Академический Документы
Профессиональный Документы
Культура Документы
I.
II.
III.
IV.
Introduction
Developmental Milestones
Key Principles: Reflexes
The Neurologic Examination
A. Sequence of Exam
B. Overview of the Stages of the Exam
C. Instruments and Tools
D. Components of the Exam
V. Important Reminders
VI. Summary
I.
Hello! This is based on Maam slides, lectures, Nelsons Pediatrics 19th ed,
Bates, and pictures from the internet. We hope this helps! Focus on
developmental milestones daw. :P
PS: Maam didnt give a copy of her powerpoint to us, so we couldnt write a
more detailed descriptions of the videos. We tried to add pictures instead.
March 1, 2016
Trans Number: 10
Dr. Lukban
OUTLINE
EXAM #2
I. INTRODUCTION
Modern technology DOES NOT and CANNOT substitute
for skilled history taking (and physical/neurologic
examination)
It is...
o Not a netting operation
Age
2 wks
2 mos
2 years
3 years
3 mos
4 mos
6 mos
6.5 mos
12 mos
18 mos
4 years
5 years
6 years
Gross Motor
Moves head from side to side
Holds head steady while sitting
Follows past midline
Pulls to sit, with no head lag
Brings hands together in midline
Palmar grasp
Asymmetric tonic neck reflex gone
Sits without support
Rolls back to stomach
Walks alone
Stoops and stands
Runs
Kicks ball
Walks ups and down stairs one step at a
time
Throws overhand
Walks up and down steps with
alternating feet
Broad jump
Balances well on each foot
Hops on one foot
Skips
Heel-to-toe walks
Balances on each foot for 6 secs
Age
3.5 wks
4 mos
5.5 mos
8 mos
12 mos
13 mos
15 mos
18 mos
2 years
3 years
4 years
5 years
6 years
Fine Motor
Grasps rattle
Reaches for objects
Palmar grasp gone
Transfers object hand to hand
Thumb-finger grasp
Turn pages of book
Scribbles
Builds tower of 2 blocks
Builds tower of 4 blocks
Builds tower of 6 blocks
Copies line
Builds tower of 8 blocks
Wiggles thumb
Copies circle
Draws person with 3 parts
Copies square
Copies triangle
Draw person with 6 parts
Age
2 wks
1.5 mos
2 mos
9-10 mos
12 mos
15 mos
18 mos
4 mos
6 mos
7 mos
of 10
3 years
4 years
5 years
6 years
Age
2 wks
2 mos
4 mos
6 mos
8 mos
9 mos
12 mos
15 mos
17 mos
2 years
3 years
4 years
Social/Cognitive
Regards face
Smiles responsively
Lack of object permanence
Stares at own hand (self-discovery)
Cause and effect
Feeds self
Holds bottle
Bangs 2 cubes (active comparison of
objects)
Object permanence
Waves bye-bye
Plays patty cake
Begins symbolic thought
Egocentric symbolic play
Drinks from cup
Imitates others
Uses spoon and fork
Helps with housework
Able to link actions to solve problems
Symbolic thought
Pretend play
Washes and dries hands
Brushes teeth
Puts on clothes
Uses spoon well, spilling little
Puts on t-shirt
Brushes teeth without help
Dresses without help
Observation
Inspection
Palpation
Manipulation
B. Overview of the Stages of the Exam
Table 5. Stages of Neurologic Examination
Stage 1
Stage 2
Stage 3
Stage 4
Observation
Inspection
Child allowed to play around, baby carried by
mother in the lap
Palpation
Manipulation
Baby on examination table
Intrusive tests
Ex: Fundoscopy, head circumference
Special maneuvers to elicit function
Neuro kit
Stethoscope
Toys
o Ex. rattle, plush toys, pretty/colorful toys
Children's books
Age
3mo
6mo
20mos
8 yrs
12 yrs
Primitive reflexes:
o Reflex actions originating in the central nervous
system that are exhibited by normal infants, but not
neurologically intact adults, in response to
particular stimuli
Postural reflexes:
o Automatic movements that control the equilibration
(balance, posture, and movement) we require once
upright and moving and having to combat the effects
of gravity
20 yrs
th
8
decade
Development
Posterior fontanel closed
Fibrous union of suture lines occurs & serrated
edges interlock
Anterior fontanel closed (others close at 18 mos.)
