peds PA exam 3 Flashcards
Neurodevelopment symptoms
vision problems hearing loss changes in weight persistent N/V headaches fainting, blackout, memory change hyperactivity weakness in one part of body clumsiness- (posterior fossa?) changes in bowel or bladder habbits
5 Important components to neuro History
1) health history
2) behavioral assessment
3) psychosocial assessment
4) school performance
5) development history
* must adjust neuro exam to developmental age of child*
types of neuro exams
neuro eval
neuropsychological eval (brain and nervous system effect way you behave- IEP is example)
and Neurodevelopment Eval* the best one
history problems, cont
attention problems memory behavior language/communication problems vision neck pain-occipital head pain-bad weakness/jerks gait, sensory changes diplopia, mother's projection
If there is a problem with thinking or remembering, where could the problem be?
the hemispheres
if there’s a problem with coordination, the problem is:
in cerebellum
Balance problems? + N/V
Infratantorium
problem with arms/legs with bladder/bowel control, the problem might:
be in spinal cord
if problem with speech, the problem might be in the
left hemisphere
if the child presents with multiple problems that do not localize to 1 area, and things don’t fit together, consider:
psychosocial realms
significant fall
3x the child’s height
9 parts of neuro exam
1) overall inspection
2) general cerebral function
3) Cranial Nerves
4) reflexes
5) motor strength
6) sensory
7) proprioceptive and cerebral fx
8) Soft sign
Overall inspection: what do i Look for?
neurocutaneous lesions? muscle atrophy, weakness in gait, abnormal positioning, hand dominance before 18months, skin
temors? tremors of tongue or hands when not crying
hypermobility
ash leaf:
tuberosclerosis
cafe au lait;
> 5 of them assoc with neurofibromatosis
flammeus nevus
on side of face, that side associated with glaucoma
large calves indicate possible:
muscular dystrophy (is there pelvic girdle weakness?)
Marie Charcot Tooth Syndrome
Thin, stork like legs high arches sensory loss decreased reflexes neuropathy will present with distal weakness before wasting
myopathies vs neuropathies
myop; present as central weakness ex) proximal girdle eakness
Neuropathy presents with distal weakness ex) stork like legs, wasting of marie charcot
Diastematomyelia
split cord malformation; longitudinal split in spinal cord
multiple leasions + glutteal fold–>abnormality
-may be minimally affected or entirely asymptomatic; present as leg weakness, low back pain, scoliosis, incontinence
Cerebral Function, part II
JOMAC
*consider dev. milestones Judgement, problem solving Orientation to time/space Memory Affective disturbances Calculation disturbances
pre school child- cerebral function, assess:
comon objects? know family members, where you buy food, name something in refrigerator, knows if they have pets, can count 3 objects, draw a picture, 3 wishes
2 year old developmental tasks
- 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
3-5 year dev tasks
• 3-5 YEARS PRESCHOOL—Initiative-vs.-Guilt • Gain 4-5 pounds and 2.5 - 3.5 inches • 3 years – 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
4 year old tasks
• Lordosis and round abdomen starts to disappears • 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
5 year old task
• 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
SCHOOL AGE—Industry-vs.-
Inferiority
• 6-12 years • 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
first grade dev tasks
- Print 1st and last name
- Write #’s 1-10
- Draws a person-6 parts
- Copies a square
- Heel to toe walk
- Knows the letters of the alphabet
- Walk on alternate heels
- Play sports
- Friends
- Peers
CN 1
olfactory-not often done, do it when there’s a direct blow to forehead above nasal bridge
CN II
optic nerve;
VISION testing
after head trauma
shape of pupil
penny test-follow with eyes, cold sensation
optic fundus, visual acuity, pupillary reactions, size in mm. accommodation
Horner’s syndrome
decreased sweating on affected side of face can happen post op cardiac pts ptosis sinking eyeball into ace constricted pupil
CN III, IV, VI
oculomotor, trochlear, abducens
eyelids for droopng, size, 6 fields of gaze, reaction to light and accom
CN VI
longest subarachnoid course of all, dyunfunction of itcan result from lesions anywhere along its course btw 6th nerve nucleus in dorsal pons and alteral rectus muscle in the orbit
Increased ICP
result in downward displacement of brain stem, causing stretching of the 6th CN
can happen from: shunt failure (check EOMs), pseudotumor cerebri (6th nerve palsy)
posterior fossa tumors
neurosurgical trauma, venous sinus thrombosis, meningitis, lyme
6th nerve palsy, differential
thyroid eye disease
myasthenia gravis
duane’s synrdome
send to neuropthalmologist for:
spasm near reflex
delayed break in fusion, old fracture in orbit
Papilledema: Grades
Grade 1: c shaped halo of edema surrounding optic disk
Grade 2- halo of edema now surrounds optic disc, margin not well defined
Grade IV- SEVERE- more severe swelling + circumferential halo, edema covers major vessels as they leave disc (grade III) and vessels on disk (grade IV)
nystagmus-if recent onset, think
posterior fossa tumor?
