Introductory lecture, Neurological Examination

Quick advice: go back and watch the videos in the last page before reading this sheet.

General overview:
Before doing any physical examination for the patient you have to take History, so careful and
accurate neurological history is the most important part before doing physical examination. (Of
course analyzing the chief complaint is important while taking history).
For pediatrics we take what is called birth history where you ask about gestational age,
complication during pregnancy or delivery and Apgar scores.
We also take:
- Past medical history: Head trauma, febrile seizure, status epileptics, meningitis.
- Developmental history (the 4 developmental milestones): gross motor assessments, fine
motor assessments, language assessments and social assessments.
- Family history: like you ask if there was a history in the family of Epilepsy, Neurocutaneous
syndrome or Migraine.
We have some physical examination that are not neurological but of a highly relevance:
1) Head Circumference: we take it from the most prominent part anteriorly to the most
prominent part posteriorly and then we blot it on the chart.
2) We check if theres any dysmorphisim (dysmorphic features), ex: upslanting palpebral
fissures... or anything abnormal in the face that will help you reach a diagnosis.
3) Skin exam (Hypo or Hyper pigmentation), for example Sturge-Weber disease which leads to
reddish discoloration or when you have tuberous sclerosis which leads to hypopigmentation on
the body.
4) Others: we check for Hepatosplenomegaly or we check the back for sacral dimple, Lordosis
or scoliosis.

Neurological examination:
First of all it is divided into 6 parts:
1) Mental status evaluation.
2) Cranial nerves (full examination).
3) Motor nervous system, we check the tone, the power and the reflexes.
4) Sensory nervous system, we examine it by following each dermatome.
5) Cerebellum we have 5 or 6 maneuvers to check if it functioning well.
6) Primitive reflexes (for infants).

Mental status:
1) Level of consciousness: (conscious or sleepy)
the most important part of neurological exam, for example patients with meningitis or
encephalitis will have decreases level of consciousness.
2) Orientation:
to know who you are, where he is and what time is it (person, place and time).
3) Memory test: age appropriate test
- Immediate - short term
- Long-term.

Cranial Nerves examination:

1) CN 1 (Olfactory): we rarely examine it in children because it needs cooperation. We test
each nostril separately with non-irritant odor.
2) CN 2 (Optic): we test the Visual field, Visual acuity (ophthalmologist does this and
uses Snellen chart), Funduscopic exam (we use an ophthalmoscope to examine the
fundus at the back of the eye, in cases like increase ICP you will have papillary edema
which compresses the nerve and an abnormal optic disc appearance), Pupillary reflex
(focus shiny light to the pupil and you will notice constriction of it) by this you can also
test for oculomotor.
3) CN III (Oculomotor): Extra-ocular movement (do all the movement for the extra
ocular muscles and see if theres any limitation), Pupillary reflex (through the efferent
part) so you check pupillary size and reaction to light.
4) CN IV (Trochlear): superior oblique muscle, one of the extra ocular muscles.
*so for both 3 and 4, We ask the patient to follow your finger and you see all the
movements of the extraocular muscles (lateral rectus, medial rectus, superior and inferior
rectus, superior oblique muscle) so when we find a limitation in any of these muscle we
know the problem is in which cranial nerve.
5) CN V (Trigeminal): Sensation of the face (ophthalmic, maxillary and mandibular) so
you touch patients face after he closes his eyes and check if sensation is intact, Motor
part: Masseter (clench their teeth) and temporalis muscle, Corneal reflex (ophthalmic
branch) you have to touch the cornea and he should blink.