Ossification of craniobasal bones is complete
Sutures cannot be separated by raised intracranial
pressure more dangerous
Sutures still visible on radiographs
Solid bony union of all sutures is complete
* check for symmetry of the head
Closure:
o Anterior fontanel 18-20 mos
o Posterior fontanel 3 mos
Craniosynostosis microcephaly (complete closure of
all sutures)
of 10
Crouzon's syndrome
Abdomen
Scoliosis
Sacral abnormalities
Down syndrome
o Macroglossia and Mongolian slant of eyes
Eye examination
Disorder
Tuberous
sclerosis
with infantile spasms
At least 3 spots
Usually 0.5-2 cm in
diameter,
and
resemble
a
thumbprint
Watch
out
for
because might be
with seizures
Sturge Weber
Caused by vascular
anomaly
Watch
out
for
because might be
with seizures
Lesion
Ashleaf
patch
Figures 8, 9, 10
2. Stages
Stage 1: Mostly Observation
By observation:
o Detect abnormal involuntary movements
o Assess facial and eye movements
o Allow the child to play (should be appropriate for
his/her age) check for motor skills
Stage 1: Mental Status and Cranial Nerve Exam
Cranial nerves
Table 8. Strategies to Assess Cranial Nerves in Newborns and Infants
from Bates Guide to Physical Examination and 2018 (in italics)
CN
Facial portwine stain
II
II and
III
III, IV,
VI
V
VII
VIII
Neurofibromatosis
Hyperpigmented
May be present at
birth or develop
within the first1-2
years of life.
At least 6 spots
Watch
out
for
tumors in the ears
and eyes
Caf au lait
spots
IX, X
XI
XII
V, VII,
IX, X,
XII
Strategy
Have baby regard your face and look for facial response and
tracking. Response to light while head is in midline.
Darken room, raise baby to sitting position to open eyes
Use light and test for optic blink reflex (blinking in response
to light). Use otoscope to assess papillary response.
Observe tracking as the baby regards your or mothers
smiling face move side-to-side.
Test rooting reflex. Test sucking reflex. Eye blinking as
response after visual threat.
Observe baby crying and smiling, note symmetry of face and
forehead.
Observe response to sound, turning of the head to the
source. Test acoustic blink reflex (blinking of both eyes in
response to noise).
Note the quality and strength of the cry. Observe
coordination during swallowing.
Observe symmetry of shoulders. Observe head and truncal
control
Observe coordination of swallowing, sucking, and tongue
thrusting. Pinch nostrils, and observe reflex opening of
mouth with tip of tongue midline.
Observe how the patient sucks and swallows milk
of 10
CN 7: symmetrical
Smiling
No facial asymmetry
Should already be able to turn over and lift the chest with
hands when placed on a prone position
4 year old
Some notes:
o Preterm
Figure 11. Sample picture of baby in prone position. (Not from video)
9 months (abnormal)
Figure 12. Sample picture of baby with frog-leg position. (Not from
video)
Figure 13. Sample picture of baby with head lag during the pull-to-sit
maneuver. (Not from video)
18 months
Just crying
Figure 14. Sample picture of baby with in ventral position (Not from
video)
Motor function
o Gait and balance abnormalities walk on toes,
walk on heels, stand on one feet, tandem gait,
Romberg's test
o Motor strength traction or pull to sit maneuver,
parachute
response,
wheelbarrow
maneuver,
crawling
o Fine motor skills test hand function (give child
crayon, observe how he grasps it while scribbling)
of 10
Figure 16. Parachute reflex. This occurs in slightly older infants when the
child is held upright and the baby's body is rotated quickly to face forward
(as in falling). The baby will extend his arms forward as if to break a fall,
even though this reflex appears long before the baby walks
Sensory function
Mask-like facies
Asymmetric legs
Tightness of adductors
Scissoring
V. IMPORTANT REMINDERS
Throughout the Examination, testing for mental abilities:
o Degree of alertness and interest in surroundings
o Verbal and nonverbal language function
o Intelligence ability to learn and follow instruction,
picture and object identification, memory and
calculation
Behavior
Cranial nerves
Resting posture
UE tone
Arm traction
Arm recoil
Scarf sign
Hand position
LE tone
Leg traction
Leg recoil
Popliteal angle
Heel to ear
Neck tone
Term Newborn
Head lag
Head control
Prone
Vertical and ventral suspension
Deep tendon reflex
Plantar reflex
Sucking and rooting reflex
Moro reflex
Stepping reflex
Grasping reflex
Head shape and sutures
Head circumference (last)
VI. SUMMARY
Neurologic exam should always be a part of the
developmental and routine evaluation of a child
The success in obtaining a good result is dependent on
the cooperation of the child
A significant part is made thru observation
Neurologic exam is NOT DIFFICULT to do!!
