Paediatrics: CNS Examination Flashcards
Tips for communicating and examining children
- Address children by their name (ask parents)
- Keep interactive
- Do examination at their level
- Parent’s help
- Warm hands
- Praise
- Gentle voice
- Toys, Games
***Paediatric neurological exam
- General inspection
- General state (well / unwell, calm / irritable, alert / drowsy)
- Growth (weight, height, head circumference / OFC (occipital frontal circumference))
- Head size and shape (plagiocephaly, brachycephaly (Down’s), scaphocephaly (hydrocephalus))
- Dysmorphic features + deformity
- Neurocutaneous markers (cafe au lait spots: NF, hypopigmented macules: Tuberous sclerosis, port-wine stain: Sturge-Weber syndrome)
- Skin (hyper / hypopigmented lesions; rash) - Head + Neck
- Face (symmetrical / asymmetrical facial grimace, abnormal facial movement, facial expression)
- Eyes (spontaneous eye opening, ptosis, nystagmus, ophthalmoplegia)
- Mouth (drooling) - Musculoskeletal
Inspection:
- Spine (tuft of hair, dimple, curve)
- Spontaneous movement
- Posture (resting posture, spontaneous active movement)
- Hand preference (before 24 months is abnormal)
Palpation:
- Tone
—> Hypotonia: scarf sign, traction maneuver, ventral suspension (inverted U shape), vertical suspension
—> Hypertonia: spasticity (pyramidal tract lesion), dystonia (basal ganglion lesion (extrapyramidal tract)), rigidity (rare, basal ganglion lesion (extrapyramidal tract))
- Muscle bulk
—> Anterior horn cell disease (Atrophy, Fasciculation) (e.g. SMA)
—> Muscular dystrophy (Pseudohypertrophy e.g. gastrocnemius, deltoids) (e.g. Duchenne)
—> Myotonic dystrophy (Myotonia by tapping over thenar eminence)
- Power
- Deep tendon reflex, Primitive reflexes
—> Hyperreflexia / Crossed adductor reflex
—> Hyporeflexia
—> Ankle clonus (newborn - 2 months: 3-6 beats of clonus; persistence + sustained: UMN lesion)
—> Babinski reflex (normal before 1 yo)
- External genitalia
- Response to touch
- Consciousness / Alertness
- CN system
- Motor system
- Sensory system
- Vibration
- Proprioception
- Light touch
- Pain - Cerebellar system
- Rapid alternating test (Dysdiadochokinesia)
- Finger-to-nose test (Intentional tremor + Dysmetria)
- Heel shin test
- Tandem walking
- Truncal ataxia
Primitive reflex
(Disappear at which month)
- Stepping reflex (2 months)
- hold baby vertically and walk with feet touching ground —> feet move in stepping motion - Rooting reflex (4 months)
- stroke cheek —> mouth moving to that side - ATNR reflex (Asymmetrical tonic neck reflex) (4 months)
- rotate infants head to side for 15 secs —> extension of limbs on side turned to with flexion of limbs on opposite side - Palmar grasp reflex (4 months)
- place index finger in palm —> flexion of fingers - Moro reflex (4-6 months)
- startle response - Galant reflex (4-6 months)
- truncal incurvation reflex
- child held prone, stroke along side of spine on one side —> flexion of trunk on that side (掃兩邊背脊會曲向個邊) - Plantar reflex (1 yo)
- extensor - Ventral + Vertical suspension
- level / 90oC
In general rule:
- most are gone by 6 months (with voluntary movement takes over)
- all are gone by 1 year
- lost in a cephalocaudal direction
Neonates examination
General inspection
1. Head size (OFC) (plot on percentile chart)
2. Head shape
3. Dysmorphism + Deformity (face, hand, feet, spine)
4. Skin, external genitalia
Consciousness / Alertness
5. Alertness / Responsiveness
CN system
6. Face (symmetrical / asymmetrical facial grimace)
7. Eyes (spontaneous eye opening, ptosis)
8. Mouth (drooling)
Motor system
9. Resting posture
10. Spontaneous active movement
11. Muscle tone
12. Deep tendon reflex
13. Primitive reflex
Sensory system
14. Response to touch
Cerebellar system
15. Nystagmus
Infant / Younger children examination
Extra:
CN system
1. Visual follow
2. Bulbar (making sounds, feeding)
Motor system
3. Postural reaction (***Forward parachute reflex)
4. Motor milestones (Gross + Fine motor)
Cerebellar system
5. Coordination
6. Hand tremor
7. Supportive + ***Lateral propping (6 months)
8. Toddler gait (wide based, 12 months)
Older children
Extra:
Consciousness / Alertness
1. Orientation (time, place)
2. Knowledges
3. MMSE
CN system
4. Similar to adult CN exam
Sensory system
5. Response to Light touch, Pain, Temp
6. Vibration, Proprioception
7. Cortical sensation: stereognosis, tactile discrimination, graphesthesia
Cerebellar system
8. Heel knee shin test
9. Finger nose test
10. Repetitive rapid hand movement
11. Romberg test (stand with close eyes)
12. Gait (base, speech, symmetry, stability, arm swing)
Behaviour and Developmental assessment
- Level of alertness
- Attention / Social communication / Understanding of commands
- Unable to fully cooperate during exam
- Like games
SpC Paediatric (Paed HKU website): Neurological Examination
Hypotonia
Hypotonia confirmed
—> Assess muscle bulk, power, deep tendon reflexes
—> Normal —> Non-paralytic
—> Decreased —> Paralytic
Non-paralytic:
1. CNS disease
2. Syndromal / Chromosomal disorders
3. Systemic illness
4. Connective tissue disease
5. Benign hypotonia
6. Neonatal asphyxia (early phase)
Paralytic:
1. Spinal cord
2. Anterior horn cell
3. Peripheral nerve
4. NMJ
5. Muscle
Hypertonia
Spasticity:
- Pyramidal tract lesion
- Velocity-dependent increase in resistance to passive stretch
- Increase by anxiety, emotional state, pain etc,
- Fixed posture: Only in severe cases
- Voluntary activity on activated muscles: Minimal
- Behavioural task / emotions on activated muscles: Minimal
Dystonia:
- Extrapyramidal tract lesion (Basal ganglion)
- Involuntary sustained / intermittent muscle contractions —> twisting / repetitive movements / abnormal postures
- Severity may vary with body position, specific tasks, emotional states, level of consciousness
- At rest: muscle tone can be normal / low
- NOT velocity-dependent
- Fixed posture: Yes
- Voluntary activity on activated muscles: Yes
- Behavioural task / emotions on activated muscles: Yes
Rigidity:
- Extrapyramidal tract lesion (Basal ganglion)
- Resistance to passively stretching muscle which is NOT velocity-dependent
- Simultaneous co-contraction of agonist + antagonist
- Does not tend to return towards a particular fixed posture / extreme joint angle
- Fixed posture: No
- Voluntary activity on activated muscles: Minimal
- Behavioural task / emotions on activated muscles: Minimal
