

Sensorineural hearing loss (4)

A

Noise induced hearing loss

Presbycusis

Meniere’s disease

Tumors of the auditory nerve

61
Q

CN 9

Glossopharyngeal

A

Test ability to swallow

Gag reflex is also part of the 9th CN but is not routinely done in school setting

Test for sweet/sour taste

62
Q

CN 10 - VAGUS

A
  • Listen to vocal quality
  • Look for rise of soft palate as child says ah ah.
  • Swallowing difficulties?
  • Another way of getting the child to open his mouth is to have him say ha ha. Ha ha is funny and allows the child to be in control.
  • Watch the child swallow without giving fluid if head injured.
63
Q

CN 11 - Spinal Accessory

A
  • Head rotation against resistance to test the strength of the sternocleidomastoid
  • Upward shoulder movement that is stronger than examiners downward pressure tests the trapezius muscle strength.
64
Q

CN 12 - hypoglossal

A
  • Inspect tongue in the mouth. Look at symmetry, tremors, and atrophy
  • Pressure the tongue against cheek and check for strength.
  • Quality of lingual sounds like l, t, d, and n
  • With a unilateral lesion, the protruded tongue deviates toward the affected weaker side
65
Q

Reflex Pearls

A
  • Patient must be relaxed and positioned properly
  • Response depends on force of your stimulus
  • Use no more force than you need to provoke a definite response
  • Reflexes can be reinforced by having the patient perform isometric contraction of other muscles (clenched teeth)
  • Must evaluate for equality
  • Must make sure there is no spread if they are brisk
  • Distraction
66
Q

Tendon reflex grading scale

A

0 – absent

1 – hypoactive

2 – normal

3 – hyperactive without clonus

4 – hyperactive with clonus

67
Q

BICEPS C5,6

A
  • The patient’s arm should be partially flexed at the elbow with the palm down.
  • Place your thumb or finger firmly on the biceps tendon.
  • Strike your finger with the reflex hammer.
  • You should feel the response even if you can’t see it.
68
Q

Triceps C6,7

A
  • Support the upper arm and let the patient’s forearm hang free.
  • Strike the triceps tendon above the elbow with the broad side of the hammer.
  • If the patient is sitting or lying down, flex the patient’s arm at the elbow and hold it close to the chest.
69
Q

Clonus

A
  • If the reflexes seem hyperactive, test for ankle clonus: ++
  • Support the knee in a partly flexed position.
  • With the patient relaxed, quickly dorsiflex the foot.
  • Observe for rhythmic oscillations
70
Q

Brachioradialis C5-C6

A
  • Have the patient rest the forearm on the abdomen or lap
  • Strike radius about 1-2 inches above the wrist
  • Watch for flexion and supination of the forearm
71
Q

Abdominal (T8, T9, T10, T11, T12)

A
  • Use a blunt object such as a key or tongue blade.
  • Stroke the abdomen lightly on each side in an inward and downward direction above (T8, T9, T10) and below the umbilicus (T10, T11, T12).
  • Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus.
72
Q

Knee (L2, L3, L4)

A
  • Have the patient sit or lie down with the knee flexed.
  • Strike the patellar tendon just below the patella.
  • Note contraction of the quadraceps and extension of the knee.
73
Q

Ankle

S1, S2

A

Dorsiflex the foot at the ankle

Strike the achilles tendon

Watch and feel for planter flexion at the ankle

74
Q

Babinski

A

Should be upward until child walks

Once child walks then downward

75
Q

Chaddock

A

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

76
Q

Oppenheimer

A

Firmly press down on the shin and run the thumb and knuckles along the anterior medial tibia toward the foot

In a positive test, there is a dorsiflexion of the great toe

77
Q

Snouting Reflex

A

wrinkling of nose like giving a kiss

78
Q

9 months

A
  • Roll to both sides
  • Sit well without support
  • Demonstrate motor symmetry without established handedness
  • Should be grasping and transferring objects hand to hand
79
Q

