Neurologic System
Adapted from Mosby’s Guide
to Physical Examination, 6th Ed.
Ch. 22
Development
1st year of life
• Myelinization of the brain and nervous
system
“Any intruding event (infection, trauma,
or biochemical imbalance), that upsets
brain development and growth during
this time, can have profound effects.”
*Brain growth continues until 12-15 years
• Motor maturation proceeds in a
cephalocaudal direction
– Control of the head and neck develops first
– Followed by trunk and extremities
• Motor development is a succession of
integrated milestone
– Many may be developed simultaneously
– Orderly sequence to development
– Considerable variation in timing exists
Developmental Milestones
• See Table
(Musculoskeletal)
Infant Exam
Infant Cranial Nerve Evaluation
CN II, III, IV, & VI
• Optical blink reflex
– Shine a light at the infant’s open eyes
– Observe quick closure of the eyes and dorsal
flexion of the infant’s head
*No response: poor light perception
• Gazes intensely at close object or face
• Focuses on and tracks an object with
both eyes
• Doll’s eye maneuver (CN VIII)
CN V
• Rooting Reflex
– Touch one corner of the infant’s mouth
– Infant should open its mouth and turn its head in the
direction of stimulation
*If recently fed, minimal response is expected
• Sucking reflex
– Place your finger in the infant’s mouth
– Feel the sucking action
– Tongue should push up against your finger with good
strength
– Note pressure, strength, and pattern
CN VII
• Observe the infant’s facial
expression when crying
• Note ability to wrinkle the forehead
• Symmetry of the smile
CN VIII
• Acoustic Blink Reflex
– Clap your hands about 1 ft. from the infant’s
head
– Note the blink in response to sound
• Infant will habituate to repeated testing
*No response after 2-3 days of age may
indicate hearing problems
• Moves eyes in direction of sound
• Freezes position with high-pitched sound
CN VIII (continued)
• Doll’s Eye Maneuver
– Hold the infant under the axilla in an upright
position
• Head held steady by parent, facing you
– Rotate the infant, first in one direction and
then the other
– Infant’s eyes should turn in the direction of
rotation
– When movement stops, eyes should move in
the opposite direction
*If not, suspect vestibular problem or eye
muscle paralysis
CN IX, X
• Swallowing and gag reflex
CN XII
• Coordinated sucking and
swallowing ability
• Pinch infant’s nose
– Mouth will open and tip of tongue will
rise in a midline position
Observation
• Coordinated sucking and swallowing
(cerebellum)
• Hands are usually held fisted for the 1st 3
months (but not constantly)
– After 3 months they open for longer periods
• Observe for spontaneous activity
– Symmetry
– Smoothness of motion
• Posture and movement
– Rhythmic twitching
• Facial, extremity, trunk musculature
– Sustained asymmetric posturing
• Paroxysmal episodes… associated
with seizure activity
• Sensory function
– Withdrawal of limbs to painful stimulus
Reflexes
• Patellar reflex present at birth
• Achilles and brachioradial reflexes
appear at 6 months
– Use a finger to tap the tendon
– Interpret findings as for adults
*NOTE: ankle clonus is common
Babinski sign
• Positive – fanning of toes and
dorsiflexion of the great toe
• Retained until 16-24 months of age
Primitive Reflexes
Present in the newborn
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Yawn
Sneeze
Hiccup
Blink at bright light and loud sound
Pupillary constriction with light
Withdrawl from painful stimuli
• As the brain develops, some primitive
reflexes are inhibited
– more advanced cortical functions and
voluntary control take over
Primitive Reflexes
• Used to evaluate posture and
movement of the developing infant
• Appear and disappear in a
sequence corresponding with CNS
development
• Palmar Grasp (birth)
– Infant’s head midline
– Touch palm of the infant’s hand from
the ulnar side
– Note the strong grasp of your finger
– Sucking facilitates the grasp
– Strongest between 1-2 months
– Disappears by 3 months
• Plantar Grasp (birth)
– Touch the plantar surface of the
infant’s feet at the base of the toes
– Toes should curl downward
– Strong up to 8 months
• Moro (birth)
– Infant supported in semi-sitting position
– Allow the head and trunk to drop back to a
30 degree angle
– Observe symmetric abduction and extension
of the arms
• Fingers fan out &thumb and index finger form a C
– The arms then adduct in an embracing
motion, followed by relaxed flexion
– Legs follow a similar pattern
– Diminishes in strength by 3-4 months
• Placing (4 days)
– Hold the infant upright under the arms
– Touch the dorsum of the foot to the
edge of a flat surface
– Observe flexion of the hips and knees
and lifting of the foot (as if stepping up)
– Age of disappearance varies
