SAN BEDA COLLEGE OF MEDICINE

Batch 2017
NEURO-PEDIA CHECKLIST
GENERAL DATA
Name: _____________________________ Age: ________ Gender:_______Birthday: ______________Address: ______________________ Religion:______________Source of Data: ____________

CHIEF COMPLAINT: ______________________________________________

HISTORY OF PRESENT ILLNESS:

MATERNAL AND BIRTH HISTORY

______Maternal illness:
( ) Herpes infection ( ) Syphilis ( ) Varicella-zoster ( ) Toxoplasmosis ( ) Rubella ( ) CMV ( ) Hepatitis ( ) Anemia ( ) Gestational diabetes
( ) UTI ( ) HPN ( ) Group B streptococcal disease ( ) HPV ( ) Heart disease ( ) Tuberculosis ( ) Pneumonia
______Exposure to legal and illegal drugs: ____________
______Alcohol: ____________
______Smoking: _____sticks/day

Prenatal
GP-FPAL:
Date Diagnostic tests, Duration, Complications during Pregnancy

Natal
Date of Labor Type of Delivery Complications

Neonatal
APGAR Score:______
( )cyanosis ( ) Breathing
( ) Feed well after birth
Weight: ______kg or _____lbs
( ) Requirement for resuscitation
( ) Develop infection ( ) Jaundice
Head circumference: _____cm ( ) obvious birth defects

Developmental History (For ages 0-6 years old, please see last page)
a. Enumerate age at which developmental milestones were attained
Age Developmental milestone

b. School age (6-11 years old)

Age Performance Problems

c. Growth (height and weight in sequences of ages):___________________________

d. Sexual development
Present Status
*Female
( ) Breast development:____________
( ) Nipples:_____________________
( ) Sexual hair:__________________
( ) Menstruation:________________
( ) Acne:_______________________
*Male
( ) Sexual hair:__________________
( ) Voice changes:_______________
( ) Nocturnal emissions:__________
( ) Acne:_______________________

Immunizations
Vaccine Specific date Dose Sites given Any untoward reactions

Comments:_______________________________

Past Illnesses: including dates and complications

a. General health
i. Body weight (present, maximum and minimum, with dates of each):________________________________________
Neurotrans Team 2017 1
 ii. Previous physical examinations (dates and findings):____________________________________________________
b. Medical illness:________________________________________________________________________________________
c. Surgeries, injuries/accidents:______________________________________________________________________________
d. Drug reactions/allergies:_________________________________________________________________________________
e. Hospitalizations:_______________________________________________________________________________________
f. Blood transfusion:______________________________________________________________________________________

FAMILY HISTORY
a. Parents and Grandparents
i. Birth year:______________________________________________________________________________________
ii. Current health or age at death and causes:_____________________________________________________________
b. Aunts, uncles, siblings, and children
iii. Birth year/First name:____________________________________________________________________________
iv. Current health or age at death and causes:_____________________________________________________________
c. Family history
( ) Hypertension ( ) Tuberculosis ( ) Heart disease ( ) Diabetes ( ) Kidney disease ( ) Autoimmune diseases ( ) Gout ( ) Atopy
( ) Asthma ( ) Obesity ( ) Endocrine disorders ( ) Osteoporosis
( ) Cancer (particularly breast, colon, ovarian and endocrine cancers) ( ) Hemophilia or other bleeding diseases
( ) Venous thromboembolism ( ) Stroke ( ) Migraine ( ) Neurologic or muscular disorders
( ) Mental or emotional disturbances ( ) Substance abuse ( ) Epilepsy

PERSONAL AND SOCIAL HISTORY

a. Number of people in the house:______
b. Presence of grandparents:__________
c. Marital status of the parents: ( )Single ( ) Married ( )Separated ( ) Lived-in ( )Widow
d. Significant caretaker:___________
e. Total family income and source:____________
f. Occupation of mother and father:_________________________
g. If pertinent to the current problems of the child, family’s attitude toward the child and toward each other:_________________
h. Spiritual orientation and culture:_________________________

