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. In particular, 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. 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. 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.
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, even narrowing down to, for example, a central versus peripheral origin, can guide further evaluation and treatment. Localization begins with the general physical examination (see Chapter 9). Growth parameters should be noted, particularly head circumference, since macro- or microcephaly are often associated with neurologic disorders (see Chapter 3). Developmental assessments, using a small toy or an appropriate screening tool, are fundamental for infants and young children (see Chapter 3). Expected infant reflexes and other age-related examination findings are included in Chapter 2.
Table 25–1 outlines key 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, jumping, and drawing can reduce anxiety and allow assessment of motor coordination, balance, and handedness. In the older child, “casual” conversation can reveal both language and cognitive abilities.
Table 25–1.Neurologic examination: toddler age and up. ||Download (.pdf) Table 25–1. Neurologic examination: toddler age and up.
|Category ||Operation ||Assesses |
|Mental status ||Level of consciousness; level of awareness; orientation, language, development/cognition; affect ||Cortical and subcortical pathways, executive functioning |
|Cranial nerves || |
CN I: Smell (usually omitted)
CN II: Pupillary light reflex (sensory), visual acuity, visual fields, fundi
CN III, IV, VI: Pupillary light reflex (motor), eye opening, extraocular movements, convergence
CN V: Facial sensation (upper, middle, lower; V1, V2, V3); muscles of mastication (jaw clench)
CN VII: Upper—eye closure, brow raise; Lower—smile, ...