NEUROLOGIC ASSESSMENT & NEURODIAGNOSTICS
Even in this era of increasingly sophisticated neurodiagnostic testing, the assessment and diagnosis of a child with a possible neurologic disorder still hinges on a detailed history and examination. The standard pediatric history and physical examination are presented in Chapter 9. In particular, determining the temporal progression of the neurologic signs and symptoms (acute vs chronic, progressive vs static, episodic vs continuous) can direct the evaluation. Episodic events, such as headaches or seizures, warrant emphasis on the symptoms preceding, during, and succeeding the event. Spells can also be videotaped, allowing the examiner to obtain first-hand observation of important details that can clarify the diagnosis. Both acute and chronic neurologic symptoms may be associated with other organ system involvement, such as joint pain, changes in appetite or bowel/bladder habits, or a preceding viral illness, which can provide additional clues to the diagnosis. Birth history should include assessment of fetal movement and whether the infant was breech or vertex. A thorough past medical history and family history can illuminate risk factors for certain neurologic disorders. Social history should include school performance, preferred activities, and travel history.
A general physical examination is essential in any neurologic assessment. Growth parameters and head circumference should be charted (see Chapter 3). A developmental assessment, often with an appropriate screening tool, is fundamental for every neurologic evaluation of an infant or young child (see Chapter 3 for details of developmental landmarks and example screening tools). The specifics of the neurologic examination are determined by the age of the child and the ability to cooperate with the examination. Expected infant reflexes and other age-related examination findings are included in Chapter 2. The hallmark of neurologic diagnosis is localization—determining where within the nervous system the “lesion” is located. While not all childhood neurologic disorders are easily localized, the part of the nervous system involved—for example, central versus neuromuscular—can often guide further evaluation and diagnosis.
Table 25–1 outlines components of the neurologic examination—mental status, cranial nerves, motor (including tone, muscle bulk, and strength), reflexes, sensation, coordination, and gait. Much of the examination of the frightened or active child is, by necessity, observational, and the examiner must capitalize on moments of opportunity while maintaining a systematic approach to avoid overlooking a key component. Playing games engages a toddler or preschooler; activities such as throwing a ball, stacking blocks, hopping, jogging, counting, and drawing (circles, lines) can reduce anxiety and allow assessment of fine and gross motor coordination, balance, and handedness. In the older child, “casual” conversation can reveal both language and cognitive competence.
Table 25–1.Neurologic examination: toddler age and up.