REVIEW OF SYSTEMS
* If information has been obtained previously, simply state, “See history of present illness” or “See history of past illness”
a. Head: ( ) injuries ( ) Headache
b. Eyes: ( ) Visual changes ( ) Crossed or tendency to cross ( ) Discharge ( ) Redness ( ) Puffiness ( ) Injuries
( ) Glasses
c. Ears: ( ) Difficulty hearing ( ) Pain ( ) Discharge ( ) Ear infections ( ) Myringotomy ( ) Ventilation tubes
d. Nose: ( ) Watery ( ) Purulent discharge ( ) Difficulty in breathing through nose ( ) Epistaxis
e. Mouth and throat: ( ) Sore throat or tongue ( ) Difficulty in swallowing ( ) Dental defects
f. Neck: ( ) Swollen glands ( ) Masses ( ) Stiffness ( ) Symmetry
g. Breasts: ( ) Lumps ( ) Pain ( ) Symmetry ( ) Nipple discharge ( ) Embarrassment
i. Lungs: ( ) Shortness of breath ( ) Hoarseness ( ) Wheezing ( ) Hemoptysis ( ) Pain in chest
j. Heart: ( ) Cyanosis ( ) Edema ( ) Heart murmurs or “Heart trouble” ( ) Pain over heart
k. Gastrointestinal: ( ) Appetite ( ) Nausea ( ) Vomiting with relation to feeding ( ) Blood or Bile stained or Projectile
( )Abdominal pain or distention ( ) Jaundice
l. Genitourinary: ( ) Dysuria ( ) Hematuria ( ) Frequency ( ) Oliguria ( ) Enuresis ( ) Urethral or Vaginal Discharge
( ) Sores ( ) Pain ( ) Sexually active ( ) Birth control ( ) Sexually Transmitted Disease and protection
( ) Abortions
m. Extremities: ( ) Weakness ( ) Deformities ( ) Difficulty in moving extremities or in walking ( ) Joint pains and swelling
( ) Muscle pains or cramps
n. Neurologic: ( ) Headaches ( ) Fainting ( ) Dizziness ( ) Incoordination ( ) Seizures ( ) Numbness ( ) Tremors
o. Skin: ( ) Rashes ( ) Hives ( ) Itching ( ) Bruises or bleeds easily
p. Psychiatric: ( ) Usual mood ( ) Nervousness ( ) Tension ( ) Drug use or abuse

PHYSICAL EXAMINATION
Vital Signs
Temperature:_____C Heart rate:_____BPM Respiratory rate:______CPM Blood pressure:_______mmHg
Height:______cm or _____ft Weight:______lbs or _____kg
Head circumference:_______cm Chest circumference:______cm Abdominal circumference:_______cm
General Appearance:_______________________________________
Skull: ( ) Microcephaly ( ) Macrocephaly ( ) Craniosyntosis ( ) Prominence of scalp veins ( ) Flattening of occiput
( ) Ridging cranial sutures ( ) Tenderness on percussion ( ) Macewen (cracked pot) sign ( ) Bulging anterior fontanelle
( ) Intracranial bruits on auscultation
Skin exam: ( ) Ash leaf spot ( ) Cafe au lait spots ( ) Angiomas ( ) Adenoma Sebaceum ( ) Axillary freckling ( ) Shagreen patches
( ) Location of hair whorls ( ) Palmar creases
Quality of scalp hair:__________, eyebrows:____________, nails:____________
Neck/spine: ( ) scoliosis ( ) kyphosis ( ) palpable or visible spine defect ( ) meningeal signs:_____________
Midline of the back and neck: ( ) sacral dimples ( ) tufts of hair ( ) Other signs of spinal dysraphism:________
Comparison of thumbnail sizes and their convexity:__________________ ( ) Unusual body odor:_________________
Cardiovascular: ( ) Cardiomegaly ( ) Heart murmurs ( ) Peripheral pulses
Abdomen: ( ) Hepatomegaly ( ) Splenomegaly ( ) Distended bladder
Musculoskeletal: ( ) Atrophy ( ) Hemiphypertrophy ( ) Contractures ( ) Muscle tenderness ( ) Pes cavus ( ) Club foot ( ) Other deformities:______________