• Stepping (birth-8 weeks)
– Hold the infant upright under the arms
– Allow the soles of the feet to touch the
surface of the table
– Observe for alternate flexion and
extension of the legs (walking)
– Disappears before voluntary walking
• Asymmetric Tonic Neck (by 2-3 months)
AKA Fencer’s
– Infant supine
– Turn head to one side
– Observe for ipsilateral extension &
contralateral flexion of the arms and legs
– Repeat, turning head to the other side
– Diminishes around 3-4 months and disappears
by 6 months
– Must disappear before the infant can roll or
bring its hands to its face
– Concern if infant never exhibits the reflex or
seems locked in the fencing position
• Galant (birth-4 weeks)
– Suspend the infant prone over your
hand
– Stroke paraspinally from the shoulders
to the buttocks
– Trunk should curve toward the side
stroked
– Repeat on the other side
• Perez
– Suspend the infant prone over your
hand
– Stroke over the spinous processes from
sacrum to occiput
– infant extends head and brings knees
to chest; urinates
• Landau (birth-6 months)
– Suspend the infant prone over both
hands
– Observe the infant’s ability to lift its
head and extend its spine on a
horizontal plane
– Diminishes by 18 months
– Disappears by 3 years
• Parachute (4-6 months)
– Hold the infant suspended
(prone)
– Slowly lower it head first
toward a surface
– Observe the infant extend
its arms and legs
(protecting itself)
– This reflex should not
disappear
• Neck Righting (3 months; after Tonic
Neck disappears)
– Infant supine
– Turn head to the side
– Observe the infant turn its whole body
in the direction the head is turned
Child Exam
Cranial Nerve Examination
CN II
• Snellen E or Picture Chart may be
used to test vision
• Visual fields may be tested; child
may need the head immobilized
CN III, IV, and VI
• Have child follow an object with
eyes; immobilize head if necessary
• Move the object through the
cardinal points of gaze
video
CN V
• Observe the child chewing; note
bilateral jaw strength
• Touch forehead and cheeks with
cotton
– watch the child bat it away
CN VII
• Observe the child’s face when
smiling, frowning, and crying
• Ask child to show teeth
• Demonstrate puffed cheeks and ask
the child to imitate
CN VIII
• Observe the child turn to sounds
(bell or whisper)
• Whisper a commonly used word
behind the child’s back and have
him or her repeat the word
• Refer for audiometric testing
CN IX and X
• Elicit gag reflex
CN XI and XII
• Instruct older child to stick out the
tongue
• Instruct older child to shrug the
shoulders or raise the arms
Observation
• Observe the child at play
– Gait
– Fine motor coordination
• Beginning walker: wide-based gait
VIDEO
• Older child: feet closer together, better
balance
VIDEO
• Observe skill in reaching for,
grasping, and releasing toys
VIDEO
– No tremors or constant overshooting
movements should be apparent
• Coordination skills (heel-to-toe
walking, hopping, and jumping)
– Modify into a game
Three Penny Games
• Ask child who is standing to pick up a
penny up off the floor
– Tests vision and balance
• Stick a moistened coin to the child’s nose
and ask the child to walk across the room
– Observe gait and posturing
• Have child balance a penny on the nose
and dorsum of each extended hand
– Tests Romberg
Deep Tendon Reflexes
VIDEO
• Use same technique as adults
• Responses should be the same
• May use finger instead of reflex
hammer (less threatening)
Light Touch
• Ask child to close eyes and point to
where you touch
– Discriminate between rough and soft
Vibration
• Tuning fork; “buzzing” sensation
Superficial pain
• not routinely tested in kids due to
their fear of needles and sharp
objects
Graphesthesia
(cortical sensory integration)
• Use geometric figures
• Draw each figure twice and ask the
child if the figures are the same or
different
*May need practice session with
eyes open
Neurological Soft Signs
• Nonfocal, functional neurologic
findings
– Provide subtle cues to an underlying
CNS deficit or a neurological
maturation delay
– Children with multiple soft signs are
often found to have learning problems
Walking, running gait
Soft Sign Finding
• Stiff-legged with a foot slapping quality,
unusual posturing of the arms
Latest Expected Age of Disappearance
• 3 years
Heel walking
Soft Sign Finding
• Difficulty remaining on heels for a
distance of 10 ft
Latest Expected Age of Disappearance
• 7 years
Tip-toe walking
Soft Sign Finding
• Difficulty remaining on toes for a
distance of 10 ft
Latest Expected Age of Disappearance
• 7 years
Tandem gait
Soft Sign Finding
• Difficulty walking heel-to-toe, unusual
posturing of arms
Latest Expected Age of Disappearance
• 7 years
One-foot standing
Soft Sign Finding
• Unable to remain standing on one foot
longer than 5-10 sec.
