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Clinical Paediatric Examination > Neurology > Flashcards

Neurology Flashcards

1
Q

what are the four different areas to test the optic nerve

A

visual acuity, fundocopy, visual fields and pupillary reflex

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2
Q

what is the direct light reflex

A

pupillary constriction on the stimulated side

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3
Q

what is the consensual light reflex

A

constriction of the pull on the unstimulated side

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4
Q

what is the accommodation reaction

A

when the child looks near objects the eyes converge and the pupils constrict. Look at the ceiling then look at my finger

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5
Q

what is the amblyopic light reaction

A

afferent defect due to damage of the optic nerve: there is no direct light reflex but a consensual light reflex as the motor pathway is intact

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6
Q

Argyll Robertson pupil

A

loss of direct and consensual light reflexes but near convergence reflex is preserved (midbrain lesion usually syphilus)

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7
Q

what is the tonic pupillary reaction

A

this is the Holmes Adie pupil- the reaction to light appears absent and there is a delayed and sustained accommodation reaction. They is a benign condition due to a lesion in the ciliary ganglion, generally encountered in young adult women and is associated with absent ankle jerks.

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8
Q

what causes constricted pupils

A

horners syndrome
drugs

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9
Q

what are the symptoms of horners syndrome

A

partial ptosis
pupillary constriction
enophthalmos
anhidrosis
the lesion can occur at different sites central, brain stem, or peripherally.

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10
Q

what cranial nerve palsy causes a dilated pupil

A

CN III palsy

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11
Q

how to test for confrontation perimetry

A

for an older child bring an object from beyond their field of vision and ask them to say yes when they see the object. test each eye separately t=and then test the two together

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12
Q

how do you test for scotomata

A

testing for defects in the central field: with one eye closed combare your visual filed with that of the child, using a small red pin held midway between you and the child and asking him to focus on your eye.

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13
Q

what are scotomata seen in

A

bending raised intracranial pressure
raised intracranial pressure
migraine
(also with eye signs of pailloedema and optic atrophy)

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14
Q

how to test for field of vision in a younger child

A

shine a light or show a toy at the periphery of the visual fields and move it around until the child attention is caught

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15
Q

what is the menace reflex

A

in a child with homonymous hemianopia or where vision is questionable in an infant, a reflex blink is produced in response to your hand rapidly passing by the eye to the ear.

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16
Q

what are some causes of homonymous hemianopia

A

cerebral haemorrhage or neurosurgical procedure

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17
Q

what are the causes of bitemporal hemianopia

A

pituitary tumour or craniopharyngioma

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18
Q

what causes disorders of ocular movement

A

cerebral palsy
tumours
raised ICP
post- meningitis
Guillian Barre Syndrome

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19
Q

what are the signs of a third nerve palsy

A

a paralytic divergent squint
lateral deviation of the eye
ipsilateral pupil may be normal or larger and unreactive
ipsilateral ptosis
demonstrate diplopia using a pen except during lateral gaze to the side of the lesion

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20
Q

signs of a 4th nerve palsy

A

down and out eye
with compensatory torticollis

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21
Q

what are the signs of a sixth nerve palsy

A

convergent squint as the affected eye deviates inwards
compensatory torticollis
failure of lateral gaze to the affected side

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22
Q

in internuclear ophthalmoplegia which side do the eyes look towards

A

they look towards the normal limbs (there is usually contralateral hemiparesis)

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23
Q

what are the three devisions of the trigeminal nerve - sensory

A

ophthalmic, maxillary and mandibular

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24
Q

who do you test the motor component of the trigeminal nerve

A

inspect the muscles of mastication for wasting or fasculations
ask the child to open his mouth and to keep it open while you push against the child.
in unilateral lower motor lesions the jaw deviates to the weak side.
ask the child to clench the teeth hard and assess the bulk and symmetry

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25
Q

in Duchenne what can happen with the bulk of mass esters

A

it may be increased

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26
Q

how do you test the sensory and motor reflexes of cranial nerve 5

A

corneal reflex (can be done but not needed) which test the sensory of CN 5 and the motor component of CN 7
Jaw jerk reflex

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27
Q

what does an increased jaw jerk reflex mean

A

it is only present if there is a bilateral upper motor neurone CN 5 lesion (pseudo bulbar palsy)

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28
Q

what are some causes of a trigeminal nerve lesion

A

peripheral: trauma, tumour of the base of skull, herpes zoster infection of the ophthalmic division
central: cavernous sinus lesion
cerebellopontine tumour
bulbar palsy (motor nuron disease)
bilateral pseudo bulbar palsy (hypoxic ischemic injury)

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29
Q

how do you test the motor component of the facial nerve

A

raise the eyebrows
close the eyes tight
smile and show your teeth

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30
Q

what is the sensory component of the facial nerve

A

the anterior two thirds of the tongue

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31
Q

what is the parasympathetic division of the facial nerve

A

this supplies the lacrimal gland and inability to produce tears is a feature of some of the congenital sensory neuropathies.