NEUROLOGIC EXAMINATION
CRANIAL NERVES ASSESSMENT

CN I (Olfactory)
Right Nostrils Left Nostrils Familiar odor?
Odor Yes No Yes No Yes No

CN II (Optic)
a. Visual Acuity:
Snellen test: RIGHT EYE (OD): _________LEFT EYE (OS): __________Other test: (describe if any):____________________________________________________

b. Peripheral Vision:
Quadrant Upper Right Upper Left Lower Right Lower Left
Right Eye
Left Eye

c. Ophthalmoscopy
a. Anterior Segment
Describe:

b. Posterior Segment
Describe:

Neurotrans Team 2017 2

CN III (Oculomotor)
a. Eyelid Position
Right Eye Left Eye

Normal drooping Normal drooping

b. Pupil size & shape

Size Right eye Left eye
Normal
Abnormal
Shape
Normal
Abnormal

c. Pupillary Reflex (0 to 4+): Direct: _______________ Consensual:___________

d. Convergence Pupillary Reflex: [ ] NORMAL [ ] with DEVIATION Describe: _______________________
e. Eye Movement
Eyeball movement Right eye ( + or - ) Left eye ( + or - )
Straight Up
Straight Down
Down Right
Down Left
Up Right
Up Left

f. Cover & Uncover test: [ ] NORMAL [ ] with DEVIATION Describe: _______________________

g. Check for Nystagmus: [ ] NORMAL [ ] with DEVIATION Describe: _______________________

CN IV (Trochlear)
a. Ability to look at tip of nose:
Right eye: [ ] NORMAL [ ] with DEVIATION Describe: _____________________________________
Left eye: [ ] NORMAL [ ] with DEVIATION Describe: _____________________________________

CN V (Trigeminal)
a. Corneal Reflex: Right Eye: [ ] Present[ ] Absent Left Eye: [ ] Present [ ] Absent
b. Masseter Contraction strength: Right Side is EQUAL to Left Side [ ] Yes [ ] No
c. Open mouth: Is the Jaw deviated? [ ] Yes [ ] No If Yes, to what side? [ ] Right Side [ ] Left Side
d. Detection of light touch & pain
Light Touch Pain

Division Right Left Right Left

Ophthalmic (V1)

Maxillary (V2)

Mandibular (V3)

Remarks if any: ___________________________

CN VI (Abducens)
a. Ability to move eye laterally:
Right eye: [ ] NORMAL [ ] with DEVIATION Describe: ______________________________
Left eye: [ ] NORMAL [ ] with DEVIATION Describe: ______________________________

CN VII (Facial)
a. Expression
Symmetrical?

YES NO Remarks

Facial Expression
Smile, show teeth
Lift eyebrows
Frown
Close eyes tightly

b. Taste (salt solution or sugar solution) anterior 2/3 of tongue:

Right Side of Tongue: [ ] Present [ ] Absent Left Side of Tongue: [ ] Present [ ] Absent

CN VIII (Vestibulocochlear)
a. Whisper Test:
Right Ear: [ ] NORMAL [ ] with DEVIATION Describe: ______________________________
Left Ear: [ ] NORMAL [ ] with DEVIATION Describe: ______________________________

b. Tuning Fork Test:

Conduction Right ear ( + or - ) Left ear ( + or - )
Bone (BC) (mastoid)
Air (AC)
BC = AC Yes No Yes No

c. Frontal bone conduction:

Is the sound heard equality in both ears? [ ] Yes [ ] No

CN IX & X (Glossopharyngeal & Vagus)

a. Phonation Test (“say ahh”)
a) 1. Uvula & Palate rise & remain in the midline? [ ] Yes [ ] No
b) Deviation of the uvula to the right or to the left? [ ] Yes [ ] No
b. Speech: vocalization, pronunciation, intonation: [ ] NORMAL [ ] with DEVIATION Describe: __________________________________________
c. Swallowing: [ ] NORMAL [ ] with DEVIATION Describe: __________________________________________
d. Gag Reflex: [ ] NORMAL [ ] with DEVIATION Describe: __________________________________________
Neurotrans Team 2017 3
 e. Taste (posterior 1/3 of tongue): [ ] NORMAL [ ] with DEVIATION Describe: __________________________________________