Horizontal nystagmus
seen with labyrinthine, cerebellar or brainstem pathology
vertical nystagmus seen in
cerebellar or brainstem pathology
Medication toxicity can cause
horiz or vert nystagmus* ex) Dilantin
CN V
trigeminal facial muscle atrophy/tremors palpate jaw muscles- monster face test for touch and temp sensation 3 parts of CN V- test in all 3
CN VII
Facial Nerve
look for symmetry when face is clenched for CN V test, (monster), then do smile/frown, close eyes, puff cheeks
note- lyme presents with CN II
facial nerve palsy: central
forehead is unaffected
facial nerve palsy, peripheral
forehead has problem- eyes roll up when try to close
CN VIII
Acoustic
tuning fork-hard in young kids
use of audioscope or audiometer for routine screening
Weber test
for CN VIII
middle forhead place tuning fork
does patient hear it equaly or on one side louder? normal is same on both sides
unilateral conductive hearing loss, patient hears best in which ear?
the abnormal ear
Rinne Test
comparing Bone conduction-place fork on mastoid process behind ear–
Air conduction- assess by holding fork in air near front of ear
AC>BC
CN IX
Glossopharyngeal
swallow
gag reflex
CN X
Vagus
vocal quality
rise of soft palate a child says A AH
swallowing problems?
CN IX and X
do HA HA- rise of soft palate intact vagus , plus ulnar deviation is both
CN XI
accessory
head rotation gainst resistence to test STCLM
shrug shoulders to test trapezius
CN XII
hypoglossal
inspect tongue in mouth- symmetry, tremors, atrophy? lingual sounds like l, t, d, n
unilateral lesion: protruded tongue deviates toward affected weaker side
Reflexes- grading
0 abscent 1+ hypoactive 2+ normal 3+ hyperactive without clonus 4+ hyperactive with clonus
Reflexes;
biceps triceps patellar achilles tendon (ankle) abdominal babinski snouting
babinksi
after walking, normal is downward curl
before walking - curl upwar
an abnormal or positive sign is upward curling in a walking child
Chaddock
stroke with blunt point around side of foot from external malleous to small toe
positive test: if there is dorsiflexion of big toe
oppenheimer
firmly press down on shine and run thumb and knuckles upward along medial tibia]
positive test: if there is dorsiflexion of big toe
muscular dystrophy bloodowork
TSH
CK
Liver enzymes
a child should tandem walk by
earliest; 4
latest- 6
fine motor
tap hands on thigh, alternate, touch each finger to thumb, look for intentional tremors, gait abnormalities,
grading motor 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
duchenne muscular dystrophy
boys
difficulty w climbing stairs, running, jumping frmo standing position, falls, slow motor progression,
18 months start waling, clumsy age 2-3, difficulty keeping up w peers 3-5yo
calf muscle hypertrophy
weakness- proximal before distal* legs before arms weaken, extensors weaken before flexors
to walking, calf pseudohypertrophy, lumbar lordosis, multifocal contractures, trendelenburg gait, fatigue,
WALK LIKE DUCK
gower’s maneuver
to stand from sitting, they will walk their hands up their legs slowly and climb up them
pronator drift
pt stand for 20-30sec arms straight forward, palms up, eyes closed
pt will not be able to maintain extension and supination if they have upper motor neuron problem
graphesthesia
adolescent- with blunt end of pen draw large number in their palm
stereognosis
familiar object in child’s hand and have them tell you what it is
Dystonic posturing
• Dystonic posturing is stiffening of the
extremities during a stressed gait or
rhythmic movements.
– The child hops in place or heel toe walk
-hand goes up on the weak side
penny on nose test
proximal inhibitation
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
simple skull fracture
linear
depressed skull fracture
- Hematoma at site
* Piece of bone depressed into brain
compound skull fracture
- Laceration and depressed skull fracture
- Dura usually pierced
- Skull fragment may be displaced into the brain tissue.
Basilar fracture
• break in the posteroinferior portion of the skull occurs. • produces dural tears that result in leakage of cerebrospinal fluid (CSF). – meningitis early S&S -blood behind TM nerve palsies, deafness or ringing dizziness, NV battle sign raccoon sign
epidural hematoma
older kids more often
• 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.