6) CN VI (Abducens): Lateral rectus muscle so any limitation in the later gaze then this is a
sixth nerve palsy.
7) CN VII (Facial): check for Facial asymmetry, Facial muscle expression (raise
eyebrows, shut eyes tight and do not let me open, smile and show me teeth) and taste of
anterior 2/3 of tongue.
8) CN VIII (Vestibulo-cochlear): for hearing and balance, Hearing tested with a bell and
you have to examine the ext. auditory meatus.
9) CN IX (Glossopharyngeal) & CN X (Vagus) at the same time: check uvula and palate
movement (open mouth), if there is a vagal nerve problem the uvula will deviate toward
the unaffected side, check for Gag reflex.
CN X controls muscle of pharynx and elevation of palate.
10)
CN XI (Accessory): Shrug the shoulders (checks trapezius muscle if its strong
or have any weakness), Turn the head against resistance (checks Sternocleidomastoid
muscle).
11)
CN XII (Hypoglossal): ask him to stick his tongue out and move it from side to
side and the tongue will deviate toward the affected side, watch Tongue movements so
look for abnormal movement, twitching or fasciculation of the tongue.

Motor Nervous System:

1) Inspection (just by looking): we check the muscle bulk and look for wasting,
pigmentation and fasciculation. For example, in DMD you have proximal muscle
weakness and pseudohypertrophy of the calf muscle.
2) Palpation (feeling deeply, , I have no other words to put it): we check for
tenderness, twitching and fasciculation.
*Note: looking for fasciculation as mentioned in the slides are part of the inspection put
the doctor stated multiple times that it is a part of palpation so I think its found in both.
3) Muscle tone (v.imp): you move the limbs of the patient and check his resistant. First keep
the patient relaxed and still, because you cant examine the tone if the patient is helping you
with the movement, so you just move his limbs so normally you will only have a small
resistant (of the normal tone), so any abnormality like Hypotonia the patient will be
completely floppy or in case of hypertonia you will feel he has more resistant.
Hypertonia = either spasticity or rigidity (Spasticity = speed related resistant during the
movement in other words its a rapid build-up of resistance during few degree of passive
movement, then resistant lessens. Rigidity = sustained high resistant during the movement).

4) Muscle Strength: ask the patient to push and pull against the physicians hands, compare
both sides, check upper and lower extremities and test flexion and extension at each joint.
For example:
Shoulders: abduction C5, adduction C6, 7
Elbows: flexion C5, 6
. extension C7,8
Wrist: Flexion/extension C6,7,8
Fingers: abduction/adduction T1
Strength chart:
0 no contraction
1 Flicker of contraction (only slight movement, like moving his fingers while his hand is
on the table)
2 Active movement (gravity eliminated, right and left on the table)
3 Anti-gravity movement (up and down)
4 Movement against resistance (but weaker)
5 Normal power (can oppose you)
*if you have proximal muscle weakness, Gower sign will appear, its when you ask the
patient to stand from squatting position, he will climb his on his body.
5) Deep Tendon Reflexes: The patient must be still and relaxed so you can elicit them.
For example:
Triceps C7, 8, Biceps C5, 6, Supinator C5, 6, Knee L3, 4 (common) and Ankle S1, 2.
Chart:
0 = absent
1 = trace (hypo reflexes)
2 = normal
3 = brisk (exaggerated reflexes)
4 = non-sustained clonus (hyper reflexes)
5 = sustained clonus
* Clonus: rhythmic series of involuntary muscle contraction evoked by stretching the
muscle. For example when you do a sudden dorsiflexion of the ankle joint and results
sustained contraction, this indicates clonus.
* When you stroke the lateral aspect of the feet, normally the patient will flex his toes. If
theres an abnormal reflexes Babinski's sign (dorsiflexion of the great toe and fanning of
the toes) will appear. This Babinskis sign is a normal finding in babies younger than 1
year old, so it doesnt indicate abnormal reflexes in them.