CN XI (Spinal Accessory)
a. Sternocleidomastoid strength (turning head) (0, very weak to +4, very strong):
RIGHT SCM: _______________________________
LEFT SCM: _________________________________
b. Trapezius strength (shrugging shoulders) (0, very weak to +4, very strong):
RIGHT Trapezius: _______________________________
LEFT Trapezius: ________________________________

CN XII (Hypoglossal)
a. Inspection of the tongue at rest: ____________________________________________________________________________
b. Tongue motility & deviation:
Alignment: [ ] Symmetrical[ ] Asymmetrical
c. Tongue Strength: [ ] Strong [ ] Weak
d. Involuntary movements: Rippling of the tongue: [ ] Present [ ] Absent
e. Phonation (forming vowel & consonant sounds): [ ] Normal [ ] With Deviation, Describe: __________________
f. Protrusion of the tongue: [ ] Symmetrical [ ] Asymmetrical

Speech assessment
( ) Repeat phrases and sentences (for cooperative child) For infants: ( ) coo( ) babble ( ) say single word
( ) Immature speech ( ) Dysarthia ( ) Telegraphic or scanning speech ( ) monotonous slow speech
( ) Monotonous speech with poor breath control

MOTOR EXAMINATION
POSTURE
( ) Extension in preterm ( ) Flexion of the extremities in full-term ( ) Slumping forward in younger child beginning to sit
( ) Lordotic posture in older children ( ) Holds arms steadily and symmetrically ( ) Pronation and downward drifting of one of the limbs
( ) frog-leg posture of newborn ( ) Slumping of the child in a sitting position ( ) Head posturing ( ) Excessive lumbar lordosis
( ) Decerebrate ( ) Decorticate ( ) Scissoring posture of the legs ( ) Unusual postures at the neck, spine and limbs
( ) Waiter’s-tip position

MUSCLE TONE
Tone Left Right
Hypertonia
Spasticity
Rigidity
Myotonia
Percussion myotonia
Hypotonia
If present, degree (mild, moderate, or
severe) and distribution (focal, axial,
appendicular, or generalized)

MUSCLE STRENGTH
5 – Normal strength
4 – Moves joint through full range against resistance greater than gravity but the examiner can overcome the action
3 – Moves part full range against gravity but not against any resistance
2 – Moves part only when positioned to eliminate gravity
1 – Only a flicker of contraction of muscle but cannot move joint
0 – Complete paralysis

A. Weakness of the shoulder girdle muscles 5 4 3 2 1 0

1. Arm abduction/elevation
2. Arm adduction downward
3. Arm adduction across the chest
4. Scapular adduction
5. Scapular winging
B. Weakness of the upper arm muscles 5 4 3 2 1 0
1. Elbow flexion
2. Elbow extension
C. Weakness of the forearm muscles 5 4 3 2 1 0
1. Wrist flexion
2. Wrist extension
D. Weakness of the finger muscles 5 4 3 2 1 0
1. Abduction-adduction of the fingers
2. Finger flexion
3. Finger extension
E. Weakness of the abdominal muscles 5 4 3 2 1 0
1. Lower abdominal muscle
2. Upper abdominal muscle
F. Weakness of the large back muscles 5 4 3 2 1 0
1. Bending at the waist and straightening up
G. Weakness of the hip girdle muscles 5 4 3 2 1 0
1. Hip flexion
2. Hip extension
3. Thigh abduction and adduction
H. Weakness of the thigh muscles 5 4 3 2 1 0
1. Knee extension
2. Knee flexion (hamstring)
I. Weakness of the ankle and toe movement 5 4 3 2 1 0
3. Dorsiflexion
4. Inversion
5. Eversion
6. Plantar flexion

