Pediatric Neurological Exam Checklist Systemic Exam

Learnpediatrics.com - Written by Dr. R. Acedillo, modified by Dr. D. Louie

EXAMINATION OSCE ITEMS
Initial Inspection
ABCs
Distressed?
Well vs unwell looking
Level of consciousness


General Appearance Inspection
Body Habitus
Dysmorphic features
Measure and Plot on Growth Chart
Weight
Height
Head circumference
Vital Signs
Heart rate
Respiratory rate
Blood pressure
O2 Sat
Temperature
Screening Exams Cardiac
Heart sounds
Abdominal
Hepatic enlargement
Neck
Supple/Meginismus
Kernigs test
Brudzinskis test

Skin
Hyperpigmented lesions caf au lait spots
Hypopigmented lesions ash leaf spots
Spine
Scoliosis
Tuft of hair







































Pediatric Neurological Exam Checklist Mental Status (for children > 7 yrs)
Learnpediatrics.com - Written by Dr. R. Acillo, modified by Dr. D. Louie

*Mini-mental Status Exam (MMSE) items where indicated in italics (value of MMSE items also shown)
EXAM OSCE ITEMS (use as necessary to test each component of the exam)

Inspection

1. Level of Alertness, Attention and Cooperation
Spell WORLD forwards and backwards (MMSE=5)
Digit span (minimum 6 forward, 4 backward)
Name months forwards and backwards

2. Orientation
Persons name, day, month, season, year (MMSE=5)
Floor, hospital, city, province, country (MMSE=5)

3. Concentration and Memory
Recent memory: Recall three items (MMSE=3) from
language tests (see below)
Remote memory: Any historical or verifiable personal
events (birth date, prime ministers, etc)

4. Language
Spontaneous speech: Fluency, phrase length,
abundance, paraphasic errors (inappropriate substituted
words), neologisms, errors in grammar, prosody
Comprehension: Logical thinking, abstract thinking
(include simple questions and 3-step commands
[MMSE=3])
Naming: Identify easy objects (pen, watch etc
MMSE=2) and difficult ones (fingernail, stethoscope, etc).
Repetition: No ifs, ands, or buts (MMSE=1, repeat
three words cat, red, baseball, etc (MMSE=3)
Reading/Obeying: Read aloud single words, brief
passage, paragraphs, read and obey ([MMSE=1] test for
comprehension)
Writing: Ask patient to write their name and a sentence
(MMSE=1, copy design (MMSE=1)

5. Non-Language Dominant Parietal
(Gertsmanns Syndrome)
Calculations: simple addition, subtraction (100 minus 7,
etc MMSE substitute for WORLD)
R/L Confusion: identify body parts, obey commands
(take your right finger and touch your left ear)
Finger agnosia: Name and identify each digit
Agraphia: Write name and sentence (see language)


6. Apraxia
Pretend to comb your hair
Pretend to brush your teeth
Pretend to hammer a nail
Pretend to strike a match and blow it out

7. Non-dominant Parietal Functions (Neglect and
Constructions)
Neglect: Neglect drawing test (clock, line-cut-in half),
extinction double simultaneous stimulation, look for
anosoagnosia
Construction: Copy complex drawing (e.g. house, two
pentagons, clock test [additional MMSE challenge])
Dressing

8. Sequencing Tasks and Frontal Release
Signs/Frontal Lobe Dysfunction
Perseveration: Written or manual alternating
sequencing task)
Motor impersistence: Raise your arms, look to your
right, auditory Go-No-Go tests
Frontal release signs: Changes in personality, grasp
reflex

9. Logic and Abstraction
Problem solving, series generation (AZ BY, CX)
Abstract thinking (proverb interpretation)

10. Hallucinations and Delusions
Auditory or visual hallucinations (ask them questions)
Delusions (ask them questions)

11. Mood
Signs of depression, anxiety, or mania
Mood, changes in eating, sleeping patterns, loss of
energy, loss of motivation and initiative, low self-
esteem, poor concentration, lack of enjoyment of
previously pleasurable activities, self-destructive or
suicidal thoughts and behaviours.



