Neurologic Evaluation

    Neurological disease may produce systemic signs and systemic disease may affect nervous system.A comprehensive neurologic evaluation-including:

1- history,

2- physical examination, and

3- the judicious use of ancillary studies/ Tools for test

allows the clinician to localize and determine the etiology of central and peripheral nervous system pathology.A detailed history is the cornerstone of any neurologic assessment. Although parents may be the primary informants, most children older than 3-4 yr are capable of contributing to their history and should be questioned directly.The history should begin with the chief complaint, as well as a determination of the complaint's relative significance within the context of normal development.The latter step is critical because a 13 month old who cannot walk may be perfectly normal, whereas a 4 yr old who cannot walk might have a serious pathology.Next, the history of present illness should provide a chronological outline of the patient's symptoms, with attention paid to location, quality, intensity, duration, associated features, and alleviating or exacerbating factors.It is essential to perform a review of systems, because abnormalities of the central nervous system (CNS) often manifest with vague, nonfocal symptoms that may be misattributed to other organ systems (e.g., vomiting, constipation, urinary incontinence).A detailed history might suggest that vomiting is due to increased intracranial pressure (ICP) rather than gastritis or that constipation and urinary incontinence are due to a spinal cord tumor rather than behavioral stool withholding.Following the chief complaint and history of present illness, the physician should obtain a complete birth history, particularly if a congenital disorder is suspected. The birth history should begin with a review of the pregnancy, including specific questions about common complications, such as pregnancy-induced hypertension, preeclampsia, gestational diabetes, vaginal bleeding, infections, and falls. It is important to quantify any cigarette, alcohol, or drug (prescription, herbal, illicit) use. Inquiring about fetal movement might provide clues to an underlying diagnosis, because decreased or absent fetal activity can be associated with chromosomal anomalies and CNS or neuromuscular disorders. Finally, any abnormal ultrasound or amniocentesis results should be noted.The most important component of a neurologic history is the developmental assessment.Careful evaluation of a child's social, cognitive, language, fine motor, and gross motor skills is required to distinguish normal development from either isolated or global (i.e., in two or more domains) developmental delay. An abnormality in development from birth suggests an intrauterine or perinatal cause, but a loss of skills (regression) over time strongly suggests an underlying degenerative disease of the CNS, such as an inborn error of metabolism.The social history should detail the child's current living environment, as well as his or her relationship with other family members.It is important to inquire about recent stressors, such as divorce, remarriage, birth of a sibling, or death of a loved one, because they can affect the child's behavior. If the child is in daycare or school, one should document his or her academic and social performance, paying particular attention to any abrupt changes.

   

      The neurologic examination begins at the outset of the interview. Indirect observation of the child's appearance and movements can yield valuable information about the presence of an underlying disorders.For instance, it may be obvious that the child has dysmorphic facies, an unusual posture, or an abnormality of motor function manifested by a hemiparesis or gait disturbance. The child's behavior while playing and interacting with his or her parents may also be telling. A normal child usually plays independently early in the visit but will rapidly engage in the interview process. A child with attention-deficit/hyperactivity disorder might display impulsive behavior in the examining room, and a child with neurologic impairment might exhibit complete lack of awareness of the environment. Finally, note should be made of any unusual odors about the patient, because some metabolic disorders produce characteristic scents (e.g., the “musty” smell of phenylketonuria or the “sweaty feet” smell of isovaleric acidemia). If such an odor is present, it is important to determine whether it is persistent or transient, occurring only with illnesses.The examination should be conducted in a nonthreatening, child-friendly setting. The child should be allowed to sit where he or she is most comfortable, whether it be on a parent's lap or on the floor of the examination room. The physician should approach the child slowly, reserving any invasive or painful tests (e.g., measurement of head circumference, gag reflex) for the end of the examination. In the end, the more that the examination seems like a game, the better the child will cooperate. Because the neurologic examination of an infant requires a somewhat modified approach from that of an older child, the two groups are considered separately.

Common or Concerning Symptoms of the Nervous System

•       Observing mental status, speech, and language

•       Observing sensorium, memory, abstract thinking ability, speech, mood, emotional state, perceptions, thought processes, ability to make judgments