Neurotrans Team 2017 4

CEREBELLAR FUNCTION

I. Observe for any of the four cardinal cerebellar signs: II. Observe the following:
 Ataxia/ Dystaxia: ________________(Specify) A. Eye movement
 Tremor: _______________________(Specify)  Nystagmus: ___________________ (Specify)
 Hypotonia: ____________________(Specify)  Saccadic dysmetria: ___________________
 Asthenia: _____________________  Others: _____________________________
(Specify: e.g., weakness, fatiguability, reluctance to move) B. Speech
 Dysarthria
 Others: _____________________________
Clinical Tests
A.
Dystaxia of Station and Gait
1. Inspect the patient for: 2. Ask the patient to do tandem walking.
 Broad-based stance  Able to do
 Broad-based gait  Not able to do
 Swaying when standing Other observations:____________________________
B. Arm dystaxia
(Note: Self-demonstrate first)
1. Finger-to-nose test Left Right Both 2. Pronation-supination test
(Note: Separately and together)  Dysdiadochokinesia
 Uneven excursion:
 Postural tremor ___Left
 Kinetic /Intentional tremor ___Right
 End-point tremor 3. Thigh-patting test
 Dysmetria:  Dysdiadochokinesia
___undershoot  Slower than normal
___overshoot  Dysrhythmia/ Irregular slapping
Others: _____________________  Dysmetria:
___overshoot
___undershoot
Others: _______________________________
C. Overshooting and checking test of the arms
1. Finger-tapping test Left Right both D. Decomposition movement(Note: Touch nose)
(Note: Normal – 50 taps/ 10 sec) Movement 1: ___Slow ___Spontaneous
Movement 2: ___Slow ___Spontaneous
 Dysrhythmia
 Slow Other observations: _______________________
2. Wrist-tapping test
 Returns quickly to initial position
 Overshoots
 Oscillation

3. Arm-pulling test
(Note: Pull and release the flexed arm of the patient.
Observe SAFETY of the patient)

 Overshoots
 Able to return and maintain given
posture

E. Leg dystaxia

1. Heel-to-shin test Left Right Both F. Hypotonia

(Note: Position may be in supine or sitting)
1. Inspection:
 Postural tremor
 Kinetic/Intentional AT REST WHEN WALKING
 End-point tremor ___Normal position ___ Normal
 Dysmetria: ___Floppy posture/ ___ Presents floppy, sagging,
___undershoot dump-in-a-heap posture loose-jointed appearance
___overshoot ___Arms don’t swing properly
Others: ____________ ___Genu recurvatum
Others: _______________________ ___________________
Others: _____________
____________________

2. Heel tapping test 3. Passive range of motion (PROM): _______________

(Note: Make sure to tap in one place only)
 Dysmetria:
___undershoot
___overshoot

 Dysrhythmia
 Dysdiadochokinesia
Others: _______________________

G. Romberg’s test: ____ (+) ____ (--)

Neurotrans Team 2017 5

 REFLEX TESTING

Muscle Stretch Reflex (MSR)

0 [Areflexia]
1 [Hyporeflexia]
2 [Normal]
3 [Hyperreflexia]
4 [Clonus, if present]

1. Jaw Reflex Right Left

(Note: Makes sure that the jaw of the patient is sagging and open. The finger should be rest across the tip.)
2. Biceps Reflex
(Note: Examiner’s thumb on the patient’s biceps tendon and the bicipital aponeurosis. Apply slight tension.)
3. Triceps Reflex
(Note: The patient’s forearm should be dangling and cradle as you strike the triceps tendon.)
4. Brachioradialis Reflex
(Note: Make sure that the you don’t strike the patient’s unprotected bone)
5. Finger Flexion reflex( Tromner’s method)
(Note: Flip the distal phalanx upward.)
6. Finger Flexion Reflex (Hoffman’s method)
(Note: Depress the patient’s distal phalanx and allow it to flip up. Effective only if with very brisk MSR)

7. Quadriceps Reflex(Sitting)
(Note: Allow the patient to sit. Place hand on the patient’s knee.)
8. Quadriceps Reflex (Supine)
(Note: Place a slight tension on the patient’s patellar tendon.)
9. Pull Method(of Jendrassik)
(Note: Make sure that the patient locks the hands and pulls apart hard.)
10. Triceps Surae Reflex (Sitting)
(Note: Examiner dorsiflexes the foot for applying slight tension on the triceps surae. Try reinforcement if no
response)
11. Triceps Surae Reflex(Supine)
(Note: Patient’s knee is bent and relaxed)

