ORGANUM
Gathering neurologic history follows the traditional methods with two additions: the pace of the problem and the localisation of the problem. The symptom evolution provides clues to the underlying process as symptoms may evolve in one of three fashions:
Progressive
Static
Episodic
Progressive symptoms may evolve suddenly; seizures and strokes; acutely over minutes or hours (epidural hemorrhage); subacutely over days or weeks (brain tumor); or slowly over years (hereditary neuropathies). Static neurologic abnormalities are observed early in life and do not change in character over time (cerebral palsy). Static lesions are often caused by congenital brain abnormalities or prenatal/perinatal brain injury. Intermittent attacks of recurrent, stereotyped episodes suggest epilepsy or migraine syndromes, among others. Episodic disorders are characterized by periods of symptoms, followed by partial or complete recovery (demyelinating, autoimmune, vascular diseases).
Observation of the child's appearance, movement and behaviour begins at the start of encounter. For example, the child may display an unusual posture, abnormal gait, or lack of awareness of the environment.
The brain and the skin have the embryonic origin (ectoderm), abnormalities of hair, skin teeth, and nails are associated with congenital brain disorders (neurocutaneous disorders) such as neurofibromatosis (NF type 1) in which cafè au lait macules (flat, light brown macules) are characteristic. Irritability, lethargy, or more severely depressed consciousness are nonspecific signs of abnormal brain function.
Examination of the primitive reflexes.
Posture is the position that a calm infant naturally assumes when placed supine. An infant at 28 weeks gestations shows an extended posture. By 32 weeks, there is a slight trend toward increase in tone and flexion of the lower extremities. At 34 weeks, the lower extremities are flexed; the upper extremities are extended/ The term infant flexes lower and upper extremities.
Recoil, the readiness with which an arm or leg springs back to its original position after passive stretching and release, is essentially absent in very premature infants but is brisk at term. Because of the asymmetric tonic neck reflex, it is essential to maintain the infant's head in a neutral position (not turned to the side) during assessment of posture and tone.
Spontaneous movements of premature infants are slow and writhing; those of term infants are more rapid
The purpose of the neurologic examination is to localise or identify the region within the neuraxis from which symptoms arise.
The mental status examination assess the cerebral cortex.
The cranial nerve examination evaluates the integrity of the brainstem.
The motor examination evaluates upper and lower motor neuron function
The sensory examination assess the peripheral sensory receptors and their central reflections
Deep tendon reflexes assess upper and lower motor connections.
Gait assessment evaluates the motor system in a dynamic state for better functional assessment.
Alertness is assessed in infants by observing spontaneous activities, feeding behaviour, and visual ability to fix and follow objects. Response to tactile, visual, and auditory stimuli is noted. If a consciousness is altered, the response to painful stimuli is noted. Observation of toddlers are play allows a non threatening assessment of developmentally appropriate skills. In addition to language function, older children can be tested for reading, writing, numerical skills, fund of knowledge, abstract reasoning judgement, humour and memory.
The simpliest way to assess intellectual abilities is through language skills. Language function is recpetive (understanding speech and gestures) and expressive (speech and use of gestures). Abnormalities of language resulting from cerebral hemisphere disorders are referred to as aphasias. Anterior, expressive or Broca aphasia is characterised by sparse, non-fluent language. Posterior, receptive or Wernicke aphasia is characterised by an inability to understand language, with speech that is fluent but nonsensical. Global aphasia refers to impaired expressive and receptive language.