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HISTORY TAKING IN PEDIATRICS Chest pain

Facial puffiness, edema.
1. Personal data Fleeting joint pain
2. Presenting complaints High fever, rashes, and joint pain.
3. History of present illness; contact history; history
of allergy Respiratory system
4. History of past illness
5. Antenatal, natal and post-natal history Cough
6. Developmental history Noisy breathing
7. Nutritional history and diet Respiratory distress
8. Immunization history Chest pain
9. Family history Hemoptysis
10. Socioeconomic and environmental history Halitosis
11. Summary Sleep disturbances
Headache
Personal Data Upper abdominal pain

1. Name GIT
2. Age in completed years and months; date of
birth. Abdominal pain
3. Sex Diarrhea
4. Place of residence Constipation
5. Informant’s name and reliability. Dysphagia / Odynophagia
Vomiting
Regurgitation
Presenting complaints
Abdominal distension
Hematemesis
Presenting complaints with duration are to be recorded in
Hematochezia
chronological order. The complaints should be quoted in
Malena
patient’s own words, avoiding medical terminology.
Renal
History of present illness
Edema
1. Mode of onset – sudden / insidious High colored urine
2. Duration Painful micturition
3. Progress – increasing / decreasing / relapsing /
recurring Musculo-skeletal
4. Present status
-of each symptom to be recorded Gait
Pain
5. Associated symptoms of the organ system Swelling
involved must be enquired into and either
confirmed to be absent or if present, its onset, History of past illness
duration, and present status should be
recorded. a).History of similar illness in the past.
6. Symptoms of other organ systems
7. History of contact with infectious diseases b).History of common childhood illness:
8. History of allergy
9. Bowel & micturition habits, sleep, play and ▪ Diarrhea
interaction with others. ▪ Respiratory infection
▪ Asthma
Presenting complaints: - ▪ Allergy
▪ Epilepsy
CNS ▪ Exanthema

Abnormal movements, posture, & tone c).History of hospital admissions: (in chronological order)
Altered sensorium
Double vision, blurring or loss of vision ▪ Age at admission
Vertigo, Tinnitus. ▪ Number of admissions
Paralysis, ▪ Investigations done
Developmental delay or regression ▪ Diagnosis
Inconsolable cry and irritability ▪ Treatment given
Ataxia, poor balance, & dysmetria ▪ Whether on any regular medications
Fever, Headache, Vomiting
Urine retention in spinal cord lesions Antenatal, Natal and Post natal history
Radiating pain in root compression

CVS a).Antenatal history:

Failure to thrive 1. Mother’s age during pregnancy

2. Birth order
Feeding difficulties
Exertional intolerance 3. Whether the pregnancy was medically
Dyspnea supervised
4. 1st Trimester (till end of 12 wk)
Cyanosis
Palpitation - Pervaginum bleeding/spotting
Syncope - Fever with rash

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- Drug intake / X-Ray exposure Key Fine Motor Milestones Age