Latest Expected Age of Disappearance
• 5 years
Hopping in place
Soft Sign Finding
• Unable to hop rhythmically on each
foot
Latest Expected Age of Disappearance
• 6 years
Motor-stance
Soft Sign Finding
• Difficulty maintaining stance (arms
extended in front, feet together, and
eyes closed), drifting of arms, mild
writhing movements of hands or fingers
Latest Expected Age of Disappearance
• 3 years
Visual tracking
Soft Sign Finding
• Difficulty following object with eyes
when keeping the head still; nystagmus
Latest Expected Age of Disappearance
• 5 years
Rapid thumb-to-thumb
Soft Sign Finding
• Rapid touching thumb to fingers in
sequence is uncoordinated; unable to
suppress mirror movements in
contralateral hand
Latest Expected Age of Disappearance
• 8 years
Rapid alternating movements of hands
Soft Sign Finding
• Irregular speed and rhythm with
pronation and supination of hands
patting the knees
Latest Expected Age of Disappearance
• 10 years
Finger-nose test
Soft Sign Finding
• Unable to alternately touch examiner’s
finger and own nose consecutively
Latest Expected Age of Disappearance
• 7 years
Right-left discrimination
Soft Sign Finding
• Unable to identify right and left sides of
own body
Latest Expected Age of Disappearance
• 5 years
Two-point discrimination
Soft Sign Finding
• Difficulty in localizing and discriminating
when touched in one or two places
Latest Expected Age of Disappearance
• 6 years
Graphesthesia
Soft Sign Finding
• Unable to identify geometric shapes
you draw in child’s open hand
Latest Expected Age of Disappearance
• 8 years
Stereognosis
Soft Sign Finding
• Unable to identify common objects
placed in own hand
Latest Expected Age of Disappearance
• 5 years
Common Conditions
Generalized Seizure Disorder
• Episodic, sudden, involuntary
contractions of a group of muscles
– Excessive discharge of cerebral neurons
Disturbances in:
• Consciousness
• Behavior
• Sensation
• Autonomic functioning
– Urinary and fecal incontinence
May be caused by:
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Systemic disease
Head trauma
Toxins
Stroke
Hypoxic syndromes
• Affects 1% of the population
• 75% new cases develop during childhood
and adolescence
Meningitis
• Inflammatory process in the
meninges
– Bacterial / viral
• *Bacterial meningitis should be
treated with appropriate antibiotics
Signs & symptoms:
• Fever
• Chills nuchal rigidity
• Headache
• Seizure
• Vomiting
• Altered level of consciousness
*Do not demonstrate nuchal rigidity until
6-9 months
Infant Signs & symptoms:
• Very irritable and inconsolable
• Fever
• Diarrhea
• Poor appetite
• Toxic appearance
Encephalitis
• Inflammation of the brain and spinal
cord (involves meninges)
Onset is often a mild, febrile
viral illness…
• Quiescent stage often precedes the
disturbance in CNS function
– Headache
– Drowsiness
– Confusion
*Progressing to stupor and coma
Motor function may also be impaired
– Severe paralysis
– Ataxia
Space-Occupying Lesions /
Intracranial Tumors
• Abnormal growth of neural or nonneural
tissue within the cranium
– Primary or metastatic cancer
– Displacement of tissue
– Pressure on the CSF circulation
Peak age of incidence:
– 3-12 years
– 50-70 years
• Threaten function by compression or
destruction of tissue
Early Signs & symptoms:
*Vary by location of the tumor
– Headace
– Vomiting
– Change in cognition
– Motor dysfunction
– Seizures
– Personality changes
Cerebral Palsy
• Nonprogressive neuromuscular disorders
– Abnormal muscle tone
– Coordination
• Results from insult to the cerebellum,
basal ganglia, or motor cortex
• Disability depends on the extent of
damage
– Some can expect near normal levels of
functioning
Signs include:
•
•
•
•
•
Delayed gross motor development
Altered muscle tone
Abnormal posture
Abnormal motor performance
Abnormal reflexes
HIV Encephalopathy
• Progressive encephalopathy
associated with AIDS
– Impaired brain growth
(cerebral atrophy)
Advanced feature of AIDS
Signs & symptoms:
• Progressive motor dysfunction
• Regression/plateau in
developmental milestones
• Generalized weakness
• Signs of UMN lesion
Less commonly:
– Dysphagia (difficulty swallowing)
– Gait ataxia
– Seizures
Rett syndrome
• Progressive encephalopathy
• Unknown cause
• Girls between 6-18 months of age
*Develops after normal neurologic
and mental development …
Signs & symptoms:
• Loss of voluntary hand movement
• Loss of previously acquired hand skills
• Hand wringing movements
• Gradual development of ataxia & rigidity
of the legs
• Growth retardation
• Seizures
• Loss of facial expression
• Deceleration of head growth
– between 5-48 months of age