Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics! I am Jared Barkes, a child neurology resident at the University of Virginia, and today we will be talking about how to master the neuro exam!
At some point during your pediatric clerkship, a patient will have a chief complaint that will require you to complete a neurologic exam. So this episode will focus on helping you to begin thinking like a neurologist. First, we will go over a quick review of the nervous system before we dive into talking about completing your first neuro exam, covering some key points as well as common abnormalities and what they may mean. Of note, I’m going to go through a formal neuro exam, which you can do on an older child, adolescent, or adult, since that is usually the goal for the exam. Finally, we will wrap up by touching on how to approach a neuro exam in a young child who may not be able to fully participate in a formal neuro exam.
But before we start, let's take a moment to frame how to start thinking like a neurologist: I like to explain that being a neurologist is sort of like being a detective. Often as a neurologist, you are trying to piece together patient complaints/symptoms, parental observations, and your exam findings to fit the map in your head of how the brain and nervous system work. Important elements like the timeline of symptom onset, patient descriptions, exam findings, and imaging studies are all just small pieces of the puzzle. Also, some neurologic complaints have a unique interplay with other systems such as the cardiovascular, immune, and endocrine systems. Diseases like Multiple Sclerosis or diabetes induced poly-neuropathy present primarily with neurologic deficits but are treated by addressing the problem with either the immune or endocrine system. Also always keep psychiatric conditions in mind when considering a possible abnormality or patient experience. Patients who have a chief complaint such as seizures like movements or inability to walk but have neurologic exams that are inconsistent with their experiences may benefit more from treatment of their anxiety or depression rather than invasive neurologic scans or tests and/or the side effects of anti-seizure medications.
With that out of the way let's review the map. For me, the nervous system is broken into 5 different parts. The cerebral cortex, brainstem, spinal cord, nerve roots and tracts, and finally the neuromuscular or neurosensory junction. While I could spend an entire hour speaking about each of these different sections we will quickly review the high points of each area of the nervous system.
The cerebral cortex can be separated into four major regions: the frontal lobe, temporal lobe, parietal lobe, and the occipital lobe.
- The frontal lobe is the primary portion of the brain that controls cognition, orientation, reasoning, and other higher cognitive functions. Damage to this area can present as disorientation to person, place, or time, and/or changes in behavior.
- The primary motor cortex which controls motor planning and sends signals for body movement is located just anterior to – or in front of - the central sulcus making it part of the frontal cortex
Broca’s area which controls the motor planning of speaking is located on the left lateral portion of the frontal cortex.
- The temporal lobe is the portion of the brain focused on memory, language, and the processing of sounds.
Wernicke's area which controls word association and sentence structure is located in the superior portion of the temporal lobe.
- The parietal lobe is the primary sensory cortex of the brain where sensory input from the body such as touch, pressure, heat, cold, and pain is received and processed.
- The occipital lobe is the portion of the brain that focuses on processing the visual information sent from the eyes.
Cortical visual damage can lead to abnormal visual interpretation and misrepresentation of visual signals coming from the eyes.
The next important area of the map is the Brainstem which consists of three main portions – the midbrain, the pons and cerebellum, and the medulla - and also contains the 12 cranial nerves.
- The most superior portion is the midbrain which provides passage of the cortical fibers descending to the body and sensory fibers ascending to the brain
The midbrain is just inferior to the thalamus, epithalamus, and hypothalamus area.
Cranial nerves 1 and 2 are located above the midbrain.
Cranial nerves 3 and 4 are located in the midbrain.
- The Pons and Cerebellum are located below the midbrain. The pons houses several cranial nerve nuclei as well as nuclei responsible for respiration and other important bodily functions. The cerebellum which sits at the back of the brainstem primarily responds to proprioception and position sense signals from the body as well as smooth movement signals sent from the cortex. These functions allow for balance and coordinated movement.
Cranial nerves 5, 6, 7 and 8 are located in the pons.
The final portion of the brainstem is the medulla. The medulla serves as the connection point between the brainstem in the spinal cord housing several motor and sensory fiber tracts.
