小兒神經學理學檢查

Fellow 黃意評2010-11-25

檢查大綱• Mental status • Cranial nerve, • Motor, • Cerebellar, • Sensory examinations

• Newborn:• Primitive reflex• Jitterness and clonus

GCS:E4M6V5 Vital sign: 36.9 /94bpm/24/min, BP:113/81 mmHg℃1. Judgement : 紅綠燈過馬路、火災時會打 1192. Orientation: Person~ Time~ Place~3. Memory: a. immediate recall 3 objects: 醫院 ( 具體 ) 、紅色 ( 顏色 ) 、勇敢 ( 抽

象 ) b. recent : 為何住院 ? c. remote : 住址、電話、姓名4. Abstract thinking: 蓮霧與西瓜異同、誠實與謙虛5. Calculation: a. Series of 7 b. Series of 36.Language: Fluency: OK Comprehension: OK Naming: OK Repetition: OK7.Hallucination: Visual: denied Auditory: denied Sensory: denied

• 純感覺 : CN1,2,8 ; 純運動 : 3,4,6,11,12• CN 1 : anosmia (Frontal lobe tumor)• CN 2 : 20/15020/20(6m/o); visual field • CN 2,3 : Pupillary light reflex(+)• CN 3.4.6: EOM full• CN 5 : face: sensory:OK, Mastication: ok• CN 7: No facial palsy, corneal reflex(+) symmetric nasolabial fold• CN 9, 10 : Swallowing(+) ; gag reflex(+)• CN 11 : Head rotation/shoulder elevation(+)• CN 12 : tongue: deviation(-) ; slur speech(-)

Cranial Nerves ( I )

• Olfactory nerve (I)• Optic nerve (II):– Visual acuity– Visual field: confrontation test

Cranial Nerves ( II )

• Extra-Ocular Muscles:– Oculomotor nerve (III)– Trochlear nerve (IV)– Abducens nerve (VI)

• Trigeminal Nerve (V):– Three divisions– Motor: masseter, temporalis

Cranial Nerves ( III )

• Facial Nerve (VII):– Motor –• Facial expression• Naso-labial fold• Eye blinking• Wrinkles

– Sound damping, taste– Central vs peripheral facial palsy

Cranial Nerves ( IV )

–Vestibulo-Cochlear Nerve (VIII)–Glossopharyngeal (IX) & Vagus (X)

Nerves• Taste• Voice• Gag reflex

Cranial Nerves ( V )

• Spinoaccessory Nerve (XI):– Trapezius muscles– Sternocleidomastoid muscles

• Hypoglossal Nerve (XII):– Tongue atrophy– Fasciculation– Deviation– Strength

Cranial Reflex

– Light reflex (II-III)–Corneal reflex (V-VII)–Gag reflex (IX, X)

MotorMuscle power/muscle toneDTR/ pathologic reflex

Babinskin’s signHoffmann's sign

Involuntary movementTremorClonus/MyoclonusChorea

Cerebellar sign:Finger-nose-fingerRomberg testGait

Pyramidal: no rigidity, no cross DTR, no ankle clonusExtra-pyramidal: no hypotonia, no spasticity, no dystonia, no chorea, no athetoid

MRC System

• 5 normal power• 4 against resistance : 4+, 4, 4-• 3 against gravity• 2 horizontal movement (no anti-gravity)• 1 muscle contraction• 0 no movement

Upper motor neuron sign

DTR (Knee jerk, strech reflex)

Supraspinal control• Inhibitory signals on gamma neurons through

lateral reticulospinal tract from• Motor Area 6 • Paleocerebellum • Red nucleus • Facilitatory signals on gamma neurons through

ventral reticulospinal tract from• Motor Area 4 • Neocerebellum • Vestibular nucleus

Babinski sign (Plantar reflex)-- Pyramidal / Lateral corticospinal tract

• In infants• This happens because the corticospinal pathways

that are not fully myelinated at this age, so the reflex is not inhibited by the cerebral cortex.

• The extensor response disappears and gives way to the flexor response around 12-24 m/o.

MotorMuscle power/muscle toneDTR/ pathologic reflex

Babinskin’s signHoffmann's sign

Involuntary movementTremorClonus/MyoclonusChorea

Cerebellar sign:Finger-nose-fingerRomberg testGait

Pyramidal: no rigidity, no cross DTR, no ankle clonusExtra-pyramidal: no hypotonia, no spasticity, no dystonia, no chorea, no athetoid

• Pyramidal tract

Movement disorder= Extrapyramidal disorders

Coordination• Romberg test : • Cerebellar dysmetria:– Finger-nose-finger test– Heel-to-shin test

• Rapid alternating movement (RAM) ex. • Gait: ataxia1.Limb ataxia = cerebellar lobes2.Gait ataxia = anterior vermis3.Truncal ataxia = posterior vermis

Heel-to-shin.htm

Proprioceptive and tactile stimuli are projected as shown in the upper (inverted) homunculus and the lower (split) homunculus. The striped area : the region from which evoked responses to auditory and visual stimuli are observed.( 聽、視覺刺激後的反應 ( 動作 ) 區 )

Sensory Examinationa. Light touch : OK b.Pinprick : OK c. Joint position sense : OK (fingers and toes) d.Vibration e.Temprature :

•

NewbornNeurology examination

http://library.med.utah.edu/pedineurologicexam/html/home_exam.html