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32
Q

how do you test the reflexes of the facial nerve

A

glabella reflex- tap the start of the nasal bridge
this will illicit blinking but should disappear after three or four contractions.
snout reflex- tapping or stroking the upper lip gives rise to Pickering response- abnormal beyond infancy

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33
Q

what does a positive glabella reflex mean

A

disorder in the extrapyramidal system- rare in children seen in parksinsons

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34
Q

what is the snout reflex positive means

A

abnormal beyond infancy and is indicative of a bilateral upper motor neurone lesion

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35
Q

what anatomically is meant when I say upper motor neuron lesion

A

above the level of the pons

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36
Q

when there is a unilateral lesion of the 7th cranial nerve what does that mean

A

that the contralateral side of the face is weak below the level of the eyes but the forehead is spared because it relies bilateral innervation

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37
Q

when there is a bilateral lesion- upper motor neuron of CN 7 what does that look like

A

obvios snout reflex, lability of emotional expression and occasional dissociation between emiotnla and voluntary movements (both muscles sides are affected.

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38
Q

what is a lower motor neuron lesion - unilateral lesion

A

asymmetry of the face may be present with loss of nasolabial fold and dropping of the corner of the mouth and drooling on the affected side.
all the muscles on the affected side are effected

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39
Q

how to determine whether or not a hearing loss is sensory or conductive

A

weber and rinne test

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40
Q

what is the causes of conductive deafness

A

chronic secretory otitis media (glue ear)

41
Q

what are the causes of perceptive deafness

A

prenatal causes (60%)
inherited (50%)- isolated or part of a syndrome (Pendres’s, Waardenburg)
intrauterine infection (toxoplasma, rubella, CMV, Syphilis)

42
Q

what are the perinatal causes of deafness

A

birth asphyxia
kernicterus
aminoglycosides

43
Q

what are the postnatal causes of deafness

A

meningitis
encephalitis
trauma
ototoxic drugs

44
Q

what are some history red flags which would have you investigating whether a child has hearing loss

A

a family history of deafness
low birthweight
cleft palate
GDD
delayed language milestones
history of recurrent ear infections or CNS infection
parental concern

45
Q

what does the auditory nerve (8th) nerve have two components of

A

vestibular nerve (conveys postural sensation from the labyrinth of the inner ear)
cochlear nerve (auditory impulse from the inner ear)

46
Q

what is nystagmus

A

characterised by involuntary oscillations of the eye, which may be horizontal, vertical or rotatory
it is defined by the direction of the fast phase but it is the slow phase which is pathological

47
Q

what is nystagmus caused by

A

a lesion of the cerebellum, brain stem, cervical cord or inner ear

48
Q

how to test for nystagmus

A

ask the child to fix on your finger (2 feet away) and move your finger through a clock face from 3 to 9 then 6 to 12 for 5 seconds at each position. If nystagmus is present the ye will drift away from fixation and must be sustained for more than a few beats

49
Q

what are the causes of central nystagmus

A

results from brain stem lesions (vertebrabasilar schema and phenytoin toxicity)
can be in any direction

50
Q

what causes up beat nystagmus

A

lesion in the floor of the fourth ventricle, pontine tegmentum

51
Q

what causes down beat nystagmus

A

extrinsic compressive lesion of the foremen magnum.

52
Q

what is cerebellar nystagmus

A

nystagmus will go towards the side of the lesion

53
Q

what are the features of vestibular nystagmus

A

only in one direction of gaze
it is always away from the side of the lesion
it is made worse by gaze in that direction (alexander’s law)
it is horizontal or rotational but not vertical
may be associated with tinnitus or deafness

54
Q

what are the features of positional nystagmus

A

occurs in benign positional vertigo and is brought on by rapid head movements often associated with a delay of a few seconds and fatiguability (hallpike test)
occurs in only one direction

55
Q

what are the features of ocular nystagmus?

A

due to poor macular vision which impairs retinal fixation
often rotatory on central fixation but can be pendular
frequently congenital

56
Q

what are the features of ataxic nystagmus

A

occurs in internuclear ophthalmoplegia due to a gaze palsy. The adducting eye does not move and there is nystagmus of the of the abducting eye

57
Q

what are the features of see-saw nystagmus

A

one eye rises and turn in and the other eye falls and turns out like a see saw
occurs in parasellar tumours

58
Q

optokinetic nystagmus

A

can be induced in normal children the catford drum or car passing fence poles

59
Q

what is congenital nystagmus

A

rapid rhythmic eye movements with normal vision the cause is unknown and can be familial. the rest of the exam is completely normal.