Pediatric Neurological Exam Checklist Cranial Nerves
Learnpediatrics.com - Written by Dr. R. Acillo, modified by Dr. D. Louie





















EXAM OSCE ITEMS (use as necessary to test each component of the exam)

Inspection/
Palpation

1. OLFACTION (CN I)
Any non-noxious odor (test each nostril separately)

2. VISION (CN II)
Visual acuity (wear corrective lenses, eye chart, one eye at
a time)
Colour vision (name colour of objects)
Visual fields (test quadrants, for each eye, have patient
detect moving fingers or number of fingers; blink-to-threat
in comatose or uncooperative patients)
Visual extinction on double simultaneous stimulation (test
for neglect)
Retinal examination (optic neuritis, papilledema, etc)

3. PUPILLARY RESPONSES (CN II, III)
Direct and consensual responses to light
Accommodation (pupils constrict when fixated on object)
Swinging flashlight test (afferent papillary defect)
Argyll-Robertson (near light dissociation) pupils, Horners
syndrome, Parinauds syndrome

4. EXTRAOCULAR MOVEMENTS (CN III, IV, VI)
Smooth pursuit: H-test (nystagmus, delay of movement,
lack of movement, ability to track, dysconjugate gaze,
gaze palsy, Parinauds, INO)
Convergence (make the patient cross eyed)
Saccades (switch between two objects)
Oculo-cephalic and caloric testing (comatose patients)

5. FACIAL SENSATION/MUSCLES OF MASTICATION (CN V)
Light touch (tissue) and temperature
Tactile extinction on double simultaneous stimulation
Corneal reflex (includes CN VII)
Jaw jerk reflex (presence is abnormal)





6. MUSCLES OF FACIAL EXPRESSION AND TASTE (CN VII)
Asymmetry and depth of folds (e.g. nasolabial)
Ask patients to smile, puff out cheeks, clench eyes, wrinkle
forehead.
Check taste on anterior part of tongue

7. HEARING AND VESTIBULAR SENSE (CN VII, CN VIII)
Sound detection (finger rubs, whisper words)
Whine and Weber tests (mechanical vs conduction
abnormalities)
Vestibulo-ocular reflex, caloric testing when indicated

8. PALATE ELEVATION AND GAG REFLEX (CN IX, X)
Ahhhhhhhhh
Gag reflex
Check taste on posterior part of tongue

9. MUSCLES OF ARTICULATION (CN V, VII, IX, X, XII)
Dysarthria vs dysphasia

10. STERNOCLEIDOMASTOID/TRAPEZOID (CN XI)
Shrug shoulders
Turn head in both directions
Flex neck when supine

11. TONGUE MUSCLES (CN XII)
Atrophy or fasiculations
Unilateral tongue weakness



Pediatric Neurological Exam Checklist Motor, Sensory, Reflexes
Learnpediatrics.com - Written by Dr. R. Acillo, modified by Dr. D. Louie

EXAM OSCE ITEMS

Inspection

Visible abnormalities
Hypertrophy
Wasting


Seizure activity
Chorea


Fasciculation
Tremor (postural, intention, resting, etc)


Athetosis
Dystonia

Palpation

Strength UPPER EXTREMITY
Fingers (resist force)
Abduct little finger (C8, T1)
Grip your fingers (C7, C8)
Make an O (C6, C7, C8)
MP joint extension (C7, C8)
Wrist
Extension (C6, C7)
Flexion (C7, C8)
Elbow
Flexion (C5, C6)
Extension (C6, C7, C8)
Shoulder
Shoulder external rotation (elbows flexed 90)
(C5, C6)
Shoulder abduction (C5, C6)
Shoulder shrug (XI, C3-5)
Thumb
Abduction (plane of palm)(radial nerve C7, C8)
Adduction (plane of palm)(ulnar nerve C8, T1)
Abduction (perpendicular to palm) (median
nerve C8, T1)
Opposition (median nerve C8, T1)


Strength LOWER EXTREMITY
Patient (do with gait)
Heel walk (L4, L5)
Toe walk (S1, S2)

Foot (resist force)
Toes extension (L5, S1)
Great toe flexion (S1)
Foot inversion (L4, L5)
Foot eversion (L5, S1)
Foot extension (L4, L5)
Foot flexion (S1, S2)