•       Headache

•       Dizziness or vertigo

•       Weakness

•       Numbness

•       Loss of sensations

•       Loss of consciousness

•       Seizures

•       Tremors or involuntary movements

 Correct measurement of the head circumference is important. It should be performed at every visit for patients younger than 3 yr and should be recorded on a suitable head growth chart.The average rate of head growth in a healthy premature infant is 0.5 cm in the 1st 2 wk, 0.75 cm in the 3rd wk, and 1.0 cm in the 4th wk and every week thereafter until the 40th wk of development. The head circumference of an average term infant measures 34-35 cm at birth, 44 cm at 6 mo, and 47 cm at 1 yr of age If the brain is not growing, the skull will not grow; therefore, a small head reflects a small brain, or microcephaly. Conversely, a large head may be associated with a large brain, or macrocephaly, which is most commonly familial but may be due to a disturbance of growth, neurocutaneous disorder (e.g., neurofibromatosis), chromosomal defect (e.g., Kleinfelter syndrome), or storage disorder. Alternatively, the head size may be increased secondary to hydrocephalus or chronic subdural hemorrhages.An infant has two fontanels at birth: a diamond-shaped anterior fontanel at the junction of the frontal and parietal bones that is open at birth, and a triangular posterior fontanel at the junction of the parietal and occipital bones that can admit the tip of a finger or may be closed at birth.If the posterior fontanel is open at birth, it should close over the ensuing 6-8 wk; its persistence suggests underlying hydrocephalus or congenital hypothyroidism.A very small or absent anterior fontanel at birth might indicate craniosynostosis or microcephaly, whereas a very large fontanel can signify a variety of problems.Inspection of the head should include observation of the venous pattern, because increased ICP and thrombosis of the superior sagittal sinus can produce marked venous distention.Palpation of a newborn's skull characteristically reveals molding of the skull accompanied by overriding sutures—a result of the pressures exerted on the skull during its descent through the pelvis. Marked overriding of the sutures beyond the early neonatal period is cause for alarm, because it suggests an underlying brain abnormality.Auscultation of the skull is an important adjunct to the neurologic examination.Cranial bruits may be noted over the anterior fontanel, temporal region, or orbits and are best heard using the diaphragm of the stethoscope.Soft symmetric bruits may be discovered in normal children <4 yr of age or in association with a febrile illness.Demonstration of a loud or localized bruit is usually significant and warrants further investigation, because they may be associated with severe anemia, increased ICP, or arteriovenous malformations of the middle cerebral artery or vein of Galen.It is important to exclude murmurs arising from the heart or great vessels, because they may be transmitted to the cranium.Deep tendon reflexes are readily elicited in most infants and children. In infants, it is important to position the head in the midline when assessing reflexes, because turning the head to one side can alter reflex tone.Reflexes are graded from 0 (absent) to 4+ (markedly hyperactive), with 2+ being normal. Reflexes that are 1+ or 3+ can be normal as long as they are symmetrical. Sustained clonus is always pathologic, but infants <3 mo old can have 5-10 beats of clonus, and older children can have 1-2 beats of clonus provided that it is symmetrical.The ankle jerk is hardest to elicit, but it can usually be obtained by passively dorsiflexing the foot and then tapping on either the Achilles tendon or the ball of the foot. The knee jerk is evoked by tapping the patellar tendon. If this reflex is exaggerated, extension of the knee may be accompanied by contraction of the contralateral adductors (crossed adductor response). Hypoactive reflexes reflect lower motor neuron or cerebellar dysfunction, whereas hyperactive reflexes are consistent with upper motor neuron disease. The plantar response is obtained by stimulation of the lateral aspect of the sole of the foot, beginning at the heel and extending to the base of the toes.The Babinski sign, indicating an upper motor neuron lesion, is characterized by extension of the great toe and fanning of the remaining toes. Too vigorous stimulation may produce withdrawal, which may be misinterpreted as a Babinski sign.Plantar responses have limited diagnostic utility in neonates, because they are mediated by several competing reflexes and can be either flexor or extensor, depending on how the foot is positioned. As with adults, asymmetry of the reflexes or plantar response is a useful lateralizing sign in infants and children.

6-1: Primitive reflexes appear and disappear at specific times during development (Table), and their absence or persistence beyond those times signifies CNS dysfunction. Although many primitive reflexes have been described, the Moro, grasp, tonic neck, and parachute reflexes are the most clinically relevant.The Moro reflex is elicited by supporting the infant in a semierect position and then allowing his or her head to fall backwards onto the examiner's hand. A normal response consists of symmetric extension and abduction of the fingers and upper extremities, followed by flexion of the upper extremities and an audible cry. An asymmetric response can signify a fractured clavicle, brachial plexus injury, or hemiparesis. Absence of the Moro reflex in a term newborn is ominous, suggesting significant dysfunction of the CNS.The grasp response is elicited by placing a finger in the open palm of each hand; by 37 wk of gestation, the reflex is strong enough that the examiner can lift the infant from the bed with gentle traction.The tonic neck reflex is produced by manually rotating the infant's head to one side and observing for the characteristic fencing posture (extension of the arm on the side to which the face is rotated and flexion of the contralateral arm).The parachute reflex, which occurs in slightly older infants, can be evoked by holding the infant's trunk and then suddenly lowering the infant as if he or she were falling. The arms will spontaneously extend to break the infant's fall, making this reflex a prerequisite to walking.Healthy is more important than money. Money cannot buy healthy and happiness. But a Healthy person remains in a very state of satisfaction and happiness.A healthy person sings your glory of life and works hard to understand his dreams. They never complains. They are always happy along with cheerful. He may be poor, he might have to work very tough to earn the living, but even your richest man would likely envy him for his  Healthy good.