Neuro Flashcards
Dermatological cues (3)
- Ash leaf spot –> Tuberous sclerosis
- Cafe au lait spots –> neurofibromatosis
- Flammeus nevus –> Sturge Weber Syndrome
Large calves compared to thighs
May indicate muscular dystrophy, especially if child has pelvic girdle weakness
Charcot-Marie Tooth Syndrome Signs (7)
- Thin, stork like legs - sign of peroneal nerve disease
- Neuopathy will present with distal weakness
- Cuts that do not hurt
- High arched
- Toe nail fungus
- Decreased reflexes
- Claw hand deformities
Myopathy vs. Neuropathy
Myopathy (disease of muscle tissue) –> central weakness (ex: Muscular dystrophy)
Neuropathy (weakness in hands and feet) –> distal weakness (ex: Charcot Marie)
Diastematomyelia clinical presentation (8)
May be entirely asymptomatic or…
- Leg weakness
- Low back pain
- Scoliosis
- Incontinence
- Nevus flammeus along spinal cord
- Abnormal gluteal fold - Slightly deviated gluteal cleft
- Assymetry of feet -Progressive inturning and plantar flexion of one foot
- Hairy patch over lumbar region
Normal 2 year old milestones (13 lol)
- Gains 5-6 pounds 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 cans and drawers
- Parallel play
- Speech should be understood
- Rotary chewing refined
Normal 3 Year Milestones (15 lolol)
- 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 share
- Likes to help
- Brushes teeth
Normal 4 year Milestones (8)
- 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
- Coppies a circle
- Can copy a + with demonstration
- Finger muscles for tasks
- Balance on 1 foot for 5 seconds
Normal 5 year Milestones (5)
- 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
Industry vs. Inferiority (5)
School aged: 6-12
- Mastering skills needed later in life
- Winning approval from others
- Building self esteem, positive self concept
- Taking place in a peer group
- Adopting moral standards
Normal growth at pre-school years
Weight: gains 4-5 lbs
Height: gains 2.5-3.5 inches
Horner’s Syndrome (5)
Disruption of nerves from one side of brain to the eye
- Decreased sweating on affected side of face
- Ptosis on affected side
- Sinking of eyeball into the face
- Constricted pupil
- Affected side will appear sunken
CN 3, 4, 6 Tests (3)
- Inspect eyelids for drooping
- Inspect pupil size and reactivity and accommodation
- Test eye movement using six cardinal fields of gaze
Grading Papilledema (I-IV)
I: Mild swelling on optic disc with C-shape
II: halo of edema now surrounds optic disc, also has C-shape
III: Edema covers major blood vessels as they leave optic disc, also has C-shape
IV: Edema covers major blood vessels as they leave optic disc and there are vessels on the optic disc, also has C-shape
Nystagmus types and indicators (3)
- 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
Lyme Disease
Palsy of CN7
A. Central palsy – ability to lift eyebrows and forehead
- Forehead doesn’t have a problem
- Can close eyes
- Loss of nasolabial fold on one side
B. Peripheral palsy – eyebrows and forehead do not work
- Eyes will roll up when trying to close
- May only affect one side
- Loss of nasolabial fold on one side
- Can’t wrinkle forehead
High frequency hearing loss that is found with mild sensorineural damage
Screen from 500-6,000/8,000 decibles
Weber Test (3, know all 3)
- Place vibrating tuning fork at middle of forehead - Does patient hear it equally or best on one side?
- Unilateral neurosensory hearing loss = best in the normal ear
- Unilateral conductive hearing loss = best in the abnormal ear
Rinne Test (3)
Comparing bone conduction to air conduction
- Bone conduction: place the tuning fork on the mastoid process behind ear
- Air conduction: place the tuning fork in the air near the front of the ear
- Normally, air conduction volume is greater than bone conduction volume
Reflex Grading
0: Absent
1+ or +: Hypoactive
2+ or ++: Normal
3+ or +++: Hyperactive without clonus
4+ or ++++: Hyperactive with clonus
Reflexes that you test (7)
- Biceps
- Triceps
- Patellar (knee)
- Achilles Tendon Reflex (ankle)
- Abdominal
- Babinski
- Snouting
Biceps Reflex
Testing C5, C6
1st: Patient’s arm should be partially flexed at the elbow with the palm down
2nd: Place thumb or finger firmly on patient’s biceps tendon
3rd: Strike finger with reflex hammer
* *Should be able to feel response, even if you can’t see it
Triceps Reflex
C6, C7
- Support upper arm and let the patient’s forearm hang free
- Strike the triceps tendon above the elbow with the broad side of hammer
- If the patient is sitting or lying down, flex the patient’s arm at the elbow and hold it close to the chest
Testing for Clonus (4)
- If the reflexes seem hyperactive, test for ankle clonus
- Support knee in a partly flexed position
- With patient relaxed, quickly dorsiflex the foot
- Observe for rhythmic oscillations
Brachioradialis Reflex
Testing C5, C6 (like biceps)
- Have patient rest forearm on the abdomen or lap
- Strike with the radius about 1-2 inches above the wrist
- Watch for flexion and supination of forearm
Abdominal Reflex
T8-T12
- Use blunt object such as key or tongue blade
- Stroke abdomen lightly on each side in an inward and downward direction above (T8, T9, T10) and below umbilicus (T10, T11, T12)
- Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus
Patellar Reflex
L2, L3, L4
- Have patient sit or lie down with knees flexed
- Strike the patellar tendon just below the patella
- Note contraction of the quadriceps and extension above the knee
Ankle Reflex
S1, S2
- Dorsiflex the foot at the ankle
- Strike the Achilles tendon
- Watch and feel for plantar flexion at ankle
Babinski Reflex
Before walking: fanning should be upward
After walking: fanning should be downward
Chaddock Sign
stroke with blunt point around side of foot from external malleus to small toe
- Positive test: dorsiflexion of big toe
- Upward going = abnormal
Oppenheimer Sign
Firmly press on the shin and run the thumb and knuckles along the anterior medial tibia toward the foot
- Positive test: dorsiflexion of great toe
- Downward shin = abnormal
Snouting Reflex
Pouting or pursing of the lips that is elicited by light tapping of the closed lips near the midline
Screening for Motor Delays: 9 month milestones (4)
- Roll to both sides
- Sit well without support
- Demonstrate motor symmetry without established handedness
- Should be grasping and transferring objects hand to hand
Screening for Motor Delays: 18 month milestones (2)
- 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.
