Neurological PE Flashcards
1
Q
What are notes in Neurological hx?
A
Identify the child at risk
Developmental milestones
Review of systems
Temporal profile and localization
Effect of the problem on daily function
Medications
Allergies
Fam Hx
2
Q
What are noted iin the pregnancy hx of the motehr?
A
Mother’s age during pregnancy
Hx of prev pregnancies
Prenatal exposure to presc
Maternal wt
INC or DEC fetal movements
Prenatal ultrasound
3
Q
What is noted in Perinatal hx?
A
Labor & delivery hx
Need for resuscitation
Birth wt, length, head circumference
4
Q
What are notes in the ROS of neuro PE?
A
Feeding problems
Respiratory difficulties
Ambulatory/coordination problems
5
Q
What are Qs asked in neuro exam?
A
Is there a neuro disorder?
Where is the lesion?
What pathologic lesions are most likely present at this site?
6
Q
What S/Sx should be noted if there is neuro disorder?
A
INC ICP
Meningeal irritation
Neurological deficits
7
Q
What are S/Sx of diff parts of the brain Corticacl, subcortical (white matter), basal ganglia, cerebellar?
A
- Cortical: seizures & strokes
- Subcortical: strokes
- Basal ganglia: strokes, dystonia, choreoathetosis, Sydenham’s chorea, Wilsons disease
- Cerebellar: viral illnesses, brain tumor causing ataxia, scanning speech, nystagmus, fine motor deficits of the hands
8
Q
What are S/Sx of diff parts of the PNS like Spinal cord, peripheral nerves, NM junction, muscle?
A
- Spinal cord: bowel & bladder incontinence, weakness below a certain level
- Peripheral nerves: Guillan-Barre syndrome
- NM junction: Myasthenia gravis
- Muscle: diffused and progressive motor weakness seen in Duchenne muscular dystrophy
9
Q
What is the ordered sequnce of examination?
A
Vital signs
Anthropometric measurements
General physical exam
MSSE
CN exam
Motor exam
Cerebellar exam
Sensory exam (peripheral and cortical)
10
Q
What are unquestionaby neurologic signs?
A
Altered sensorium
Seizures
Devt delays/regression
Language problems
Disorders of cognitive function
11
Q
What are subtle signs of INC ICP?
A
- INC head size in infants
- diminished venous pulsations in fundoscopy
- 6th nerve palsy/Abducens nerve palsy
- Head tilt/stiff neck
- “sun setting” eyes
12
Q
What subtle sign of INC ICP is common in uncorrected, severe hydrocephalus?
A
“Sun setting” of eyes
13
Q
What are diff signs of Meningeal irritation?
A
Nuchal rigiditiy
Spinal rigidity
Head tilt
Photophobia
Kernig’s sign
Brudzinski’s sign
14
Q
What is a positive Kernig’s sign?
A
When the hip & knee are flexed to 90 deg, subsequent extension of the knee is painful
Kernig, Knee EKstension, is painful
15
Q
What is a positive Brudzinski’s sign?
A
When neck is flexed, hips, and knees also flex
16
Q
What spots on the skin is indicative of neurofibromatosis?
A
Cafe au lait spots
17
Q
What type of skin ppigmentation is indicative of tuberous sclerosis?
A
Hypopigmented macules
18
Q
What is checked in the corneas & lenses for opacities?
A
Cataracts
Inborn errors of metabolism
TORCH infection
19
Q
What are inspected in the midline of the neck, back, and pilonidal areas?
A
- tufts of hair & abnormal birthmarks (along spine)
- dimples along the back at the midline -> congenital spine defect
20
Q
What is Cushing’s triad?
A
Happy Birthday Irene!!!
Hypertension
Bradycardia
Irregular breathing
All cause INC ICP & altered sensorium
21
Q
What other signs during vital signs can indicate a neuro problem?
A
Abnormal respiratory patterns for BP
Heart rate
Respiratory rate
22
Q
What is the lcoation of Cheyne-Strokes, Central hyperventilation, & Apneustic breathing?