18 month visit

A
  • 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.
80
Q

30 month visit

A
  • 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.
81
Q

48 month visit

A
  • 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.
82
Q

High Normal or Low tone

A

Measure CK and TSH

83
Q

Key elements of motor history

A
  • Delayed acquisition of skill- Is parent concerned
  • Involuntary movements or coordination impairments
  • Is there anything your child is doing that concerns you?
  • Regression of skill
  • Is there anything your child used to be able to do that he or she can no longer do?
  • Strength, coordination, and endurance issues

• Is there anything other children your child’s age can do that are difficult for your child?

84
Q

Neuromuscular exam in the infant

A
  • Postural tone is assessed by ventral suspension in the younger infant
  • Postural tone is assessed by truncal positioning when sitting and standing in the older infant.
  • Extremity tone can be monitored during maturation by documenting the scarf sign in infants and popliteal angles after the first year
  • Persistence of primitive reflexes and asymmetry or absence ofprotective reflexes suggest neuromotor dysfunction.
  • Unsteady gait or tremor can be a sign of muscle weakness.
  • Diminution or absence of deep tendon reflexes can occur with lower motor neuron disorders, whereas increased reflexes
  • Abnormal plantar reflex can be signs of upper motor neuron dysfunction.
  • Neuromotor dysfunction can be accompanied by sensory deficits and should be assessed by testing touch and pain
85
Q

Scarf sign tone assessment of shoulder girdle

A

With child supine or sitting (if able) pull arm across to the opposite shoulder until resistance occurs.

Note elbow position in relation to the bilateral midclavicular line and midline of the chest

86
Q

Popliteal angle for hamstring tone assessment

A

With child supine, flex the hip to 90 degrees, with child’s torso supine on the table. Slowly extend leg at knee until resistance occurs.

Note the angle between the lower leg and vertical

87
Q

Observe for Strength (5)

A
  • Observe symmetry while tripod sitting with symmetrical posture
  • Observe walking and then running, climbing, hopping, and skipping in the older child
  • Use of a Gower maneuver, characterized by an ambulatory child’s inability to rise from the floor without pulling or pushing up with his arms.
  • Muscle bulk and texture, joint flexibility, and presence or absence of atrophy should be observed.
  • Quality and intensity of grasp is most easily assessed by observation during play.
88
Q

PA Caveats

A
  • Must divide into fine motor skills and gross motor skills
  • Watching a child walk is important
  • Children cannot tandem walk forward until age 4 at the earliest but as late as age 6 is acceptable
  • Ask about milestones prior to coming into ed.
  • Ask about school-regular versus special education
89
Q

Motor function (7)

A

Body posture

Gait

Balance

Coordination – tap foot on floor; alternating finger with thumb rapidly

Gower’s sign

Tremors: resting, postural, intention

Gait abnormalities

90
Q

Grading Motor Strength

A

0/5 = no muscle movement

1/5 = visible muscle movement, but no movement at the joint

2/5 = movement at the joint, but not against gravity

3/5 = movement against gravity, but not against added resistance

4/5 = movement against resistance, but less than normal

5/5 = normal strength

91
Q

Myotonic vs. Neuropathy

A

Spinal muscular atrophy, muscular dystrophy, myotonic dystrophy = MYOTONIC

Marie charcot tooth disase = neuropathy

92
Q

Duchenne Muscular Dystrophy

Boys

A

Difficulty climbing stairs

Running

Jumping from standing position

Frequent falls

93
Q

DMD – slow motor milestones

A

18 months - walking

age 2-3 years = somewhat clumsy

3-5 years = difficulty keeping up with peers

94
Q

DMD

Clinical Manifestations

A

Weakness

Consistent in pattern

Proximal muscles weaken before distal

Legs weaken before arms

Extensors weaken before flexors

95
Q

Duchenne’s muscular dystrophy

Progression

A

Toe walking

Calf pseudohypertrophy (calf is as large as thigh)