Cranial nerves 9, 10,11, and 12 exist in this area of the brainstem.
We will review the cranial nerves in more detail while discussing the neuro exam later in this episode but as a quick review, the 12 cranial nerves are lower motor neurons that exit the brainstem and serve different functions in several essential body systems such as smell, sight, taste, respiration, parasympathetic/sympathetic systems as well as provide movement and sensation of the face.
The Spinal Cord is the next stop on our neurologic map and is the communication tract that houses the lower motor neuron cell bodies of the sensory and motor systems. The spinal cord works to communicate sensory signals up to the brain, via the afferent pathways, and motor signals down to the muscles via the efferent pathways. The idea of afferent vs. efferent pathways can often be confusing but one easy way to remember this is that afferent information arrives and efferent information exits the spinal cord.
These lower motor neuron bodies will send nerve roots out of the sides of the spinal cord to form nerve tracts. Finally, these nerve tracts will terminate at either motor neuron units or specialized sensory receptors located throughout the body.
And that is it! By knowing and understanding how the neurologic map of the body works and connects you can begin to link or even localize abnormalities noted on the neurologic exam to a specific area or region of the nervous system that may be damaged.
One tip before we begin speaking about the formal neuro exam is how to answer the dreaded “ipsa-lateral” vs. “contralateral” question. While there are always exceptions, in most cases damage to a majority of the nervous system will result in a contralateral deficit found on the neuro exam. In other words, damage to the left side of the brain results in right-sided findings. Notable exceptions are damage to any of the cranial nerves, nerve roots, or damage to the spinocerebellar tract or cerebellum. While the only true way to answer every one of these questions correctly is to fully understand the different pathways and tracts of the nervous systems if you don’t know… in general, damage above the medulla causes contralateral deficits and damage below the medulla causes ipsa-lateral deficits.
A second area commonly tested and asked about is whether the damage involves the upper or lower motor neuron. While there are more complex ways to think about how to answer this question the quickest way to think about it is: the cortex works to suppress our body’s natural reflexes to allow coordinated movements. Thus, damage to the upper motor neuron causes symptoms to go “up” ie. increase of reflexes, tone, and spasticity. Whereas lower motor neuron damage causes symptoms to go down ie. Decreased reflexes, tone, or spontaneous movement.
Now, with a solid foundation of the map of the nervous system, we can begin to discuss completing a neuro exam!
First and foremost a quality neuro exam when completed in a systematic head-to-toe approach should serve as a means of evaluating each major portion of the nervous system to identify new deficits or weaknesses as well as serve as a means of tracking the progression of a symptom or damage over time. Thus, each time you complete a neuro exam you should complete it in the same way regardless of the patient's chief complaint, especially if the patient has a visible or obvious deficit so that you avoid missing any subtle neurologic abnormalities which could change your differential diagnosis and/or the diagnostic and treatment plan.
The typical neuro exam should be seen as a screening exam that can be used to identify an area of concern. Once that area has been identified other more specific tests and exam maneuvers may be helpful in further diagnosing a patient's deficits. So, while the neuro exam will pick up most things it may not pick up everything so remember to always take the patient's clinical picture as a whole into consideration when deciding on the possible differential diagnoses.
While most of the neuro exams you will complete as a medical student will be conducted with willing participants like an adult, I think it is important to also cover some tips and tricks on how best to adapt the neuro exam in order to assess neurologic abnormalities in children.
The two most important things to understand about completing the neuro exam in children are that observation will be your best friend, and you must make it fun! While you may not always be able to get your patient to understand or participate in a formal finger-to-nose exam, through careful observation you can still assess a number of the different systems without doing a formal neuro exam. Important information can be understood from things like how they catch a ball or walk, whether you notice a leg or hand preference, and or if they can smoothly reach for a toy or play a game on a touch screen or iPad. The second key to making sure you gather as much information as possible is to make sure your different exam moves seem like a game! Leave your ego at the door and start acting out the moves you want the child to do! Walk like a duck or flap your wings like a chicken and you will be surprised how quickly the child will start copying you. We all remember as a child nothing was more interesting than a game that we were invited to play with a new friend! So, use that to your advantage
Now… onto the exam.