A
Cheyne-Strokes = Bihemispheric dysfunction
Central hyperventilation = Lower middbrain & Upper pons
Apneustic breathing = Mid to lower pons
23
Q
What is the location of Cluster breathing, Ataxic breathing, & Ondine’s curse?
A
Cluster breathing = lower pons & upper medulla
Ataxic breathing = central medulla
Ondine’s curse = medulla or lower cervical cord
24
Q
What are the diff general appearance with dysmorphic features?
A
- Hypotelorism = Holoprosencephaly & Trisomy 13
- Hypertelorism = Sotos syndrome, Cleft palate, Apert
- Inner epicanthal folds = Down syndrome, Rubinstein-Taybi, Zellweger
- Slanted palpebral fissue = Down syndrome, Apert, Di George, Miller Dieker
- Low set ears = Noonan, Treacher Collins, Pena-Shokeir, Trisomy 9&18
25
What are diff neurocutaneous stigmata?
1. Hypopigmented patches = tuberous sclerosis
2. Cafe au lait spots = Neurofibromatosis 1
3. Port-wine stain = Sturge-Weber syndrome
4. Petechial hemorrhage s= CMV (blueberry muffin sign)
5. Macular rash = SLE
6. Vitiligo = AID (Myasthenia gravis)
26
During head examination, what should be done?
Inspection
Palpation
Percussion
27
What are noted during Inspection?
1. Macrocephaly = open & large fontanels
2. Microcephaly = closed fontanels
3. Craniosynostosis = palpable, ridgy or pointy sutures
4. Venous distention = promninent scalp veins
5. Flattened occiput = delayed child
6. Bulging occiput = Dandy-Walker cyst
7. Biparienal enlargement (devils horns = bilatral chronic subdural hematomas
28
What is the mean head circumference from the normal population in Macro & Microcephaly?
Macrocephaly: HC >2SD
Microcephaly: HC <2SD
29
What are noted in palpation of the head?
- palpate for cranial structures & fontanels gently
- head circumference
- tenderness
- MacEwan sign (cracked pot sound) = INC ICP, abscess & hydrocephalus
- Craniosynostosis
30
What are premature fusion of the sagittal suture leading to expansion of the head from font to abck/forward and backward
Scaphocephaly
31
What condition has a premature closure of coronal suture that is shortened in the anteroposterior dimension?
Bachycephaly
32
What are diff category of Neonatal neurological examination?
Level of alertness CN nerves (CN I - XII)
Motor examination = tone & posture, motility & power, tendon reflexes & plantar response
Primary neonatal reflexes = moro reflex, palmar grasp, tonic neck response
Sensory exam
33
What are noted in mental status of neuro of the newborn?
level of consciousness
Orientation to person, place, & time (older pedia px)
Higher cortical functions
Language dunctions
Praxis
Grapho-motor/visuo-motor skills
34
What is the Pedia Glasgow coma scale threshold?
15 = normal & awake
<8 = sevre injury; traumatic brain injury
3 = brain dead
35
What is the normal Pediatric glasgow coma scale accdg to age?
Birth-6 months = 9
7-12months = 11
1-2 yrs = 12
2-5 yrs = 13
>5 yrs = 14
36
What are pediatric GCS & their scoring?
Eye opening
- spontaneous = 4
- to touch = 3
- to pain = 2
- none = 1
Verbal
- oriented = 5
- words = 4
- vocal sounds = 3
- cries = 2
- none = 1
Motor
- obeys command = 5
- localizes to pain = 4
- flexion to pain = 3
- extension to pain = 2
- none = 1
37
How do u check for visual acuity of pedia px?
Standard visual charts = toddlers
Blink reflex to bright light = 28 wks gestation
38
What is double simultaenou presentation?
- 2 obejcts are presented at the same time
- If px prefers 1 object, switch the objects and see if the baby still looks at the preferred object
- If they do not follow that object -> there may be a problem
39
What is noted in Fundoscopy of pedia px?
Shaken infant syndrome = caused by head trauma, whiplash, forceful shaking —> RETINAL HEMORRHAGE
40
What is indicated is there is Leukocoria in the red reflex test for pedia px?