Positive Gower’s maneuver

Lumbar Lordosis

Multifocal Contractures

Trendelenberg gait

Fatigue

96
Q

Pronator Drift

A
  • Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and 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.
97
Q

Sensory

A

Pain

Light touch

Vibration

98
Q

Proprioceptive and Cerebellar Function

A

Look at block stacking for intentional tremor

Look at tandem gait

Balance

Gait - wide based and ataxic

99
Q

Coordination and gait

A

Rapid alternating movements

Point to point movements

Romberg

Gait

100
Q

Rapid Alternating Movements

A
  • Ask the patient to strike one hand on the thigh, raise the hand, turn it over, and then strike it back down as fast as possible.
  • Ask the patient to tap the distal thumb with the tip of the index finger as fast as possible.
  • Ask the patient to tap your hand with the ball of each foot as fast as possible.
101
Q

Point to Point Movements

A
  • Ask the patient to touch your index finger and their nose alternately several times. Move your finger about as the patient performs this task.
  • Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patient to move their arm and return to your finger with their eyes closed.
  • Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the patient’s eyes closed.
102
Q

Two point discrimination

A
  • Use in situations where more quantitative data are needed, such as following the progression of a cortical lesion. ++
  • Use an opened paper clip to touch the patient’s finger pads in two places simultaneously.
  • Alternate irregularly with one point touch.
  • Ask the patient to identify “one” or “two.”
  • Find the minimal distance at which the patient can discriminate.
103
Q

Discrimination

Graphesthesia

A

With the blunt end of a pen or pencil, draw a large number in the patient’s palm.

Ask the patient to identify the number.

104
Q

Discrimination

Stereognosis

A
  • Use as an alternative to graphesthesia. ++
  • Place a familiar object in the patient’s hand (coin, paper clip, pencil, etc.).
  • Ask the patient to tell you what it is.
105
Q

Neurodevelopmental Markers

A

Left to right confusion

Hand preference

Dystonic posturing

Proximal inhibition

106
Q

Left-Right confusion

A

Most children can identify left and right by age 8.

Have the child touch his/her left ear with his right hand. Also ask the child to point to the examiners right hand with his/her left hand.

107
Q

Hand Preference

A
  • Hand preference is generally established by age 3. Left hand preference, or mixed hand preference are neurodevelopmental markers.
  • Screen for hand preference by asking the child to demonstrate how s/he holds a pencil, throws a ball, and hammers in a nail.
108
Q

Dystonic Posturing

A

Dystonic posturing is stiffening of the extremities during a stressed gait or ehythmic movements

The child hops in place or heel toe walk

Penny on the nose – hand goes up on weak side

109
Q

Proximal Inhibition

A

The inability to inhibit proximal musculature while using distal muscles is a neurologic marker.

• Screen for proximal inhibition by having the child rapidly alternate opening and closing of fists with arms extended, or by rapidly rotating the wrist while holding the arm up and hand above the head.

110
Q

Quick Neuro Check

A
  • Level of Consciousness
  • Motor function
  • Pupillary response
  • Vital signs
  • Signs of increased intracranial pressure
  • Glasgow coma scale
    • Best eye opening response (1-4)
    • Best motor response (1-6)
    • Best verbal response (1-5)
111
Q

Neurophychological Eval

A

Used for learning disabilities

Parents observations

Formal observation: watching the child copy designs, pronounce words, or figure out an arithmetic problem is also part of the assessment

112
Q

Head Trauma

Simple - linear

SKULL FRACTURE = Depressed***

A

Hematoma at site

Piece of bone depressed into brain

113
Q

Skull fracture

Compound

A

Laceration and depressed skull fracture

Dura usually pierced

Skull fragment may be displaced into the brain tissue

114
Q

Skull fracture

Basilar

A

Break in the posteroinferior portion of the skull occurs

Produces dural tears that result in leakage of cerebrospinal fluid

Meningitis

115
Q

Epidural Hematoma

A
  • 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 and infants, because before age two, the middle meningeal artery is not yet embedded in the bony surface of the skull.