Sensory nervous system:

Dermatomes: an area of the skin supplied by nerves from a single spinal root. We have
dermatomes for the anterior and posterior parts of the body, each dermatome is innervated by a
certain nerve, and we need to examine these dermatomes by examining certain sensations:
Light touch by cotton wool
Superficial Pain by pin prick
Deep Pain - tendon reflexes
Temperature warm-cold )we compare both sides)
Proprioception joint position (move the joint of the patient up and down, and tell him
which is which before closing his eyes, then let him close his eyes and examine him)
Vibration tuning fork
2 point discrimination (seldom done)

Cerebellar Function and Gait:

* Gait: a person's manner of walking. So while hes entering your room, see if he has a normal
or an abnormal gait.
Gait Abnormalities:
1) Broad-based;
appropriate when learning to
walk
Hypotonia of legs / pelvic girdle
Cerebellar dysfunction
Hip joint problems
4) Narrow gait; (scissoring: move (one's
legs) back and forth in a way resembling the
action of scissors )

Adductor spasm (mild diplegia)

2) Hemiplegic gait; (wide swing)

3) Waddling gait;
proximal muscle weakness

5) High-stepping gait;
Sensory neuropathy, in his legs
mostly.
Distal weakness eg. foot-drop

Cerebral function tests:

Finger to nose (if hes not normal he wont touch it probably or will have tremor)

Rapid alternating

Heel to shin , and do like circular movement.

Heel to toe (ask the patient to walk in a straight line, just putting his heel in front of his
toes, if he walks with a good balance = good cerebellum.. )

Look for nystagmus or any intention tremor

Speech

Primitive Reflexes (just in children, infants less than 1 year):

*about this topic the doctor only read the first two slides then started showing the videos, so I
will just put the slides and you can go to the last page for videos links.
The reflexes are:
Sucking reflex

Rooting reflex

Palmar reflex

Plantar reflex

Asymmetric tonic neck reflex

Moro reflex

Stepping reflex

Placing reflex

Truncal incurvation (Galant) reflex

Babiniski reflex

1) Moro Reflex (called Startle reflex):

Appears at 28-32 weeks gestation.
Disappears at 4-6 months.
Elicited by sudden loss of support to the head and shoulder by falling onto the bed.
Response: extension and abduction of arms, followed by flexion with closing of the fist.
2) Rooting Reflex:
Appears at 30-34 weeks gestation.
Disappear at 3-4months.
Elicited by touching the corner of the mouth.
Response: The head should turn toward the stimulus and mouth should open.

3) Sucking Reflex:
Appears at 26-28 weeks gestation.
Disappears at 3-4 months.
Elicited by placing gloved finger in the mouth.
Response: normal sucking reflex.
4) Palmar Reflex:
Appears at 24-30 weeks gestation
Disappears at 3-6 months
Elicited by stimulating the palmar surface of the hand with the finger
Response: baby should grasp the finger
5) Plantar Reflex:
Appears at 24-30 weeks gestation
Disappears at 8-10 months
Elicited by stimulating the sole of the foot with the finger
Response: the toes curl around the finger
6) Stepping Reflex:
Appears at 32-36 weeks gestation
Disappears at 6-8 weeks
Infant is held upright, and allow the feet to touch a flat surface
Response: Stepping movement can be observed
7) Placing Reflex:
Appears at 32-36 weeks gestation
Disappears at 6-8 weeks
Top of foot is gently scraped along the underside of the table.
Response: infant flexes the legs as if stepping up onto counter
8) Truncal incuvation (Galant) Reflex:
Appears at 28-32 weeks gestation
Disappears at 2-4 months
Apply firm pressure with thumb to the trunk, parallel to the spine.
Response: flexion of pelvis toward the side of stimulus.
9) Babinski Reflex:
Appears between Birth to 12-18 months, positive response is normal between this period
Should be negative after the child is walking
Stimulation the sole of the foot from heel to toe
Toes extend and fan out (positive response)

10)
Asymmetrical tonic neck reflex:
Appears at 28-30 weeks gestation
Disappears at 3-4 months
Baby in supine position, head turned to one side
Response: extension of the arm & leg on the side toward which the head is turned.
Flexion of arms on the opposite side

Good luck, Gladiators

Here you can find the videos, IT IS A MUST TO WATCH THEM:
https://mega.nz/#F!WFJRzbqR!2shJ3dsize_zv5pvEmSJRg
Done by: Majd H. Shalakhti