Abnormal
- no red reflex -> opacity of the cornea of the lens
41
What is the afferent & efferent limb of Pupillary light reflex?
Afferent limb: CN II
Efferent limb: CN III
42
What syndrome is seen if there is interruption of the sympathetic innervation to the pupil characterized by ptosis, miosis, & unilateral facial anhidrosis?
Horney syndrome
43
What are signs of lesion in the brainstem for pupils of comatose px?
Diencephalon (reached this) => pupils become small & reactive
Tectum = large & fixed
Midbrain = remain in midposition & fixed
Pons = pupils are tiny & pinpoint
Medulla = irreversible
CN III involvement = blown, asymmetric, dilated, fixed pupil in one side
44
What is assesed in eye movements for Oculocephalic vestibular reflex?
Doll’s eye phenomonenon
45
At what age does conjugate eye movements present?
25 wks AOG
46
What are the 3 types of diplopia?
* unilateral CN III (CN III palsy)
* Vertical diplopia
* Horizontal diplopia
47
What is seen in CN III palsy?
eye deviates down & out with associated ptsois and a dilated mydriatic pupil
48
what CN is affected in vertical diplopia?
Trochlear nerve (palsy to)
49
how does Vertical diplopia present?
wjen the px is asked to see an object, double vision is vertical -> second image of the targeted object apepars above or below the actual target
50
What CN is affected in Horizontal diplopia?
CN VI (palsy)
51
how does Horizontal diplopa present?
when the px is asked to see an object, double vision is horizontal
52
in what cases do we see Horizontal Diplopia more often?
px who have progressive INC ICP caused by a tumor
53
what is seen when there is rhymthmic oscillations of one or both eyes?
nystagmus
54
what is seen when ther is a misalignment of both eyes?
Strabismus
55
Nystagmus & Strabismus are commonly assoc with what conditions?
INC ICP secondary to cerebellar tumor
56
what causes Strabismus?
immaturity/weakness of the eye muscle, cranial nerve palsy or secondary to amblyopia
57
what are the different interior and superior oblique palsies
head tilt
inferior oblique palsy
superior oblique palsy
58
what is a type of palsy that is seen in both inferior and superior palsy with px's head tilting their heads so the eyes become aligned & they will not have a double vision?
head tilt
59
what type of palsy presents as head tilt as they compensate for double vision?
inferior obliqyue palsy
60
what type of palsy causes the head tilt to compensate for the double vision?
superior oblique palsy
61
what cranial nerve has action of muscles of mastication observed in an infant as they suck or swallow?
CN V (trigeminal n)
62
what are other movements in CN V?
jaw jerk
corneal reflex
facial sensation (V1, V2, V3)
63
what reflex becomes abnormal if asymmetric or absent?
corneal reflex
64
what is the predominant motor nerve that innervates the muscles of facial expression?
CN VII
65
how do you assess CN VII?
* observe the face during rest, crying and blinking
* facial strength: spontaneous movements, mimic a series of facial movements
66
what is UMN & LMN paresis?
* UMN paresis = CL weakness, lower quadrant on the face
* LMN paresis = ipsilateral weakness: whole
67
what should be distinguished from CN VII palsy?
hypoplastic depressor anguli oris
68
what reflex has ipsilateral blinking when tapping the supraorbital ridge?
McCarthy reflex
69
what are the 2 components of CN VIII?
vestibilar nerve
cochlear nerve
70
how do you assess hearing in infants & older children?
* Infants = ring a bell or click ballpoint pen
* Older children = repeat whispered word
71
at what age does turning of eyes with head appear?
3-4 months
72
what is the abnormality that suggests impaired brainstem function?
hypoxic ischemic encephalopathy or perinatal asphyxia
73
what is assessed in CN IX & X?
* position of uvula at rest
* quality of voice
* palatal movements during phonation
* Swallowing and drooling
74
What reflex is absent in 1/3 healthy individuals that is brisk at all ages except the very immature neonate?
Gag reflex
75
how does a lesion in CN IX & X present?
absent gag reflex
76
what are presentations of unilateral lesion?
* weakness of the ipsilateral soft palate
* hoarse voice
77
what are presentations of bilateal lesion?