The neuro exam begins the moment you walk into the room and see the patient. Your first assessment should be of the patient's general status.
Is the patient alert, awake, and able to recognize you have entered?
Or is the patient conscious but disoriented?
Are they playing with toys or slumped in their parent's arms?
Are they moving or not?
Do they appear to be responding to stimuli such as sound, touch, or pain?
Are they sedated?
Do they appear to be breathing on their own?
Are they in a coma?
All of these first general assessments will quickly give you insight into the status of the patient’s nervous system as well as how likely they are to be able to cooperate in a neuro exam. The first and most important rule of the neuro exam is to base your exam on the patient.
Patients who have altered states of consciousness such as being encephalopathic which is a broad term meaning their brain is being negatively affected by some chemical imbalance or toxin build up, or someone who is sedated, or in a coma should be evaluated based on their response to stimuli using a tool like the Glasgow Coma Scale rather than a formal neuro exam.
Pediatric patients should be evaluated based on their age and developmental status. For example, a 6-month-old patient would not be expected to walk or talk, and a 15-month-old who occasionally stumbles should be seen as normal. Remember to review some of your developmental milestones prior to completing a neuro exam on a patient in order to better understand what they should and shouldn’t be able to do at their current age.
Next, assess the patient's orientation. This can be as simple as asking the patient why they have come to the clinic. A patient who accurately and quickly provides a recent history of their symptoms and the events leading to their presentation is oriented to person, place, and time. In a patient who has challenges answering these questions, asking specific orientation questions like “Where are we” or “What day, month, or year is it” can be a quick way to gauge a patient’s orientation. Most often patients will lose orientation to time first, then place second, and finally to person.
In pediatric patients this can be accomplished by asking them what they are doing or the name animals or toys from a book. Sometimes your best resource is the parent, and you can ask if their child has seemed confused or has been behaving abnormally. Note again some things are difficult to assess based on the patient’s age, and you have to remember that some complex ideas such as time and orientation in space require developmental ideas such as object permanence and/or the idea of self.
Any abnormality in a patient's level of consciousness and orientation can be a sign of some sort of issue impacting the cortex such as a large area stroke or encephalopathy.
Next, evaluate the patient's speech. How do they answer questions? Are they able to quickly and accurately answer questions with articulate answers? Or is their speech slowed, words jumbled, speech difficult to understand? Do they have issues hearing your voice or understanding your questions? Are there any deficits in how they move their mouth or tongue to form words? All of these can be signs of either a cortical problem, hearing problem, or motor problem preventing speech. Again, in pediatrics the parents will be a great resource here as they can comment on how their current speech matches up with their typical baseline. Important areas that control speech are Broca’s area which when damaged leads to expressive aphasia or inability to formulate words but the patient can still follow directions, or Wernicke's area which can lead to loss of the ability to associate meaning to words, leading to patients being unable to follow directions and creating non-sensible sentences of well-articulated words. Meaning if you ask the patient “How did you get here?” and they respond with something like “You aren’t being since the extra little face once it is a something if you know.” This is a symptom that is referred to as a “word salad”.
Language is a complex but important element of our conscious mind and takes up a large portion of our cortical processing. Gaining an understanding of a patient's ability to understand, process, formulate a response, and articulate that response gives you insight into a large portion of their cortical region.
The final element of screening for cortical dysfunction is assessing their memory. This can be accomplished by telling the patient you would like them to remember three words. Once they are ready you can tell them any three objects such as “baseball, tree, window” and have them repeat it back to you at one minute and at five minutes. For this as well, parents can be a really great resource and can tell you if they’ve noticed that the child can’t remember things as well as usual.