- Iron folic acid supplementation Hands held mostly open 3 months
- Hyperemesis Bi-dextrous reach 4 months
- Jaundice /thyroid status Uni-dextrous reach; transfers object 6 months
5. 2nd Trimester (Wk 13 to 28) Immature pincer grasp; probes with 9 months
- Weight gain forefingers
- Gestational diabetes / preeclampsia Pincer grasp mature 12 month
- IFA tablets Imitates scribbling; Tower of 2 blocks 15 months
- Quickening Scribbles; Tower of 3 blocks 18 months
- USG – oligohydramnios, polyhydramnios,
Vertical and circular stroke; Tower of 6 2 years
IUGR, anomalies, twinning
blocks;
6. 3rd Trimester (Wk 29 to 40)
Copies circle; Tower of 9 blocks; 3 years
- GDM/PIH
- Bleeding per vaginum Copies cross; Bridge with blocks 4 years
- PPROM / Fever / UTI / foul smelling liquor / Copies triangle 5 years
abdominal tenderness
7. Infertility treatment
8. Consanguinity Key Social and Adaptive Milestones Age
Social smile (smile after being talked to) 2 months
b).Natal history Recognizes mother; anticipates feeds 3 months
Recognizes strangers; stranger anxiety 6 months
1. Term / Preterm / Post term delivery Waves bye bye 9 months
2. Spontaneous / Induced Comes when called; plays simple ball 12 months
3. Hospital / Home games
4. Normal / Assisted / LSCS Follows simple commands 15 months
5. Complications / Interventions done Copies parents in task (sweeping etc) 18 months
6. Duration of labor Asks for food, drink, toilet; pulls people to 2 years
show toys
c).Post natal history Shares toys; knows full name and gender 3 years
Plays cooperatively in group; goes to 4 years
1. Birth weight toilet alone
2. Cry, color and activity soon after birth/any Helps in household task, dresses and 5 years
abnormalities undresses
3. Any resuscitation required
4. Meconium and urine passed on the same day /
any difficulties. Key Language Milestones Age
5. Feeding – time of initiation / method / any Alerts to sound 1 month
difficulty Coos (musical vowel sounds) 3 months
6. Hospital stay / NICU admission / seizures,
Laugh loud 4 months
infections, jaundice.
Monosyllables (ba, da, pa ), ah-goo 6 months
sounds
Developmental history
Bisyllables (mama, dada, baba) 9 months
1-2 words with meaning 12 months
1. Gross Motor
Name a familiar object; jargon 15 months
2. Fine Motor
8-10 word vocabulary 18 months
3. Personal social
4. Language 2-3 word sentences, uses pronouns I, me, 2 years
you
Asks questions; knows full name and 3 years
Key Gross Developmental milestones Age
gender
Lifts chin off the mattress in prone 2 months
Says song; tells stories 4 years
position
Asks meaning of words 5 years
Neck holding 3 months
Rolls over 5 months
Sits with own support (in tripod fashion ) 6 months
Red Flag signs in development
Bounces on standing 7 months
No visual fixation or following by 2 months
Sitting without support, crawls 8 months
No vocalization by 6 months
Stands holding on (with support) 9 months
Not sitting without support by 9-10 months
Creeps 10 months
Not standing alone by 16 months
Cruises around objects (walks with 11 months
support) Not walking alone by 18 months
Stands without support; Creeps well; 12 months No single words by 18 months
walks but falls; Lack of imaginative play at 3 years
Walks alone; creeps upstairs 15 months
Runs; explores drawers 18 months
Jumps; Walks up and downstairs (2 2 years Mention whether vision and hearing normal.
feet/step) Mention whether there is developmental delay or not.
Rides tricycle; alternate feet going 3 years Record developmental age in each development domain.
upstairs Mention weather it is global or dissociated developmental
delay.
Hops on one foot; alternate feet going 4 years
downstairs.
Skips 5 years

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Nutritional history and diet Nutritional value of homemade food items

