Pnp Pa Neuro

Front 1

NS development

Back 1

**plasticity in children >> can outgrow cerebral palsy

• environmental, e.g. nutrition, hormones, maternal life-style

• neuro tube, e.g. neural plate, groove, folds, tube

• any disruption during embryonic development >> CNS DO

Front 2

neurodevelopmental history

Back 2

• health

• behavior

• psychosocial

• school performance

• developmental history

Front 3

T/F. Children >4 y/o should be able to tandem walk.

Back 3

False; >5 years old

Front 4

neuro symptom

Back 4

• vision, hearing, sensory loss

• change in weight

• n/v

• headache, memory loss

• fainting, blackouts

• hyperactivity

• weakness in one part of the body

• clumsiness

• changes in bowel/bladder habits

• neck pain

• gait problems

Front 5

types of neuro exams

Back 5

• neurological

• neuropsychological

• neurodevelopmental

Front 6

landau kleftner

Back 6

• normal EEG

• neurodevelopmental regression

• lost milestones

Front 7

localization

Back 7

• thinking/memory >> hemispheres, cerebral

• coordination >> cerebellum

• arms/legs w/ bladder/bowel control >> spinal cord

• speech >> L hemisphere

>>if a lot of problems that do not localize to one area >> psychosocial

Front 8

hyperreflexia v. hyporeflexia

Back 8

hyperreflexia- CNS

hyporeflexia- PNS

Front 9

What is the normal muscle reflex for muscular dystrophy?

Back 9

Patients initially have normal reflexes >> hyporeflexive.

Front 10

neuro PE

Back 10

**

1/ overall inspection

2/ general cerebral function

3/ cranial nerves

4/ reflexes

5/ motor strength

6/ sensory

7/ proprioception & cerebellar function

8/ soft sign

Front 11

neuro inspection

Back 11

• neurocutaneous lesions

• muscle atrophy

• gait weakness; hands should swing

• abnormal positioning, e.g. cortical thumb

• handedness in infants; normal in children >2 y/o

• large calves compared to thighs >> muscular dystrophy, esp. if child has pelvic girdle weakness

• (+) lumbar curve

• hand/tongue tremors >> spinal muscular atrophy

• hypermobility

• foot asymmetry >> diastematomyelia

Front 12

neurocutaneous signs

Back 12

• ash leaf spot >> tuberus sclerosis

• café au lait >> 6+ may indicate neurofibromatosis

• flammeus nevus

Front 13

glaucoma

Back 13

• tearing

• large pupils

Front 14

sturge webber

Back 14

• unilateral flammeus nevus

• glaucoma

• lesion of CN-V trigeminal

Front 15

marie charcot tooth syndrome

Back 15

• thin, long, legs

• loss of peripheral nerves >> does not feel cut

Front 16

myopathy v. neuropathy

Back 16

• myoppathy- central weakness

• neuropathy- distal weakness, e.g. marie charcot syndrome

Front 17

How do you test for cerebral function?

Back 17

**neurodevelopmental exam

• don't ask something they have to learn, e.g. color

• teach child something and evaluate learning ability

• judgement, problem solving; 5-6 y/o

• orientation to time/space; school age

• memory

• affective disturbances

• calculation disturbances (+/-)

Front 18

preschool child

Back 18

Front 19

2 years

Back 19

Front 20

3-5 years

Back 20

stick figure drawing--

• need all 5 fingers for full credit

• 1 point for each parts, e.g. 2 eyes, nose, mouth, head, body

Front 21

4 years

Back 21

Front 22

5 years

Back 22

• dresses w/o supervision

• copies cross

• draws person

• puts object on, under, in front of, and behind when asked

• hops on one foot 2+ times

Front 23

school age

Back 23

**industry v. inferiority

**6-12 y/o

• mastering skills needed as adult

• winning approval from peers & adults

• building self esteem, positive self concept

• adopting moral standard

Front 24

1st grade

Back 24

Front 25

ages & shapes

Back 25

3- circle

4- cross

5- square

6- triangle

Front 26

tandem walk: black v. white

Back 26

African Americans tandem walk by age 4 due to early myelination. Whites tandem walk by age 6.