If at any time you identify what appears to be cortical slowing or deficits a more formal Mini-mental status exam can and should be completed to further classify the severity of their cortical dysfunction. We’re not going to go through that today, since we don’t generally have to do that in pediatrics, but it’s a good thing to talk with your resident or attending about if you think that one needs to be done.
After completing an assessment of the patient's general status, orientation, understanding of language, and memory you can move toward the rest of the neuro exam, with the knowledge that a patient with any deficits of the cortex will have trouble completing a number of the exam portions that require the patient to follow directions from the examiner.
Now onto assessing the cranial nerves.
CN I is the Olfactory nerve responsible for the sensation of smell. Isolated anosmia is rare and is often only tested based on if the patient complains of this. Otherwise, it is typically skipped.
A recent common cause of temporary anosmia is COVID-19 infection.
Uncommon causes of anosmia are head trauma which causes shearing of the delicate nerves of the olfactory bulb.
Congenital anosmia is associated with Kallmann syndrome.
CN II is the Optic nerve responsible for vision. Testing of the visual field is completed by introducing fingers into the patient's four visual quadrants of each eye and asking the patient to identify how many fingers they see. The examiner should use their visual field as a frame of reference for a “normal” peripheral visual field. In other words, if you are standing in front of the patient and if you can see your fingers in your visual field, you can assume that the patient should be able to see them as well. Most informal visual field testing like this can only interpret visual fields into quadrants such as deficits in the upper, lower, medial, or lateral visual quadrants. Pupillary response to light is also an assessment of the ability of the optic nerve to sense stimuli and the CN III to create the appropriate response. That is pupillary constriction
Damage to the retina, optic tract, optic chiasm, or optic radiations can be identified on visual field testing. However, more formal visual testing by an ophthalmologist may be necessary to more formally localize the deficit.
Loss of the lateral field of vision in both eyes is associated with the optic chiasm often indicating a pituitary mass compressing the chiasm.
CNIII, IV, and VI or the Oculomotor, Trochlear, and abducens nerves are assessed by having the patient track an object or finger with their eyes without moving their head. Both eyes should tack smoothly with good conjugation – meaning that they move together in the same direction - through a full range of ocular motion. Any disconjugation – or not moving together - or nystagmus may represent a problem with these cranial nerves or their connection pathways. Note horizontal nystagmus may be normal depending on age. However, vertical nystagmus is never normal.
As a pediatrician strabismus, or eye misalignment such as in-turning (esotropia) or out-turning (exotropia) while the child is focusing on an abject will be one of the more common eye movement abnormalities that is important to identify.
Notable findings are ptosis or partial closing of an eye indicating possible CN III damage.
An eye that is stuck inferiorly and laterally indicates loss of CNIII’s motor function.
A sluggish pupillary response may indicate a problem with CN II or CN III
The inability to move the eye completely inferiorly can indicate a CN IV problem. This is often associated with patients reporting “difficulty walking down stairs''
The inability to move an eye laterally may indicate a CN VI problem
In children often by having them follow your face or a bright flashing toy around the room will help you assess CN II, III, IV, and VI. As young as 2 months of age babies will naturally track faces, they find interesting as this is one of the first things our brains are trained to recognize (- and this is a great chance to make a funny or interesting face to get their attention). Simple moves like covering one of the patients eyes and switching to the other can give you invaluable information and help diagnosis things like strabismus. But to the child will feel like a fun game!
CN V the Trigeminal nerve is separated into three branches and is responsible for the sensation of the face as well as the sensation of the cornea. The corneal blink reflex is often reserved for coma patients. Sensation of the face should be assessed by lightly brushing the forehead, cheek, and jawline bilaterally asking if the patient can sense touch in each region. Or in a young child if they turn their head or show response to stimuli when touched on the face. Any abnormalities may require a more formal sharp vs. soft examination of the three regions, which you can do in older children and adolescents, but probably not in younger children, who may not be able to articulate the difference between sharp and soft. Younger children will also probably cry when a sharp object is pressed into their skin, since they will perceive that as pain
CN VII the Facial nerve is responsible for the movement of the face. The patient's face should be assessed for any asymmetry while opening or clenching of the eyes closed or smiling and frowning. In pediatrics, much of this will be done with observation – is there any asymmetry when the child makes faces or cries?