The diet prior to illness by recall has to be recorded. Calorie and Food item Quantity Calorie Protein
protein yield of dietary items are to be calculated with help of a food (Kcals) ( gm)
value chart. Compare with recommended dietary allowance for the age Appam 1 70 1
and sex. Biscuit 1 20 0.5
Bread 1 slice 70 2
In a younger child details of breast feeding should be recorded. Chappathi 1 70 2
Cow’s milk 1 glass 120 6
Cooked rice 1 cup 175 4
▪ When put to breast.
Cooked dal 1 tsp 10 0.5
▪ Number of breast feeds given daily. Dosa 1 70 2
▪ Duration of exclusive breast feeding. Vada / bonda 1 50 1
▪ Reason for early introduction of other feeds. Egg 1 60 6
▪ Reason for stopping breast feeding. Fish 1 oz (28.4gm) 80 6
▪ Complimentary feeding, method of feeding. Ghee / butter 1 tsp 40 -
▪ Any feeding difficulties Ground nut 10 20 1
▪ Whether pre-lacteal feeds given or not. Green veg 100 gm 46 3.6
▪ If on formula feeds, reason. Iddli 1 50 2
Jaggery 1 tsp 20 -
Recommended dietary allowance (ICMR)2010 Mashed potato 1 tsp 40 -
Plantain 1 50 0.5
Puri 1 35 1
ICMR – RDA – 2010
Pappadam 1 20 0.5
Age group Calories Protein Ragi 6 tsp 100 2
Infant 0-6 months 92 Kcal/kg 1.16 gm/kg Sugar 1tsp 20 -
Infant 6-12 months 80 Kcal/kg 1.7 gm/kg Tapioca 100 gms 157 0.7
Upma 1cup 250 6
1 – 3 years 1060 17
Lactogen 100 ml madeup formula 67 1.4
4 – 6 years 1350 20 Dexolac 100 ml madeup formula 87 2
7 – 9 years 1700 30 Cerelac 100ml prepared (15g 55 1
10 -12 yrs male 2200 40 +90 ml water)
10 – 12 yrs female 2000 40 Amrtam Powder 100 gms 391 16
13 – 15 yrs male 2750 54
13 – 15 yrs female 2330 52
Immunization history
16 – 17 yrs male 3020 62
16 – 17 yrs female 2440 56 1. Vaccines received till date
Values have been rounded off at places 2. Reasons for fall out
3. Complications or adverse effects
4. Optional vaccines received
Bed side calculation of calories requirement : 5. Presence of BCG scar should be verified
6. Last vaccine taken
Above 1 year = 1000 + [ (age in years – 1) x 100]
National immunization schedule
Holliday and Segar formula for calculation of calories
For pregnant women
▪ Upto 10 kg – 100 kcl/kg
Early in pregnancy TT-1 or Booster
▪ 10 – 20 kg – 1000 + 50 kcl / each kg above 10 kg
One month after TT-1 TT-2
▪ Above 20 kg – 1500 + 20 kcl/each kg above 20 kg For children
At birth BCG, OPV0, HBV
In a baby < 2 years, energy needed in addition to breast milk – 6 weeks Pentavalent IPV/ OPV1 / Rota/PCV
10 weeks Pentavalent IPV/, OPV2 / Rota
▪ 6 to 8 months : 200 Kcals/day 14 weeks Pentavalent IPV/ OPV3 / Rota/PCV
9 – 12 months MR, PCV
▪ 9 to 11 months: 300 Kcals/day 16 – 24 months DPT B1, OPV4
5 – 6 years DPT
▪ 12 to 23 months: 550 Kcals/day 10 years TT/dT
16 years TT/dT

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Family history

1. Age and health of parents, siblings and other family Updated Kuppuswamy’s Socio Economic Status Scale –
members 2007
2. Consanguinity between parents
3. History of Item Score
▪ Abortions A . Education
▪ Stillbirths Professional degree/honors/ MA and above 7
▪ Death due to unknown illness BA, BSc degree 6
▪ Birth of abnormal children Intermediate / post high school certificate 5
High school certificate 4
▪ Communicable disease
Middle school completion 3
▪ Hereditary disease
Primary school / literate 2
Illiterate 1
A pedigree chart should be prepared using accepted symbols. B. Occupation
Profession 10
Semi profession 6
Clerical, shop/farm owner 5
Skilled worker 4
Semi skilled worker 3
Unskilled worker 2
Unemployed 1
C. Income in rupees
19575 and above 12
9788 – 19574 10
7323 – 9787 6
4894 – 7322 4
2936 – 4893 3
980 – 2935 2
Less than 979 1

Total score Socio economic status scale

26 – 29 Class I upper
16 – 25 Class II upper middle
11 – 15 Class III lower middle
5 – 10 Class IV upper lower
Less than 5 Class V lower

Summary of history

1. Age and sex

Socio-economic and environmental history 2. Presenting complaints
3. Relevant positive history
Social 4. Differential diagnosis

- Type of housing
- Sanitation
- Water supply

Economic

- Job of parents
- Monthly income

Environmental

- Overcrowding
- Ventilation
- Environmental pollution
- Passive smocking
- Pets in house
- Source of energy – firewood, gas,
- Flooring

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GENERAL PHYSICAL EXAMINATION Temperature