Screening for Motor Delays: 30 month milestones (3)
- 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.
Screening for Motor Delays: 48 Months Milestones (3)
- 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.
Scarf Sign for Tone Assessment of Shoulder Girdle (normal, low, high tone)
Normal Tone: elbow position is between bilateral and midclavicular line
Low Tone: elbow crosses midline to contralateral midclavicular line
High Tone: elbow doesn’t cross ipsilateral midclavicular line
Testing Scarf Sign
With child supine or sitting, pull arm across opposite shoulder until resistance occurs. Note shoulder position in relation to bilateral midclavicular line and the midline of the chest
Popliteal Angle for Hamstring Assessment
With child supine, flex the hips to 90 degrees with child’s torso supine on the table. Slowly extend leg at knee until resistance occurs. Note angle between lower leg and vertical
Gower Maneuver
Assessment of Strength
Characterized by an ambulatory child’s inability to rise from the floor without pulling or pushing up with his arms.
Grading Muscle Strength
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
3 examples of myotonia/myopathy
- Spinal muscular atrophy
- Muscular dystrophy
- Myotonic dystrophy
Duchenne Muscular Dystrophy Clinical Manifestations (8)
- Toe walking
- Calf pseudohypertrophy - calf is as large as thigh
- Positive Gower’s maneuver: inability to rise from the floor without pulling or pushing up with his arms
- Lumbar lordosis
- Multifocal contractures/Myotonia
- Trendelenburg gait
- Fatigue
- Weakness of the neck flexors, as evidenced by marked head lag when the child is pulled to sit from the supine position
Pronator Drift
1st: Ask patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed
2nd: Instruct 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) if they have upper motor neuron disease
*Indicates upper extremity weakness
Rapid Alternating Movement Tests (3)
Checks Coordination
- Ask 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 patient to tap distal thumb with tip of index finger as fast as possible
- Ask patient to tap your hand with the ball of each foot as past as possible
Point-to-point movement tests (3)
Checks coordination
- Ask 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 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. Repeated with the patient’s eyes closed
Graphesthesia
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.
Stereognosis
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.
Left to right confusion
Most children can identify left and right by age 8
Hand preference
- Hand preference is generally established by age 3
2. Left hand preference or mixed hand preference are neurodevelopmental markers
Dystonic Posturing
- Stiffening of the extremities during a stressed gait or rhythmic movements
* Child hops in place or heel toe walk
* Hand goes up on weak side
Proximal Inhibition
Inability to inhibit proximal musculature while using distal muscles
*Have 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
Glasgow Coma Scale
- Best eye opening response (1-4)
- Best motor response (1-6)
- Best verbal response (1-5)
Depressed Skull Fracture (2)
- Hematoma at site
2. Piece of bone depressed into brain
Compound Skull Fracture (3)
- Laceration and depressed skull fracture
- Dura usually pierced
- Skull fragment may be displaced into the brain tissue
Basilar Skull Fracture (2)
- Break in the posterioinferior portion of the skull occurs
- Produces dural tears that result in leakage of cerebrospinal fluid
*Meningitis = basilar
Epidural Hematoma
blood between the dural surface and the skull; usually result of a tearing in the meningeal artery
*Not common before 2 years old
Signs of Epidural Hematoma (5)
- Headache
- Decreased LOC
- Fever
- Dilation of pupil on affected side
- May originally say they’re ok but need to watch for change in affect
Signs of Basilar Skull Fracture (4 early, 2 delayed)
Early: 1. Blood behind tympanic membrane 2. Nerve palsies (paralysis) 3. Deafness or ringing in the ears 4. Dizziness; nausea and vomiting Delayed: 1. Battle’s sign (bruising over temporal area) 2. Raccoon sign (Bruising around the eyes)
Newborn presentation of Meningitis (4)
- Fever
- Nonspecific symptoms (poor feeding, v/d, rash)
- Bulging fontanel
- Irritable, restless, or lethargic
Older child presentation of Meningitis (4)
- Sudden fever (high!)
- Headache
- N/V
- Confusion, stiff neck, photophobia
Meningitis presentation in patients with VP shunts (5)
- Low grade ventriculitis
- Headaches
- Nausea
- Minimal fever
- Malaise