* respiratory distress
* nasal regurgitation
* pooling of secretions
* immobile, low-lying soft palate
78
how do u assess CN XI?
* note movements of head side to side
* shruggin of shoulders in young children
* strength of muscles and against resistance in older children
79
how do u assess CN XII?
* note position of the tongue at rest
* deviation during protrusion of the tongue also deviates towards the weak side
80
what is indicated if thre is abnormal fasciculations in the lateral aspect of the tongue?
Infantile spinal muscular atrophy (SMA 1) or
Wednig-Hoffman disease
81
what is assessed during palpation?
muscle tone
82
what is the tone of infants during 3rd month?
normal hypertonia of the elbows, hips & knees
83
what are msucle tones in infants?
* First few months = normal hypotonia of the flexors of the elbows, hips, and knees
* Between 8-12mons = DEC in flexor tone w/ corresponding increase in extensor tone
* 28 wks preterm = all 4 extremities are extended with little resistance to passive movement
* 32 wks preterm = flexor tone is visible in the lower ex
* 36 wks preterm = flexor tone is palpable in upper ex
* normal term = flexion of all 4 ex
84
what are the 3 key tests for assessing posture tone in neonates?
* traction response
* vertical suspension
* horizontal suspension
85
how do u asses for traction response in neonates?
1. grasp the infant's hands & gently pull the infant to a sitting position
2. normally, head lags slightly behind the body & then falls forward upon reaching the sitting position
86
how do u assess vertical suspension?
1. hold the infant by the axillae without gripping the thorax
2. infant should remain suspended with the infant's lower extemities held in flexion
3. hypotonic infant will slip through ur hands
87
how do u assess horizontal suspension?
1. hold the infant prone by placing a hand under the infant's abdomen
2. head should rise and limbs should flex
3. hypotoniuc infant will drape over the physician's hand forming a U shape
88
what are signs of hypotonia?
* floppy infant
* scarf sign
* U shaped on horizontal/vertical suspension
* slipping through armpit on vertical suspension
* head lag on pull-to-sit (no traction response)
89
what is a severe hyperextension of the spine caused by hypertonia of the paraspinal muscles exhibited by px with either spasticity or rigidity?
Opisthotonos
90
what is a severe hyperextension of the spine caused by hypertonia of the paraspinal muscles exhibited by px with either spasticity or rigidity?
Opisthotonos
91
what is seen in hypertonia where there is "buried" or "cortical" thumbs?
fisting
92
what is a sensitie test for weakness?
pronator sign
93
what is the muscle strength grading in power?
* Grade 0 = no muscle contraction
* Grade 1 = flicker or trace of contraction
* Grade 2 = active movement, gravity ELIMINATED
* Grade 3 = active movement AGAINST GRAVITY
* Grade 4 = Active mvement against gravity and resistance
* Grade 5 = normal power
94
what are presentation of Brachial plexus birth injury?
* Erbs-Duchenne palsy (C5-C6)
* Klumke's palsy (C8-T1)
95
what are diff motor abnormalities?
* tremors
* myoclonus
* fisting of the hand = "cortical thumb" due to hypertonia
* Opisthotonus
* asymmetry at rest in infants
96
what are the different abnormalities in movement disorders?
* athetosis
* chorea
* tics
* dystonic posturing
97
what is a movement disorder where there is slow, writhing, continuous, involutnary movement?
Athetosis
98
what is an involuntary, continual, irregular movements with var rate and direction that occur unpredictably & randomly?
chorea
99
what is an intermittent and sustained involuntary muscle contractions that produce abnormal postures?
dystonic posturing
| q
100
what is the presentation of motor weakness in UMN & LMN?
UMN: spastic w/ hyperrreflexia
LMN: flaccid with hyporeflexia
101
what are diff examples of motor weakness?
* polio
* Guillan Barre syndrome (Acute polyradiculoneuropathy)
* Myasthenia gravis
* Myopathy/Muscular atrophy (Duschennes, Beckers)
* Botulinum toxin, Saxutoxin, Cigauatera toxin)
102
what are common causes of hemiparesis/paresis?