• Signs and symptoms
– Headache
– Decreased level of consciousness
– Fever
– Dilation of the pupil on the affected side of the brain
battle’s sign
bruising over temporal area- seen in basilar fracture
raccoon sign
bruising around eyes, basilar fracture, also seen in neuroblastomas
Meningitis History
progression, exposure, history of otitis media? uderlying health, immunodef, seizures?
focal seizure is common iniital pres
generalized- febrile
presentation of meningitis in newborns
– Fever – Nonspecific symptoms (eg, poor feeding, vomiting, diarrhea, rash) – Bulging fontanel – Irritable, restless, or lethargic.
presentation of meningitis in older kids
– Sudden fever – Headache, – Nausea, vomiting, – Confusion, stiff neck, photophobia • Meningitis can cause seizures, and decreased level of awareness.
• Brudzinski sign for meningitis
– 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, inflammation of lumbar
Kernig’s sign
–Associated with meningeal irritation and hamstring spasm –Flex hip and knee, then straighten knee. –Excessive pain and resistance bilaterally suggests meningeal irritation
PATIENTS IWTH VP SHUNT and Meningitis–
present differently
inc risk of getting meningitis
sometimes dont get as high a fever
-they get low grade ventriculitis, headaches, n, malaise, low fever
viral meningitis
less toxic and acute in presentation
enterovirus
more common in summer
vomiting, headache, stiff neck
Signs & Symptoms of DMD
• Abnormal muscle function
– Delayed walking
– Frequent falls
– Difficulty with running and climbing stairs
– Calf pseudohypertrophy
• Progressive proximal musculature weakness
– Waddling gait 2° girdle muscle weakness
– Gower’s sign
• Increase in serum creatine kinase (CK) and
transaminases (aspartate aminotransferase and
alanine aminotransferase)
• Delays in attainment of developmental milestones
intoeing
normal for infant and toddler years
flat feet
normal infant and toddler years; 10% of population
only a problem if it is r/t tarsal coalition which is painful; check by raising toes/tip toes- if you see arch, there’s no torsal coaliation
metatarsus adductus
top half of foot in-toes
the top half of the upper 1/2 forehoot has deformity
skin crease may be located on medial aspect of longitudinal arch
benign
internal tibial torsion
causes in-toes
assoc w sitting on feet
associated with intrauterine positioning
femoral anteversion
can cause mild intoe-ing
peaks in late preschool, spontaneous correction by age 8
severe cases-need referral
W- sitting position
toddler years muscular dev
largest amount of growth during these years
- wide based gait “toddling”
- Genu Varum (bow leg) seen until child walks for one year
- *if geu varum has inc by age 3 and not resolved, could be blount disease** needs referall (medial growth of tibial bone)
- genu Valgum (knock knees) abnormal if child has been walking
genu valgum
knock knees; normal 3-5 years old
Developmental dislocation of hip
idiopathic- positive family history, breech presentation, dislocated and irreducible, subluxated to dislocated and reducible
teratogenic- more severe with germ plasma defect
sig. assoc w/ club foot, congenital torticollis, metatarsus adductus and scoliosis
Females > males *breech
unilateral more common
highest risk: female, first born, breech delivery- need u/s
Ortolani maneuver
hip held while thigh is tested and abducted and pulled anterior; anterior push up one side at a time
Barlow maneuver
adducting hip while pushing thigh posteriorly
if hip goes out of socket: “dislocatable” or positive
confirm dislocation by performing ortolani to reduce and relocate hip
Galeazzi sign
lower extremities- when hips and knees are 90 degrees in flexion; identifies unilateral hip dislocation– are the knees different heights? the shorter leg will stay posterior b/c its not in socket
good for 5-6 month olds b/c ortolani/barlow won’t work on them)
Evaluating DDH
ultrasound
trandelenberg gait
pelvis tils toward normal hip when weight is on affected side
when to worry for genu varum/ valgum
alignment in comparison to age is normal sharp curve lateral thrust (severe bow leg) asymmetry intercondylar distance of > 15cm or 6 in
Ricket’s
"fanning" at wrist test Vit d, phosphorous, calcium and parathyroid hormone frontal bossing protuberance on costochondral borders-rosary -widened ends of bone (fanning) -low phosphorous shrt stature abnormal Vit D
note- african americans absorb less nutrients from the sun, need vit d supplements
internal tibial torsion
nonpathologic variation of normal
patella faces anterior position
delayed correction wil usually self correct over time
femoral anteversion
normal variant max age 3 delayed correction can lead to persistent intoing b/l w no other disease process correcst w time
wind sign
measurement of thigh foot angle w patient in prone position and knees flexed;
normal external radiation: ten degrees
> 10- abnormal
clubfoot
positional- in utero
true- structurally abnormal, bones of leg or foot or muscles of calf often underdev.
will need serial casting, then bracing; need close follow up
congenital clubfoot/talipes equinovarus
male female
1/1000 births
multifactorial etiology; heel turned in, adducted and supinated