60
Q

what are the two divisions of the glossopharyngeal muscle

A

motor: the CN 9th nerve supplies the stylopharyngeus muscle which elevates the upper pharynx together with the palatopharyngeal muscle (10th CN)
sensory: sensation from nasopharynx and the soft palate and taste from the posterior third of the tongue

61
Q

what does the vagus nerve supply

A

motor: voluntary muscles for the pharynx and the larynx. the parasympathetic fibres supply the heart, lungs, and abdominal viscera

gag reflex and palatal reflex

62
Q

what are symptom clues to dysfunction in the palatal reflex

A

dysarthria, nasal speech, and difficulty in swallowing

63
Q

how do you test the spinal accessory nerve

A

ask the child to shrug their shoulders
turn their head to one side while you place your hand on the medial side of the jaw and ask them to push against you. This test the sternocleidomastoid on the opposite die to which the head is turned

64
Q

what does the hypoglossal nerve supply

A

CN 12 supplies the mussels of the tongue.

65
Q

how do you test the hypoglossal nerve

A

inspect for fascination (lower motor neuron disease)
ask the child to stick out her tongue

66
Q

what does a unilateral lesion of CN 12 look like on examination of the tongue

A

causes ipsilateral atrophy and deviation of the tongue to the affected side

67
Q

what are you looking at during inspection of a baby

A

obvious dysmorphic features
ataxic telangiectasia

68
Q

What is the definition of Sturge Weber Syndrome

A

a port wine stain affecting the are of one or more division of the trigeminal nerve usually the ophthalmic division is present from birth

69
Q

what are the things associated with Sturge- Weber syndrome

A

30% have contralateral hemiplegia
30% have learning difficulties
although learning difficulties are only present if the child had epilepsy

70
Q

what to look for in terms of posture in the neonate

A

consistently maintained asymmetric posture should always arouse suspicion. The typical posture in the newborn is flexion.
1. torticollis
2. spinal curvature
3. hypotonia
4. Hypertonia
5. generalised hypertonia
6. opisthotonus

71
Q

what is the definition of a tic

A

an identical movement repeated

72
Q

what is a tremor

A

involuntary, rhythmical alternating movement

73
Q

what is titubation

A

tremor of the head and neck

74
Q

what is chorea

A

rapid, involuntary, irregular movements usually of the extremities or the face, which may interfere with effort or excitement

75
Q

what are the causes of chorea

A

anticonvulsant therapy (rare)
benign hereditary chorea
juvenile onset Huntington’s disease
sydenhams chorea

76
Q

what is athetoid mean

A

slow involuntary writhing movements, usually of the proximal limbs.

77
Q

what are the causes of athetoid movements

A

cerebral palsy, basal ganglia disease in particular Wilsons disease

78
Q

what are the causes of unilateral ptosis

A

Horner syndrome (pupil small)

79
Q

what are the signs of myopathy

A

restricted eye movements
long thin face
drooping mouth
lack of expression
thin
may be breathless
kyphosis/ scoliosis

80
Q

what are the causes of myopathy

A

nemaline rod myopathy
centronuclear myopathy
congenital myotonic dystrophy

81
Q

what are the symptoms of dysphonia

A

a whispering, high pitched voice or cry or dysphonia suggests damage to the recurrent laryngeal branch of the Xth CN.

82
Q

when do the fontanelles close at

A

1 year, delayed closure should be investigated if present at 18 months

83
Q

delayed suture closure causes

A

hydrocephalus
down’s syndrome
hypothyroidism

84
Q

what do abnormally wide fontanelles suggest

A

rickets
hypothyroidism
cranial synostosis
rare syndromes (smith lemi opitz syndrome)

85
Q

how do you know if the anterior fontanelle is enlarged

A

length plus width divided by 2 (mean anterior fontanelle measurement)
this is 2 cm at birth but can range between 0-5cm in the first year of life

86
Q

when does handedness become obvious

A

from 1.5 to 5 years old

87
Q

when would you be concerned about handedness

A

in a child less than 18 months - look for other signs of hemiplegia

88
Q

loss of muscle bulk in a neonate may be due to?

A

lower motor neurone lesion, disuse atrophy or generalised wasting

89
Q

what upper limb posturing would suggest a pyramidal tract problem

A

shoulder adduction, elbow flexion and hand clenched suggest cp

90
Q

when should all children be able to get to their feet from the supine position

A

by 18 months (gowers sign)

91
Q

when should a child be able to sit up from a supine position

A

by 6 years old they should be able to sit up with their hands folded across the abdomen

92
Q

when should all children be able to sit unsupported

A

all children over 10 months, if not it may be due to weakness or truncal ataxia

93
Q

what are the commonest causes of delayed walking

A

bottom shuffling and familial delay

94
Q

what is the wasting pattern in muscular dystrophies and myopathies

A

prox to distal

95
Q

what is the wasting pattern in neuropathies

A

distally to proximally

96
Q

testing gait- by 3 what can you expect

A

walk on the heels and tip toes
run
stand on one leg for 5 seconds

97
Q

what can you expect from a four year old: gait

A

able to hop

98
Q

what can you expect from a 5 year old- gait

A

able to walk in a straight line for 20 steps

99
Q
A

Clinical Paediatric Examination (11 decks)

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