END OF TRANSCRIPTION
Hi! Lets watch Mediscene! :D #detox
From Maam: http://library.med.utah.edu/pedineurologicexam
of 10
2.
3.
4.
5.
6.
7.
Which of the following motor developmental milestones are expected to be performed by a 24-monthold child?
A. Walks up and down stairs one step at a time
B. Walks up and down stairs with alternating feet
C. Stands on one foot
D. Imitates circular strokes
Which of the following motor developmental milestones IS NOT expected to be performed by a 36- month old child?
A. Walks up and down stairs with alternating feet
B. Rides tricycle
C. Hops on one foot
D. Imitates circular strokes
What is the EARLIEST developmental age of a child who is able to do the following movements: stands with assistance and cruises around
holding on to furniture, waves bye-bye, holds toys and transfers objects from one hand to the other?
A. 6-8 months
B. 9-11 months
C. 12-15 months
D. 15-18 months
Which of the following primitive reflexes normally persists at 7 months of age
A. Moro reflex
B. Palmar grasp reflex
C. Plantar grasp reflex
D. Asymmetric tonic neck reflex
Which of the following reflexes is NOT expected in a normal newborn term baby?
A. Positive supporting action
B. Placing reaction
C. Cross extensor reflex
D. Neck righting reflex
The following cranial nerves can be assessed by observing the patients ability to suck and swallow?
A. Cranial nerves II, V, VII, IX, X
B. Cranial nerves V, VII, IX, X, XII
C. Cranial nerves V, VII, IX, X, XI
D. Cranial nerves VII, IX, X, XI, XII
The following postural reflexes can be normally performed by a 6 month old child EXCEPT?
A. Positive supportive
B. Landau
C. Lateral propping
D. Parachute
Answers: A, C, B, C, D, C, D
of 10
Figure
Maneuver
Place your fingers into the babys hands and
press against the palmar surfaces.
Palmar
Grasp
Reflex
Plantar
Grasp
Reflex
Moro Reflex
Age
Notes
Persistence beyond 4 mos
suggests cerebral dysfunction.
Birth to
34 mos
Birth to
68 mos
Birth to
46 mos
Birth to
2 mos
Positive
support
reflex
Birth or
2 mos
until
6 mos
Appendix E: Additional Primitive Reflexes That Should Be Tested If Neurologic Abnormality is Suspected (Bates)
Primitive
Reflex
Rooting
Reflex
Galants
Reflex
(Trunk
Incurvation)
Figure
Maneuver
Stroke the perioral skin at the corners of the
mouth.
The mouth will open and baby will turn
the head toward the stimulated side and suck.
The hip and knee of that foot will flex and the
other foot will step forward.
Alternate stepping will occur.
Landau
Reflex
Notes
Birth to
34 mos
Birth to
2 mos
Age
Birth (best
after 4
days).
Variable
age to
disappear
Birth to
6 mos
of 10
Parachute
Reflex
46 mos
and does
not
disappear
The Ballard Maturational Assessment, Ballard Score, or Ballard Scale is a commonly used technique of gestational age assessment. It assigns a score to
various criteria, the sum of all of which is then extrapolated to the gestational age of the baby. These criteria are divided into Physical and Neurological criteria.
This scoring allows for the estimation of age in the range of 26 weeks-44 weeks.
Each of the above criteria is scored from -1 through 5. The scores were then ranged from -10 to 50, with the corresponding gestational ages being 20 weeks and
44 weeks. An increase in the score by 5 increases the age by 2 weeks.
of 10
of 10
10
of 10