Front 27

CN-I

Back 27

**olfactory

• test after direct blow to forehead above nasal bridge; may be cribiform plate fracture

• adults can develop anesomia w/ age; children DO NOT

Front 28

CN-II

Back 28

**optic

• test after head trauma

• shape of pupil

• follow penny w/ eyes

Front 29

horner's syndrome

Back 29

• lack of sweat

• pupillary defect

Front 30

CN-III, IV, IV

Back 30

III- oculomotor

IV- trochlear

VI- abducens

• inspect eyelids for drooping

• pupils' size for equality and reaction to light & accomodation

• 6 cardinal gaze

Front 31

blurred border

Back 31

Front 32

papilledema

Back 32

Front 33

paralysis of CN-III

Back 33

• horizontal nystagmus a/w labyrinthine, cerebellar, or brainstem pathology

• vertical nystagmus a/w cerebellar or brainstem pathology

• medication toxicity can cause both

Front 34

CN-V

Back 34

"make monster face for me"

• inspect face for muscle atrophy & tremors

• palpate jaw muscles as jaws clenched

• test for touch and temperature sensation

Front 35

CN-VII

Back 35

• facial symmetry

• smile & frown

• close eye tight

• puff cheeks

Front 36

central v. peripheral CN-VII

Back 36

central--

• can elevate eyebrows

• can close both eyes

peripheral--

• cannot elevate eyebrow on R

• bell's phenomenon- R eye cannot close & eyeball turns up

Front 37

CN-VIII

Back 37

• turning fork can be difficult to use in younger child

• screen for hearing 500 to 6000/8000

Front 38

weber test

Back 38

• place vibrating tuning fork on middle of forehead >> heard on both sides?

• unilateral neurosensory hearing loss >> best in normal ear

• unilateral conductive loss >> best in abnormal ear

Front 39

rinne test

Back 39

**comparing bone conduction to air conduction

AC > BC is normal

Front 40

conductive v. sensorineural hearing loss

Back 40

conductive--

• eustachian tube dysfunction

• ear fluid

• hole in eardrum

• fixed middle ear bone

sensorineural--

• noise induced

• prebycusis

• meniere's disease

• tumors

Front 41

CN-IX

Back 41

**glossopharyngeal

• ability to swallow

• gag reflex; not routinely done in school setting

• sweet/sour taste

Front 42

CN-X

Back 42

**vagus

• vocal quality

• look for rise of soft palate as child says "HAHA"

Front 43

testing CN-IX and X

Back 43

Front 44

CN-XI

Back 44

**accessory

• head rotation against resistance to test sternocleidomastoid

• upward shoulder movement tests trapezius

Front 45

CN-XII

Back 45

**hypoglossal

• inspect tongue; look for symmetry, tremors, & atrophy

• pressure the tongue against cheeck & check strength

• quality of lingual sounds; l,t,d,n

• potruded tongue deviates toward affected weaker side >> unilateral lesion

Front 46

reflexes

Back 46

• patient should be relaxed

• don't use more force than necessary

• can be reinforced by having patient perform isometric contractions

• evaluate for equality & spread

Front 47

reflex grading scale

Back 47

0 absent

1+ hypoactive

2+ normal

3+ hyperactive w/o clonus

4+ hyperactive w/ clonus

newborns may have clonus up to 3-4 weeks s/p birth

Front 48

clonus

Back 48

>> support knee in partly flexed position

>> when patient relaxes, quickly dorsiflex foot

>> observe for rhythmic oscillations

Front 49

bicep & tricep reflex

Back 49

bicep--

• C5, C6

• partially flexed @ elbow w/ palm down

• should feel response even if not visible

tricep--

• C6, C7

• support upper arm & let forearm hang free

• if patient is sitting/lying down >> flex arm at elbow and hold close to chest

Front 50

brachioradialis reflex

Back 50

• C5, C6

• rest forearm on abdomen or lab

• strike radius ~1-2 inches above wrist

• watch for flexion/supination of forearm

Front 51

abdominal reflex

Back 51

• above umbilicus- T8, T9, T10

• below umbilicus- T10, T11, T12

• stroke abdomen lightly w/ blunt object on each side in an inward & downward direction