• May not have loss of consciousness.

116
Q

Epidural Hematoma

Signs and Symptoms

A

Headache

Decreased LOC

Fever

Dilation of the pupil on the affected side of the brain

117
Q

Early signs of basilar fracture

A
  • Blood behind the tympanic membrane
  • Nerve palsies (paralysis)
  • Deafness, or ringing in the ears
  • Dizziness; nausea; and vomiting.
  • Delayed signs and symptoms
  • Battle’s Sign
    • Bruising over the temporal area
  • Raccoon sign
    • Bruising around the eyes
118
Q

Meningitis

Incidence and Causes

A

4000-10000 cases per year

  • Causes
    • The childs age is the predominant determinants of the common bacteria causes
      • Neonate
      • Infant
      • Child
        • Streptococcus pneumoniae or pneumococcus
        • Neisseria meningitidis or meningococcus
119
Q

History of Meningitis

A
  • Progression of illness
  • Exposure
  • History of otitis media
  • Underlying health problems – immunodeficiency
  • Seizure
    • FOCAL - more common as initial presentation
    • GENERALIZED – febrile seizures
120
Q

Presentation of meningitis

Newborn

A
  • Fever
  • Nonspecific symptoms (eg, poor feeding, vomiting, diarrhea, rash)
  • Bulging fontanel
  • Irritable, restless, or lethargic.
121
Q

Presentation of Meningitis

Older Children

A
  • Sudden fever
  • Headache,
  • Nausea, vomiting,
  • Confusion, stiff neck, photophobia

Meningitis can cause seizures and decreased level of awareness

122
Q

Meningeal sign

Brudzinski Sign

A
  • 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 the 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
123
Q

Meningeal signs

Kernig

A

Associated with meningeal irritation and hamstring spasm

Flex hip and knee, then straighten knee

Excessive pain and resistance bilaterlly suggest meningeal irritation

124
Q

Patients with VP shunt = different presentation

A

Low grade ventriculitis

Headache

Nausea

Minimal fever

Malaise

125
Q

Viral Meningitis

PA

A

Loss toxic and acute in presentation

More common in the summer – enteroviruses

126
Q

Duchenne muscular dystrophy (DMD)

Clinical presentation, 10 years

A
  • Life limiting
    • Muscle wasting condition characterized by progressive muscle weakness and wasting
    • Due to absence of the protein dystrophin in the muscles.
  • Clinical presentation
    • Delayed or disordered motor or speech development and muscle weakness.

• Over the last 10 years, improved standards of care have significantly increased the life expectancy in DMD.

127
Q

DMD

Incidence and Prevalence

A
  • DMD is the most common muscular dystrophy in children and affects approximately one in every 4000 male newborns
  • No predilection for race or ethnic group
  • 1 in 3500 live male births
  • Estimated 8000 males in US with DMD
  • If mother is a carrier
    • 50% chance of affected male child & 50% chance of carrier female child
  • “Carrier Female”
    • ~8% of female carriers manifest mild proximal muscle weakness
    • 10% develop cardiac failure – Cognitive effects
128
Q

S & S of DMD

A
  • Abnormal muscle function
    • Delayed walking
    • Falls
    • Difficulty running and climbing stairs
    • Calf pseudohypertrophy
  • Progressive proximal musculature weakness
    • Waddling gait 2 degree girdle muscle weakness
    • Gower’s sign
  • Increase in serum CK and transaminases (aspartate aminotransferase and alanine aminotransferase)
  • Delayed in attainment of developmental milestones
129
Q

DMD dx late

A

Negatively affects access to genetic counseling, standards of care and potentially recruitment into clinical trials

PNP: Physical Assessment - BK (13 decks)

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