An isolated upper face paralysis is often due to contralateral cortical damage indicating an upper motor neuron damage.
A patient with both upper and lower face involvement often has ipsilateral facial nerve damage or a bell’s palsy.
CN VIII the vestibulocochlear nerve is responsible for hearing as well as balance based on head position. Often this is assessed by the patient's hearing being intact to conversion, finger rub near the individual ear, or more formally a tuning fork. Cochlear damage can be identified by symptoms of vertigo or nystagmus with the movement of the head or eyes. In children, we may see if they turn when they hear a sound. So if they’re sitting on their parent’s lap and you walk behind them and clap your hands or call their name, that can give you a gross idea of their hearing.
Nystagmus that is fatigable, meaning the nystagmus stops after the patient stops moving their eyes or head, indicates a peripheral nervous problem often localized to the cochlea or otoliths within.
Non-fatigable nystagmus is likely due to a stroke in the brainstem.
CN IX is the Glossopharyngeal nerve and is responsible for sensation within the nasopharynx and taste on the posterior tongue. Primarily assessed by completing a gag reflex, however unless there is a specific concern with CN IX most awake patients prefer not to have their gag reflex tested. Thus, CN IX is often skipped unless the patient is in a coma.
CN X is the vagus nerve is responsible for a majority of the parasympathetic signals to the central organs such as heart and GI system. It is also responsible for the symmetric rise of the palate. Thus, CN X is often evaluated by having the patient say “ahhh” and assessing for the rise of the palate for any deviation of the uvula. Raising the palate is a pull movement so any CN X damage will lead to deviation of the uvula away from the damaged side.
CN XI is the accessory nerve and should be assessed by having the patient shrug their shoulder or turn their head into resistance provided by the examiner.
CN XI controls muscles which again create movement through a pull function and so the inability to turn the head left is a right-sided accessory nerve problem.
Finally, CN XII is the Hypoglossal nerve and is assessed by having the patient stick their tongue out past their lips. The tongue should remain midline. The movement of the tongue is a push movement so any deviation of the tongue will be toward the damaged side.
The tongue is also the best place to see fasciculations which are often associated with a problem at the neuromuscular junction. If you have never seen fasciculations before, now is an excellent time to look up a video as it is an exam finding that is a “cannot miss” because sthis could mean something very serious, like Spinal Muscular Atrophy.
We have now completed the Cranial Nerve exam. While there are a lot of things to assess, the actual assessment of the various CNs will only take a few minutes. Early on it may be easiest to remember the various steps by listing the CN numbers in your head as you go through. Again, if trying to assess the cranial nerves of a child it can be useful to act out the movement you want the child to do with their face or even try and make them laugh by tickling them or saying something funny to look for asymmetry or abnormalities of their CN’s.
Now that we have completed the cranial nerve assessment or examination of the head and neck, it is time to assess the patient's strength of the upper and lower extremities.
Before testing the strength, it is important to understand the rating system used to understand what exactly we are assessing.
Strength classification is graded on a scale of 0 to 5 representing increasing strength.
Grade 0 represents total paralysis
Grade 1 is if there is visual or palpable muscle contraction but no active movement across the joint.
Grade 2 is if there is active movement across the joint in a full range of motion with gravity eliminated.
Grade 3 is if there is an active movement with a full range of motion against gravity but without any resistance. So again, if you’re testing strength in the arm, you will hold and support the patient's arm at 90* in front of the body with their arm flexed so their hand is next to their shoulder and having them extend their elbow and move the arm against the force of gravity.
Grade 4 is if there is active movement with full range of motion against gravity with/ some resistance provided by the examiner.
Grade 5 is if there is active movement with full range of motion to full resistance provided by the examiner.