• note contraction & deviation of umbilicus towards stimulus

Front 52

knee reflex

Back 52

• L2, L3, L4

• note contraction of quadraceps & knee extension

Front 53

ankle reflex

Back 53

• S1, S2

• have patient lean on chair w/ one knee

• dorsiflex foot of ankle >> strike achilles

• watch & feel for plantar flexion

Front 54

babinski reflex

Back 54

**fanning/outward motion is normal in children who cannot walk

Front 55

chaddock v. oppenheimer reflex

Back 55

chaddock--

• stroke side of foot from external malleolus to small toe

• (+) if dorsiflexion of great toe

oppenheimer--

• firmly press down on shin & run along anterior medial tibia toward foot

• (+) if dorsiflexion of great toe

Front 56

snouting reflex

Back 56

Front 57

motor strength

Back 57

**test according to developmental milestone

• infant- tone, hip control

• toddler- walk is broad based

• older child- fine v. gross motor

includes--

• posture, gait

• balance

• coordination

• writing

Front 58

intention tremor

Back 58

• child tremors before block placement

• sign of cerebellar disease

causes of tremor--

• familial

• hyperthyroidism

Front 59

gowers sign

Back 59

**uses push up to get off the floor

Front 60

grading motor strength

Back 60

0/5 no muscle movement

1/5 no movement @ joint

2/5 not against gravity

3/5 not against resistance

4/5 less than normal

5/5 normal strength

Front 61

myotonic v. neuropathy

Back 61

myotonic disease--

• spinal muscular atrophy

• musuclar dystrophy

• myotonic dystrophy; worse w/ every generation

neuropathic disease--

• marie charcot tooth

Front 62

myotonia

Back 62

sustained contractions

Front 63

duchenne muscular dystrophy

Back 63

boys--

• difficulty climbing stairs

• running, frequent falls

• jumping from standing position

slow motor milestones--

• starts walking @ 18 mos

• clumsy @ 2-3 yrs

• difficulty keeping up with peers @ 3-5 yrs

consistent weakness--

• proximal muscles >> distal muscles

• legs >> arms

• extensors >> flexors

Front 64

duchenne muscular dystrophy progression

Back 64

• toe walking

• calf pseudohypertrophy

• (+) gowers

• lumbar lordosis from muscle weakness

• multifocal contractures

• trendelenburg gait

• fatigue

Front 65

pronator drift

Back 65

**upper motor neuron disease

**unable to maintain supination

Front 66

sensory

Back 66

**perform all 4 extremities

• pain

• light touch

• vibratory sense

• hot/cold

• sharp/dull

Front 67

proprioceptive & cerebellar function

Back 67

**stand for 40s; if unable to perform >> cerebellar weakness

• intentional tremor during block stacking

• tandem gait

• balance

• gait--wide based & ataxic

Front 68

coordination & gait

Back 68

• rapid alternating movements

• point-to-point movements

• romberg

• gait

Front 69

two point discrimination

Back 69

• done on older children

• used opened paper clip to touch patient's finger pads in two places simultaneously

Front 70

graphesthesia. v. stereognosis

Back 70

graphesthesia--

• draw large number on patient's palm

• ask to identify

stereognosis--

• older child, use as alternative

• place familiar object in patient's hand

• ask to identify

Front 71

soft sign

Back 71

• nonstop talking, constant motion

• L to R confusion; identify by age 8

• hand preference; established by age 3

• dystonic posturing

• proximal inhibition

Front 72

T/F. Left hand preference or mixed hand preference are neurodevelopmental markers.

Back 72

True

Front 73

dystonic posturing

Back 73

stiffening of extremities during stressed gait or rhythmic movements, e.g. hop in place/toe walk w/ penny on nose

Front 74

proximal inhibition

Back 74

• inability to inhibit proximal musculature while using distal muscles

• screen by instructing child to rapidly alternate opening & closing of fists w/ arms extended or by rapidly roatating wrist while holding arms and hands above the head

Front 75

neuropsych eval

Back 75

• used for learning disabilities

• parent's observations

• formal observation, e.g. watch child copy designs, pronounce words, etc.

Front 76

skull fractures

Back 76

simple aka linear--

• most common

depressed--

• hematoma @ site

• may need surgery

compound--

• laceration & depressed skull fracture

• dura usually pierced

• skull fragments may be displaced into brain tissue

basilar--

• break in posteroinferior portion

• produces dural tears resulting in leakage of CSF >> (+) dextrose stick

Front 77

epidural hematoma

Back 77

**blood b/w dural surface and skull; usually result of tearing of meningeal artery

• more common in older children & toddlers; miningeal artery is not yet embedded in bony surface of skull prior to age 2

• slow growing

s&s--

• headache

• (-) LOC

• fever

• dilation of pupil on affected side

Front 78

basilar skull fracture

Back 78

early signs--

• blood behind typmanic membrane

• nerve palsy

• deafness, ringing in ear

• dizziness, n/v

late signs--

• battle sign- bruising over temporal area

• racoon sign

Front 79

quick neuro check

Back 79

• LOC

• motor function

• pupillary response

• VS

• ICP

• glasgow coma scale

Front 80

glasgow coma

Back 80

• eye opening response 1-4

• motor response 1-6

• verbal response 1-5

Front 81

bacterial meningitis

Back 81

**child's age is predominant determinant of common bacteria cause

• headache, fever

• stiff neck

• toxic

if child is <2 y/o--

• NO stiff neck

• (-) LOC

• otitis media

• focal seizures

Front 82

meningitis history

Back 82

• progression

• exposure

• history of otitis media

• underlying health problems

• seizures--focal v. generalized

Front 83

menigitis signs

Back 83

kernig's sign--

• complains of lower back pain

• flex hip and knee >> straightening knee will cause excessive pain & resistance

• complains of lower back pain

brudzinki sign--

• tests for nuchal rigidity

• flexion of neck causes flexion of hips and knees

Front 84

T/F. Patients with VP shungs have classic signs of menigitis.

Back 84

False; they present differently--

• low grade ventriculitis

• headaches

• nausea

• minimal fever

• malaise

Front 85

viral meningitis

Back 85

• less toxic

• more common in summer

• treated @ home unless patient is vomiting and needs fluids