1. APPEARANCE Interpretation of body temperature

2. VITAL SIGNS
3. ANTHROPOMETRY 0C 0F
4. GENERAL EXAMINATION Normal 36.6 – 37.2 98 – 99
5. HEAD TO FOOT EXAMINATION Sub normal < 36.6 < 98
Hypothermic < 35 < 95
Appearance / general comment Febrile >37.2 >99
Hyper >41 >106
pyrexia
- Awake
-
- Cheerful and co-operative / active
- Irritable
Anthropometry
- Sick looking
- Drowsy Use WHO/IAP growth charts for interpretation of weight, height,
- Dyspneic and head circumference. (Standard Deviation or Percentile).
- Conscious
- Unconscious Weight
- Bedridden
- Dysmorphic features Weech’ formula –
- Abnormal movements
o 3-12 mo =( age + 9) / 2
Vital Signs o 1 – 6 yrs = (age x 2 )+ 8
o 7 – 12 yrs = [ ( age x 7) – 5 ] / 2
1. Pulse Rate o Wt for age% = ( O / E)x100
2. Respiratory Rate
3. Blood Pressure IAP classification of PEM
4. Temperature Wt for age Grade of PEM
>80% Normal
Pulse Rate 71-80 % I
61-70% II
Age Pulse 51-60% III
rate/minute ≤ 50% IV
New born 130 – 150
1month – 12 months 110 – 130
1 – 2 years 100 – 120 Height
2 – 4 years 110
4 – 6 years 100 Weech’s formula
6 – 8 years 90 – 100
8 – 10 years 90 o Ht cm = Age x 6 +77
10 – 12 years 80 – 90 o Ht for age% =( O / E)x100.
More than 12 years 80
Waterlow classification of stunting
Ht for age Degree of stunting
Respiratory Rate >95% Nil
90-95 % I
• New born – 40 – 60/minute 85-89 % II
• Infant – 30 – 40/minute < 85 % III
• Child – 20 – 30 /minute

Fast breathing Wt for Ht % = (Wt of child / Ideal wt for actual Ht)x100

Infants - > 60 breaths/ minute Waterlow classification for wasting

Wt for Ht % Grade of wasting
2 mon – 12 mon- > 50 breaths / minute >90 % N
81-90% I
1 – 5 years - > 40 breaths / minute 70-80 % II
< 70 % III
Blood Pressure

Head Circumference
BP is routinely measured in the right upper arm in the sitting or lying
position.
- At birth – 35.3 ± 1.2 cm.
- Dyne’s formula (< 1 yr of age)
Approximate value of 95th percentile BP above the age of 1 year can be
- 5th -95th percentile = (Length in cm /2)+ 9.5 ± 2.5 cm.
calculated by the formula:
- HC increases by 2 vcm in second yr; at rate of 1 cm /yr
100 + (age in yr x 3) / 70 + (age in yr x 1.5) from 2-5 yrs of age.

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Growth during infancy:- 12. Pustules

13. Wheals
Age Wt gain Ht gain HC gain 14. Plaques
in mo gm/day cm/mo cm/mo 15. Erythema
0-3 30 3.5 2.0 16. Scar marks
3-6 20 2.0 1.0 17. Scratch marks
6-9 15 1.5 0.5
18. Bite marks
9-12 12 1.2 0.5
19. Infections
20. Infestations
21. Deficiency states
Allowance for catch up growth in preterms

Head to foot examination

- 18 months for HC
- 24 months for Wt
1. Head
- 40 months for Ht
2. Hair and hairlines
3. Scalp veins
Chest Circumference
4. Fontanelle
- At birth HC is 3 cm more than CC. CC=HC by 9-12 5. Face
months, thereafter CC exceeds HC. 6. Orbits and eyes
7. Nose
Mid Arm Circumference ( 1 – 5 years) 8. Ears
9. Jaws
- 15 – 17 cm : Normal 10. Mouth
- 12.5 – 13.5 cm : moderate under nutrition 11. Tongue
- Less than 12.5 cm : severe PEM. 12. Neck
13. Chest
Upper segment / Lower segment ratio 14. Abdomen
15. External genitalia
- 1.7 at birth; 1.6 at 6 months, 1 at 7 years. Adult ratio is 16. Lower limbs
1:1.1 17. Upper limbs
- US/LS = 1.6 – (age in yrs x 0.1)

Arm span

- 2 cm less than Ht in underfive. Between 5-10 the

difference is less than 1 cm. span = ht at 10 years. In
adults arm span exceeds 2 cm more than Ht.

