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. J udgement : 紅綠燈過馬路、火災時會打 119 2. O rientation: Person~ Time~ Place~ 3. M emory: a. immediate recall 3 objects: 醫院 ( 具體 ) 、紅色 ( 顏色 ) 、勇敢 ( 抽象 ) 4. A b. recent : c. remote : 為何住院 ? 住址、電話、姓名 bstract thinking: 蓮霧與西瓜異同、誠實與謙虛 5. C alculation: a. Series of 7 b. Series of 3 6.Language: Fluency: OK Comprehension: OK Naming: OK Repetition: OK 7.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 : 20/150  20/20(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)

Motor

 Muscle power/muscle tone  DTR/ pathologic reflex  Babinskin’s sign  Hoffmann's sign  Involuntary movement  Tremor  Clonus/Myoclonus  Chorea  Cerebellar sign:  Finger-nose-finger  Romberg test  Gait Pyramidal: no rigidity, no cross DTR, no ankle clonus Extra-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.

Motor

   Muscle power/muscle tone DTR/ pathologic reflex  Babinskin’s sign  Hoffmann's sign  Involuntary movement  Tremor  Clonus/Myoclonus  Chorea Cerebellar sign:  Finger-nose-finger  Romberg test  Gait Pyramidal: no rigidity, no cross DTR, no ankle clonus Extra-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: ataxia 1. Limb ataxia = cerebellar lobes 2. Gait ataxia = anterior vermis 3. Truncal ataxia = posterior vermis

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 Examination

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

• Newborn Neurology examination

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