Strength should be assessed by testing the various spinal segments that control the nerves. However, remembering the cervical and lumbar segments and nerve innervations is challenging Thus most people remember the strength exam by simply testing strength across each joint. Meaning testing the patient's shoulder, elbow, wrist, fingers, hips, knees, ankles, and toe strength.
Remember particularly in young kids acting things out and turning this portion of the exam into a game is a great way not only to communicate the moves but also help improve the patient's effort and cooperation in the exam. One way I use to remember the various strength movements is by visualizing the different patient positions used to isolate the different muscle groups. That is:
“Chick wing” testing the shoulder pushing against resistance
“Boxer” testing the push and pull ability across the elbow against resistance
“Motorcycle” testing the patient's ability to flex and extend the wrist against resistance
“Splat” testing the patient's extension of the fingers against resistance to pushing them back together
“OK” testing the strength of the PIP joint by trying to break an OK symbol
“Squeeze” testing the patient's hand grip by having them grab two of the examiner's fingers. Always have the patient squeeze two of your fingers overlapping one another as it is very difficult to accidentally damage the examiner's fingers in this way.
Legs are tested by:
“Knee up” testing strength at the hip against resistance
“Kick out” testing strength by extending at the knee against resistance
“Pull in” testing the strength of flexion of the knee against resistance
“Toes up” testing the ability to flex at the ankle against resistance
“Gas pedal” testing the ability to flex at the ankle against resistance
“Wiggle the toes” testing the strength of the toes against resistance
The goal of strength testing is to attempt to identify any weakness or wasting of the muscles paying attention to which side of the body is affected as well as whether it is an isolated upper or lower limb weakness or a combined upper or lower limb involvement. Hemiplegia or a loss of the upper and lower limb on one side is often damage to the brainstem on the contralateral side. Isolated upper or lower limb damage can often be seen in either a Middle Cerebral Artery stroke if the hands and arms are involved or an Anterior Cerebral Artery stroke if the legs are involved.
After or while examining strength, you should also attempt to identify any abnormalities of tone or spasticity which are assessed by passively moving the arms and legs across the same joints tested in strength. Tone is a natural resting level of contraction we all have in our muscles. Some patients will have very little tone which can be felt as joints and limbs that are overly loose when you passively move them. Or too much tone which is felt if the patient has excessive resistance to passive movement. Spasticity is easily confused with tone, however uniquely spasticity is considered a velocity-dependent “catch” experienced when the joint is moved passively quickly. Patients with upper motor level damage will have different levels of spasticity noted in areas where they likely have a motor weakness.
Tone in babies is often assessed by feel. This can be completed by moving the babies' arms across midline to check for decreased tone or increased tone. Most babies should be able to move their arm across midline with their elbow coming in line with their chin prior to meeting resistance. Anything past this could indicate hypotonia, anything less than this could indicate hypertonia. Other exam findings such as head lag where the baby is lifted by their arms and their shoulders do not tense and their head flops back or a positive slip through sign, when you pick the baby up by the underarms and feel them “slip” through your hands can all be indications that the baby has decreased tone based on their age. While identifying low or high tone in babies is rather difficult early on. It can be useful to practice often by assessing the tone of all babies you examine so you can get a feel for a baby with normal tone and are able to identify a low or high tone baby in the future.
The next step would be to assess sensation. This is often completed by finger touch of the skin of the arm and lower legs to assess a patient's ability to identify sensation in the upper and lower limbs. Again, like in the face, depending on the patient's chief complaint, a more formal soft vs sharp evaluation of different sensory levels may be warranted.
Following a quick assessment of the patient’s sensation, the next step will be to assess the patient’s coordination. Coordination exam maneuvers primarily focus on assessing the patient’s ability to sense their arms and legs in space and relay that information appropriately to the brain to create smooth and coordinated movements. Most problems with coordination indicate an issue with how the cerebellum is processing information or smoothing movements sent down from the brain to the body.
Coordination is primarily assessed by completing the finger-to-nose testing. It is important to know that the examiner should be sure to place their “target” finger at the extremes of the patient's reach to assess their coordination when their arm is fully extended. Common errors such as target inaccuracy of the nose or the finger as well as past pointing “missing the target finger by overshooting” often indicate an issue with the cerebellum on the same side of the affected limb, which makes the cerebellum one of the exceptions for the typical contralateral rule.