General Examination

Look for:-

1. Pallor
2. Cyanosis
3. Jaundice
4. Clubbing
5. Edema
6. Lymphadenopathy
7. Bone tenderness
8. Bleeding tendency
9. Capillary filling time
10. Dehydration

In skin look for:-

1. Hypopigmented areas
2. Hyperpigmented areas
3. Café-au-lit spots
4. Shagreen patches
5. Macules
6. Patches
7. Papules
8. Nodules
9. Tumors
10. Vesicles
11. Bullae

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Respiratory system examination Examination of upper respiratory tract

Symptoms Nose

1. Cough 1. Movement of alae nasi

2. Noisy breathing 2. Patency of nostrils
- Wheeze 3. Congenital anomalies – DNS, Choanal atresia
- Stridor 4. Ulceration, crusting
- Grunting 5. Purulent /blood-stained discharge
- Snoring 6. Presence of foreign bodies
- Rattly breathing 7. Trauma
3. Respiratory distress 8. Tumors
4. Sputum production 9. Sinus tenderness
5. Chest pain
6. Hemoptysis Ear
7. Dysphagia
8. Halitosis 1. Congenital anomalies
9. Sleep disturbances 2. Infections
10. Headache 3. Foreign bodies
11. Recurrent vomiting 4. Impacted wax
12. Acute abdominal pain 5. Tragal tenderness
6. Mastoids and retro-auricular area for eczema,
Severity of respiratory problems is assessed by noting - tenderness lymph node enlargement.
7. Otoscopic evaluation
- Physical activity ▪ Light reflex
- Sleep disturbance ▪ Dull appearance
- Medicine intake ▪ Bulging
- Loss of school days ▪ Retraction
- Frequency of hospitalization ▪ Perforation

Throat

General assessment / appearance 1. Tonsils

▪ Size
1. Breathing pattern ▪ Congestion
- Abdominothorasic ▪ Follicles
- Thorasic ▪ Membranes
- Abdominal 2. Palate
2. .Work of breathing 3. Uvula
- Flaring of ale nasi 4. Retropharyngeal, lateral pharyngeal, peritonsillar
- Head nodding abscess
- Chest retraction 5. Adenoids
3. Abnormal breathing patterns
- Apnea Examination of lower respiratory tract
- Cheyne Stokes breathing
- Biots breathing Neck
- Kussmaul breathing
- Gasping or jaw breathing 1. Trachea
- Rapid shallow breathing ▪ Trails sign
4. Altered sensorium, convulsions, cyanosis ▪ Tracheal tug
5. Clubbing 2. Signs of superior mediastinal obstruction
▪ Dilated veins
Vital signs ▪ Edema of neck and head
▪ Cyanosis
1. Respiratory rate ▪ Proptosis
2. Pulse rate ▪ Horner’s syndrome
3. Blood pressure 3. Subcutaneous emphysema
4. Temperature

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Chest examination

Inspection

1. Shape and appearance

2. Shoulders for drooping
3. Cardiac apical impulse
4. Localized bulge
5. Indrawing
6. Retraction
7. Working of accessory muscles
8. Veins/scars

Palpation 2. Added sounds

▪ Wheeze
1. Temperature, tenderness, crepitus
▪ Crackles
2. Apex beat
▪ Pleural rub
3. Movement of chest
▪ Mediastinal crunch
4. Expansion of chest
▪ Peristaltic sounds
5. Tactile vocal fremitus
▪ Crepitus
Percussion ▪ Conducted sounds
3. Vocal resonance
1. Start with direct percussion over clavicle ▪ Normal / Increased/ Decreased
2. Percuss down the midclavicular line ; percuss all ▪ Whispering pectoriloquy
areas, compare with the other side.
3. Midclavicular line
- Right side : liver dullness 5th ICS
- Left side: stomach tympanitic note 5th
ICS
4. Midaxillary line
- Right : liver dullness 7th ICS
- Left: splenic dullness 7th ICS
5. Infrascapular area
- Right: liver dullness 9th ICS
- Left: splenic dullness 10th ICS
6. Tidal percussion
7. Kronig’s isthmus
8. Traube’s area
9. Shifting dullness
10. Auscultatory percussion