* acute arterial ischemic stroke
* hemorrhagic stroke
* demyelinating disease
* venous thrombosis
* brain tumors
103
what are diff gait abnormalities?
* circumduction gait at the hips -> spasticity
* broad-based ataxia -> cerebellar
* Waddling hip gait -> myopathies like DMD
* Dystonia
104
how can u assess Dysmetria?
child reaches for and manipulates toys
105
at what age can u expect tandem gait to be performed?
6 yo
106
what parts of the brain is indicated if tremor is approaching the target and tremor is resing?
resting = basal ganglia
approaching the target = cerebellar
107
what are routine DTRs?
Biceps, triceps, brachioradialis, patellar, ankle jerks
108
in what cases do you see crossed adductor reflex?
spastic cerebral palsy
109
when does cross adductor reflex disappear?
9-12 months
110
what does a sustained lonus suggest?
pyramidal tract lesion
111
what are the diff modiciations of babinski reflex?
oppenheim
gordon
chaddock
gonda
bing
112
what are the diff primitive reflexes?
* moro reflex
* tonic neck reflex
* sucking & rooting reflex
* righting reflex
* palmar & plantar grasps
113
when does Moro reflex appear and when does it fade out?
appears = 28-32wks AOG
fades out = 3-5 mons
114
what if moro reflex persists beyond 6 mons?
abnormal
| absent in very small prematures & depressed newborns
115
what if moro reflex persists beyond 6 mons?
abnormal
| absent in very small prematures & depressed newborns
116
what is the tonic neck reflex?
assumes a "fencing-like" posture
117
when does tonic neck reflex occur?
* appears: 1st wk, fully developed by 1 month
* disappears: 6 mons; persistent beyond is abnormal
118
when does the sucking & rooting reflex appear and when does it end?
appears: 28wks
disappears: 3 mons
119
in what cases does sucking & rooting reflex absent and persist?
* absent = depressed or septic babies
* persistent = cerebral palsy, neurodegenerative disorders, dementia
* reappears: frontal lobe dysfunction
120
in what cases does sucking & rooting reflex absent and persist?
* absent = depressed or septic babies
* persistent = cerebral palsy, neurodegenerative disorders, dementia
* reappears: frontal lobe dysfunction
121
what is the motion of Righting reflex?
ifnant supine -> turn head to one side -> ifnant rotates thr shoulder to same direction -> trunk & finally the pelvis
122
what are obligatory synergies?
shoulder, trunk, and pelvis rotate simultaneously like rolling a log, is always abnormal
123
when does palmar and plantar reflex appear and disappear?
appear: 28-32 wks
disappears: 5-6 months
124
what are different developmental reflexes?
* Buttress response
* Parchute response
125
what developmental reflex has an infant extending the CL arm & spreading the fingers?
Buttress response
126
when does Buttress response normally appear & if delayed, what does that mean?
* appears at 5months
* delayed: neurologic dysfunction
127
what developmental reflex has a child suspended horizotnally & THEIR arms extended & fingers spread when projeted toward the floor?
parachute response
128
when does parachute response emerge & when is it well-developed?
emerge: 6 months
well-developed: 8-10mons
128
when does parachute response emerge & when is it well-developed?
emerge: 6 months
well-developed: 8-10mons
129
when is parachute response abnormal?
if not expressed by 1 yr or asymmetric
130
what are diff autonomic functions that need to be noted?
* excessive salivation
* excessive lacrimation
* sweat pattern
* skin color & temperature
* bowel & bladder symptoms
* vital signs
* Horner's syndrome
131
what are most common "soft" neurological signs?
* choreiform movements
* jerky ocular pursuit
* motor impersistence
* reflex asymmetry
* gross & fine motor incoordination
* R/L disorientation
* inability to distinguish double tactile stimulation
* Synkinesia
132
what is the cut off stage for most of the "soft" neurological signs?
6 yrs
133
what are modes of prsnetation of developmental delays?
* 1st months = poor suck, hypotonia or hypertonia, lack of visual or auditory response
* 18 months = motor delays
* >2 yrs = speech delay and aberrant behavior
* school-age: academic underachievment adhd symptoms