Reflexes LOWER EXTREMITY
Knee jerk (L2, L3, L4)
Posterior tibialis (L5)
Ankle jerk (S1)
Babinski sign
Crossed adduction


Knee (resist force)
Knee extension (L2-L4)
Knee flexion (S1, S2)

Hip (resist force)
Hip flexion (L1-L3/L4)
Hip extension (L5, S1)
Hip adduction (L2-L4)
Hip abduction (L5)

Reflexes UPPER EXTREMITY
Biceps (C5)
Brachioradialis (C5, C6)
Triceps (C7)
Finger flexors (C8)



Other
Components

Muscle Power
0 = none
1 = flicker
2 = move with no gravity
3 = against gravity
4 = against some resistance
5 = against resistance

Muscle Tone
Normal
Spasticity and clonus
Rigidity and cogwheel
Hypotonia

Deep Tendons Reflexes
0 = absent
1 = trace
2 = normal
3 = brisk
4 = clonus (non-sustained)
5 = sustained clonus




Pediatric Neurological Exam Checklist Motor, Sensory, Reflexes
Learnpediatrics.com - Written by Dr. R. Acillo, modified by Dr. D. Louie





















EXAM OSCE ITEMS

Palpation

Sensory LOWER EXTREMITY
Perianal (S2-S4)
Lateral/sole of foot (S1)
Dorsum of foot/1
st
web space (L5)
Medial ankle and shin (L4)
Medial thigh above patella (L3)
Anterior mid thigh (L2)
Lateral thigh below inguinal ligament (L1)

Sensory UPPER EXTREMITY
Medial arm near elbow (T1)
Little finger, distal radial border,
dorsal base of thumb near web space (C8)
Middle finger (C7)
Lateral forearm (C6)
Lateral arm/deltoid (C5)



Modalities
Touch
Pain
Temperature
Vibration
Proprioception
Cortical sensation
stereognosis
tactile discrimination
graphesthesia



Pediatric Neurological Exam Checklist Coordination and Gait
Learnpediatrics.com - Written by Dr. R. Acillo, modified by Dr. D. Louie

EXAM OSCE ITEMS

Supine

Cerebellar System
Coordination of Extremities
Upper extremity: Finger-to-nose (change location,
assess accuracy and speed)
Lower extremity: Heel-knee-shin test

Fine Finger/Hand Movements
Rapid thumb-to-index finger tapping
Rapid hand taping (against examiner assess rate,
rhythm, depth/force of tapping)
Screw light bulb actions
Rapid alternative movements (dorsum tap-to-palm tap)


Observe and Recognize

Dysdiadochokinesia (slow, irregular, clumsy movements)
tested by rapid alternating movements
Dysmetria (past pointing/overshoot, intention tremor) tested
by finger-to-nose and heel-knee-shin tests
Ataxic movements

Standing

Balance and Gait
Balance
Romberg test (stand and close eyes)

Gait (Regular, Tandem, Forced*)
Stance (width of feet), posture, stability
Raise of foot off ground, circumduction (arched medial to
lateral swing of legs), leg stiffness, knee bend, arm swing
Rate and speed, tendency to fall, difficulty initiating
walking
Involuntary movements and turns

* Forced gait = walk on heels/walk on toes

Observe and Recognize
Cerebellar ataxia: Appendicular (lateral cerebellar
hemispheres) vs trunkal (vermis e.g. alcohol intoxication)
(Wide based gait, difficulty with tandem gait)
Sensory ataxia: Dorsal column (overshoot, wide-based
steady gait much worse with eyes closed)
Gait apraxia: For some perplexing reason, patient can
perform the actions of walking while supine, but cant do it
for real when standing.
Foot drop: Peripheral nerve lesion
Spastic gait: Unilateral or bilateral corticospinal tract (stiffed
legged, circumduction, unsteady, tendency to fall towards
side of spasticity)
Parkinsonian gait: Basal Ganglia/substantia nigra lesion
(slow, shuffling narrow gait, difficulty initiating walk)
Myopathic gait: Due to muscle pathologys (waddling and
lurching gait, Trendelenburgs sign)