Auscultation

1. Breath sounds
▪ Intensity – Normal/ Increased/Decreased
▪ Quality – Vesicular/ Bronchovesicular/
Bronchial

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EXAMINATION OF CVS 4. Blood pressure

Pulse pressure
▪ Cardiac history Flush method
▪ General physical examination
▪ Vital signs – arterial examination Examination of JVP
▪ Jugular Venous Pulse
▪ Precordial examination ▪ Jugular Venous Pulse (JVP) – observe for JVP and
measure if visible.
Cardiac history
Examination of Trachea
History should include
▪ Position of trachea – inspection and palpation
- Antenatal, natal and postnatal problems
- Symptoms of cardiovascular disease Precordial Examination
- Family history of sudden death, rheumatic fever, sudden
infant death syndrome or a structural cardiac anomaly in a Inspection
first degree relative
- Acute/chronic maternal diseases, congenital infections 1. Look for precordial bulge.
- Medications 2. Pulsations
3. Surgical scars
Symptoms and signs of heart disease. 4. hyperkinetic or hyperdynamic
5. quite or silent
1. Failure to thrive
2. Feeding difficulties Palpation
3. Exertional intolerance
4. Dyspnea 1. The apex beat
5. Cyanosis 2. Parasternal heave:
6. Palpitation 3. Palpable Heart sounds:
7. Syncope 4. Thrills
8. Chest pain 5. Pericardial rub
9. Facial puffiness, edema and protrusion of chest may
indicate heart disease in children. Percussion
10. Fleeting joint pain may indicate rheumatic fever.
11. High fever, rashes and joint pain may suggest Kawasaki 1. Left border
disease. 2. Right border

General physical examination Auscultation

1. Assess the appearance and state of distress

2. Cyanosis
3. Clubbing
4. Pallor
5. Edema
6. Capillary filling time

Look for symptoms and signs of Infectve Endocarditis and

CCF

Vital signs

1. Temperature:
2. Respiratory rate: Conventional areas for auscultation of heart are
3. Pulse – The arterial examination
▪ Carotid, Brachial, Radial, Femoral, Popliteal, 1. Mitral area:
Posterior tibial, Dorsalis pedis 2. Tricuspid area:
▪ Rate pulse deficit 3. Pulmonary area:
▪ Rhythm 4. Aortic area:
▪ Volume equality of pulses
▪ Character Four additional areas are:
▪ Radio-femoral delay / radio-radial delay
- The pulse should be described as:- - Second aortic area – left 3rd space close to the sternum
Rate 86/mt, regular in rhythm, normal in volume and of - Axilla
normal character. All peripheral pulses are equally felt - Back, and
bilaterally and there is no radio-femoral delay. - Neck.

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• First heart sound - S1 Other points to be evaluated are

o Normal S1
o Loud S1 o Presence of capillary pulsations
o Soft S1 - Over uvula
• Second heart sound – S2 - Ear lobule
o Normal splitting of second heart sound - Lips
o Wide inspiratory splitting ( >0.04 sec) - Nailbeds
o Wide and fixed split o Pistol shot sounds – sounds heard over brachial or femoral
o Reverse split artery through stethoscope
o No split - Single S2 o Duroziez sign – systolic murmur heard when pressure is
• In the cardiac assessment of children, the ability to clearly applied to partially occlude the femoral artery proximal to
characterize the S2 is the most crucial one. Normal inspiratory the chest piece of stethoscope and diastolic murmur when
splitting of S2 should be sought and established in all patients. pressure is applied distally.
• Third heart sound – S3 o Visible arterial pulsations over extremity vessels (dancing
• Fourth heart sound – S4 peripheral arteries) – seen in AR.
• Murmurs o Evaluation of spleen (in SABE) and auscultation of lungs
(crepitus in CHF) are also part of cardiovascular
• Clicks
assessment.
• Opening snap OS
• Pericardial rub
Examination of liver and spleen – look for organomegaly

