Neurological Assessment of the School Age Child
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1 O U T R E A C H E D U C A T I O N Neurological Assessment of the School Age Child April 3, 2008 Program Handouts This information is provided as a courtesy by Children's Health Care System and its related organizations (CHCS). Persons accessing this information assume full responsibility for the use of the information and understand and agree that CHCS is not responsible or liable for any claim, loss or damage arising from the use of the information. The views and opinions of the document authors do not necessarily state or reflect those of CHCS. Neither the authors nor CHCS nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information.
2 Neurological Assessment of the School Age Child Nadine Nielsen ARNP, CPNP Nurse Practitioner, Neurosurgery Children s Hospital, Seattle Serial, consistent and well documented neuro assessment is vital Subtle changes may be first noted by someone close to child-caregiver, school nurse, etc History Timely response to changes in neuro status of child is essential in preventing complications associated with neurological disorders Prenatal, perinatal, neonatal issues Medical and surgical history Family history Overall development / school performance Current medications Review of symptoms History Current concerns history of present illness During hx observe child Will see much of exam while observing the child Development Does child meet developmental expectations? Knowledge of normal development is essential Normal milestones (smile, sit, crawl, pull to stand, walk, words, words together), does the child meet the milestones appropriate for his age 1
3 Development If child delayed, do current concerns reflect loss of milestones, slowness in developmental progress or any developmental effect? Loss of milestones is always red flag Examination of Child Initial appearance and observation Technique of successful exam is to observe and engage child in ageappropriate manner Airway Activate Breathing Circulation AED ABCs Vital Signs Neurological alterations can affect vital signs Changes in VS may be a late sign in increased ICP in children Sequential observation Cushings Tirad (widening pulse pressure, bradycardia and altered respiratory patterns) sx of increased ICP (not always in kids) Mental Status Glass Coma Scale Sequential assessment is most important Alert, aware of environment, oriented Interactive / communication Normal thought process / memory Follow directions (age appropriate) Affect Cognition (age appropriate) 2
4 Head If injured visually examine and palpate the head and neck for lacerations, swelling, bleeding, etc If neck injury suspected or if accident not observed should immobilize neck Cranial Nerves Cranial Nerves I II Olfactory (sensory) smell Optic (sensory) visual acuity, pupil size and reactivity to light Nerves III Oculomotor ) IV Trochlear Extraocular movements- EOMs VI Abducens (motor) EOMs Have child follow light with eyes with head stationary thru 6 planes of movement, normal-eoms intact Conjugate-eyes move together Dysconjugate-eyes do not move together Nystagmus-jerky motion of eyes, horizontal, vertical, rotary 3
5 III Nerves Pupil response, raise eyelids, move eye Palsy dilation / pupil NR ptosis with eye down and out IV Downward with inward movement of eye VI Lateral movement palsy eye deviates medially Nerves V Trigeminal (motor and sensory) sensation of face, corneal reflex, muscle of mastication VII Facial (motor and sensory) facial motor, facial symmetry VIII Acoustic (sensory) hearing, equilibrium 4
6 IX X XI XII Nerves Glossopharyngeal (motor and sensory) gag, movement of palate Vagus (motor and sensory) swallow, voice, phonation Accessory (motor) shoulder shrug Hypoglossal (motor) tongue midline, tongue movement Cerebellar Exam Overall balance and coordination Observe gait, toe, heel and tandem walking (tandem walk >5yr) Ataxia may result from cerebellar lesion, drug intoxications, post seizure Finger, nose, finger exam dysmetria Rapid alternating movement Motor Exam Muscle size, shape and symmetry Tone Strength and symmetry of movement Quality of movement Observe spontaneous movement and response to verbal directions Hold arms up/eyes closed and look for drift (subtle weakness) Muscle Strength 0 No movement 1 Flicker of movement 2 Movement with gravity eliminated (horizontal plane) 3 Movement against gravity but not resistance 4 Full movement that can be overcome by examiner 5 Normal strength Sensory Response to light touch, pin prick If abnormal consider affected dermatome Proprioception where part is in space 5
7 Infantile Reflexes Normal in infancy, may persist in delayed child Disappear first year of life Moro birth to 6 mos. Babinski birth to 2 yrs. tonic neck birth to 6 mos. placing (stepping) 6 mos. 1 yr. rooting birth to 6 mos. sucking birth to 12 mos. Palmar birth to 6 mos. Deep Tendon Reflexes 0-4 quality (1/sluggish, 2/active, 3/hyperactive, 4/brisk, transient clonus) Bicep Triceps Tadialis Patellar Achilles Babinski Clonus Back and Spine Contour and symmetry Scoliosis (curve to left red flag ) Dimples, lumps, tuft of hair Skin Patches of hyper or hypopigmentation signs of neurological disorders Birth marks, port wine stain / face-scalp Pain Pain may be related to a known diagnosis or new problem Assessment using 1-10 scale 1 no pain-10 worst pain ever Anxiety and pain may increase each another Chronic pain may be related to nerve injuryneuropathic pain Developmentally delayed child may be difficult to assess pain Soft Signs Gross motor clumsiness, awkwardness Problem with motor planning Fine motor handwriting, handling small items Speech / language expressive, receptive Behavior interaction with others, toys, aggression, impulsiveness, distractiveness 6
8 Signs of Increased Intracranial Pressure Infants OFC Separation of sutures Bulge tense fontanelle Poor feeding Lethargy High pitched cry Child Signs of ICP Headache Nausea / vomiting Lethargy Diplopia, blurred vision Papilledema (not necessarily) Memory problems Decline cognitive function Red Flags of Hx and Exam Headache awaken from sleep or in a.m. or worsening over time Nausea / vomiting in a.m. Changes in gait / coordination Cranial nerve dysfunction Loss of cognitive function or milestones Scoliosis with curvature to the left Questions 7
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Neuro Exam Charlie Goldberg, M.D. Professor of Medicine, UCSD SOM cggoldberg@ucsd.edu Elements of The Neuro Exam Cranial Nerves Motor bulk, tone, strength Coordination fine movements, balance Sensation