The lower limb coordination can be assessed by completing a heel on shin rub which should have the patient run the heel of the opposite foot from the knee down to the ankle bilaterally. Again, looking for any error in their ability to keep the heel connected to the shin throughout the length of the movement.
In young children again it may be useful to throw or kick a ball, try running, or even have them reach out for a toy or iPad using either of their hands in order to assess their coordination. This can be very challenging to assess because children will have different levels of coordination for age depending on their developmental status.
Finally, an assessment of the ability to complete rapid alternating movement such as hand flapping. A fast movement followed by a slower less coordinated movement again indicates an issue with the cerebellum. Also known by a much fancier term dysdiadochokinesis.
A patient’s gait and balance should then be assessed by having them walk a few steps looking for a smooth walking movement as well as observing for any obvious signs of instability or balance issues. Finally, a Romberg assessment should be completed to assess the patient's balance when their visual input is removed by having them close their eyes. This will be difficult in young children, so again you’ll need to depend on the parent, who may tell you that their child is falling more, or always falls to one side.
The final aspect of the neuro exam should be the reflexes. While most trainees early on focus the most on eliciting reflexes, in terms of your assessment reflexes should be seen as the cherry on top of your already working differential diagnosis. All of the information you have gathered up to this point should point you toward the type of reflex response you would expect in the patient.
Reflexes are often assessed after strength and are graded on a scale from 0 to 4 with 2 being the normal reflex value allowing for indicating if the patient's reflexes are hypo or hyper functioning. Hyporeflexia often indicates damage to the sensor or motor nerves at the level of the spinal cord. Hyperreflexia often indicates damage to the cortex or brainstem leading to dis-inhibition of the reflex arc contained in the spinal cord. Reflex grades are as follows:
Grade 0 is no reflex response noted
Grade 1 is diminished reflex response noted
Grade 2 is a normal reflex response
Grade 3 is an increased reflex response
Grade 4 is if clonus is present.
Reflexes commonly tested are the brachioradialis and triceps reflexes in the upper extremities and then reflexes at the knee and ankle in the lower extremities.
Of note children are often at baseline hyper-reflexive particularly the younger they are. Thus, a Grade 3 reflex in a child or a few beats of clonus in an infant could be completely normal. Again, if you have concerns be sure to discuss your findings with your resident, attending or even your friendly child neurologist.
And that is it! You have finished a complete neuro exam. While the number of steps involved, and the detail-oriented nature of the assessment is often seen as daunting and time-consuming, with practice it will become something that you can complete in approximately 10 minutes with good accuracy and thoroughness!
While most of the neuro exams you will complete as a medical student will be conducted with willing participants like an adult, practicing them on children can be a great way to hone your skills in observation and can also be useful for finding abnormalities in the future.
I also think it is important to understand that any time a child is at a hospital or clinic it can be a stressful time for the parents. But especially if you are completing an exam which tests their brain and the function of their nervous system. Every parent worries but conversations about a child’s development, or ability to move or think can cause families a lot of anxiety. Questions like “Will my child be able to walk, talk, or do well in school, or live a normal life?” are common occurrences in the world of pediatrics and especially child neurology so remember that no matter the situation all parents can benefit from empathy, compassion, and a little hope. But if you are asked a question and you don’t know the answer, to be sure to defer to the resident or attending you are working with.
And that is it! A rapid-fire review on how to do a complete neuro exam and common things to watch out for! Now the most important step is to practice! It's great to complete a few normal neuro exams but nothing is better and more memorable for your learning than when you begin to identify abnormalities on the exam. So always remember to go from head to toe, review the neuro map, and pack your reflex hammer! - Have fun.
Thanks for listening to Clerkship Ready - Pediatrics. Hope you found today’s podcast helpful. Don’t forget to subscribe below and rate the podcast!