12. Toe Flexion Reflex (Rossolimo’s Sign)

(Note: Identical with Finger flexion reflex; Tap the ball of the foot)
Superficial Skin Muscle Reflex
Head Present Absent
(Indicate if Left eye or Right eye for the Corneal reflex)

1. Test the Corneal Reflex (optional)

2. Test the Gag Reflex (optional)

Abdominal Reflex (optional)
Cremasteric Reflex (optional)
Bulbocavnernosus Reflex (optional)
Lower Extremities Left Foot Right Foot

1. Plantar toe Reflex

2. Check for other extensor toe reflex (optional):
i. Chaddock Sign
ii. Gonda Sign
iii. Gordon Sign
iv. Oppenheim Sign
v. Schaeffer Sign

DEVELOPMENTAL REFLEXES

Reflexes Present Absent

Adductor spread of knee jerk
Moro
Palmar grasp
Plantar grasp
Rooting
Tonic neck response
Truncal incurvature
Parachute
Landau

SOMATOSENSORY
A. EXAMINATION OF SUPERFICIAL SENSORY MODALITIES

I. FACE
Light Touch Left Right

Ophthalmic Branch
Maxillary Branch
Mandibular Branch
Corneal Reflex

Neurotrans Team 2017 6

 Temperature Discrimination Tuning Fork Finger
Left Right Left Right
Ophthalmic Branch
Maxillary Branch
Mandibular Branch
Warm Test Tube Cold Test Tube
Left Right Left Right
Ophthalmic Branch
Maxillary Branch
Mandibular Branch

Pain Perception (Sharp or Dull) Left Right

Face

II. HANDS
Light Touch Left Right

Dorsum of the Hand

Temperature Discrimination Tuning Fork Finger

Left Right Left Right
Dorsum of the Hand
Warm Test Tube Cold Test Tube
Left Right Left Right
Dorsum of the Hand

Pain Perception (Sharp or Dull) Left Right

Dorsum of Hand

III. FEET
Light Touch Left Right

Dorsum of the Feet

Temperature Discrimination Tuning Fork Finger

Left Right Left Right
Dorsum of the Feet
Warm Test Tube Cold Test Tube
Left Right Left Right
Dorsum of the Feet

Pain Perception (Sharp or Dull) Left Right

Dorsum of the Feet

Left Right

Delayed Pain
Dorsum of the Foot
Deep Pain
Achilles Tendon
Straight Knee Leg Raising Test for Pain (+) (-)

Laseague’s Sign

B. EXAMINATION OF THE DORSAL COLUMN, DISCRIMINATIVE OR DEEP MODALITIES

Hand Foot
Position Sense Left Right Left Right
Digital movements (4th digit)

Directional scratch test

Romberg’s test

Hand Foot
Vibration Sense
Left Right Left Right
Pallanesthesia

Astereognosis and Tactile Object Agnosia

Left Right
Test Item Astereognosis Tactile Agnosia Astereognosis Tactile Agnosia

Key
Safety Pin
Paper Clip
Coin
 25 centavo
 1 peso
 5 peso
 10 peso

Neurotrans Team 2017 7

Things to bring for preceptorials
a. Neurohammer
b. Penlight
c. Odor testing for CN I (coffee)
d. Ophthalmoscope
e. Snellen chart for CN II
f. Cotton wisp and any blunted object for CN V and somatosensory
g. Salt or sugar solution for CN VII
h. Tuning fork for CN VIII
i. Key, safety pin, paper clip and different coins for astreognosis and agnosia
j. Picture of a famous personality for prosopagnosia
k. Picture of a bicycle wheel with spokes or face of a clock for left side hemispatial inattentation and constructional apraxia
l. Vital signs kit
m. Candies
n. Toys

References:
a. Pedia Checklist 2017
b. Previous neuro checklist (1st year - Section B)
c. DeMyer’s The Neurologic Examination 6th edition
d. http://www.sco.edu/assets/1813/course_5_b_handout.pdf
e. Neurological Examination in Infancy and Childhood by WIlliam J. Logan
f. Pediatric and Infant Neurologic Examination by William Hills, MD
g. 2nd year trans (PD-Pedia Neurologic Examination)

Neurotrans Team 2017 8

Neurotrans Team 2017 9