Murmurs

The following characteristics of the murmur should be described:-

1. Timing
2. Intensity – There are six grades (Levine’s grading)
I. Heard with intense concentration
II. Faint but heard immediately
III. Easily heard of intermediate intensity
IV. Easily heard and associated with thrill
V. Loud, thrill present, audible with edge of
stethoscope on chest wall.
VI. Audible with stethoscope off the chest wall.
3. Point of maximum intensity and selective propagation
4. Duration of murmur from beginning to end.
5. Configuration – the dynamic shape of the murmur.
6. Pitch – the frequency range of murmur.
7. Relation with respiration.

Timing and duration of murmur: - The murmurs can be –

- Systolic
- Diastolic
- Systolic-diastolic or
- Continuous

Systolic murmurs

1. Holosystolic murmurs
2. Ejection systolic murmur –
3. Early systolic murmurs
4. Mid to late systolic murmurs

Diastolic murmurs

1. Early diastolic murmurs –

2. Mid diastolic murmurs –
3. Late diastolic murmur

Identify Functional murmurs (Innocent murmurs)

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EXAMINATION OF GASTROINTESTINAL SYSTEM - Palate

- Tongue
Common gastrointestinal symptoms - Teeth
- Tonsils
1. Abdominal pain - Uvula and pharynx.
2. Diarrhea
3. Constipation Examination of Abdomen:
4. Dysphagia / Odynophagia
5. Vomiting Inspection:
6. Regurgitation
7. Abdominal distension Observe
8. Hematemesis
9. Hematochezia • shape of abdomen,
10. Melena • umbilicus,
• movements,
General examination • pulsations,
• peristalsis,
The additional points to be noted to assess the severity of • scars
illness are:
Palpation
• Coma (encephalopathy)
• Dyspnea (ascites, pneumonia) Assess the direction of blood flow (in dilated veins) by tripping
• Quite posture (peritonitis) and of the veins.
• Restlessness (colicky pain)
Light palpation to elicit tenderness and temperature, followed
Eyes should be evaluated for: by deep palpation.

▪ Bitot spots (dry silver gray plaques on the bulbar Each part of the abdomen should be palpated recollecting the
conjunctiva), normal anatomical structures beneath the hand.
▪ Keratomalacia (wrinkling and cloudiness of cornea),
▪ Bleeding and Kayser-Fleisher (KF) ring (a golden- Palpate nontender areas first as perceived from complaint or
brown ring in peripheral cornea better seen with slit facial expression.
lamp).
▪ KF ring should not be mistaken for arcus juvenilis • Begin from the left iliac fossa, palpate lightly
(grayish white ring seen at the limbus). proceeding anticlock-wise to end in the suprapubic
region; repeat the sequence using deeper palpation
Features of hepatic failure are: with both hands so as to assess the feel of the
abdomen – soft, tense, doughy or rigid.
1. Altered sensorium • Subsequent steps are palpation of left kidney,
2. Ascites, spleen, right kidney, liver, urinary bladder, aorta,
3. Bleeding para-aortic glands, common femoral vessels and
4. Fetor hepaticus abnormal swellings if detected.
5. Flapping tremors • Hernia orifices, external genitalia, anus, perianal
6. Gynecomastia region, and the spine should be examined by
7. Jaundice inspection and palpation.
8. Palmar erythema • Rectal examination if indicated.
9. Pruritus • Lastly renal angle should be inspected to detect
10. Spider naevi edema and fullness and pressed to elicit
11. Testicular atrophy. tenderness.

Examination of mouth and pharynx When a swelling is palpable in the abdomen the following
points are to be considered. Is it a normal structure or
A good intraoral lighting is essential. Use a tongue depressor enlargement of normal organs? What is the pathologic nature?
for better view of oropharynx.
Percussion
Inspect:-
Normally a resonant or tympanitic note is heard all over
- Lips abdomen except over the liver where the note is dull.
- Buccal mucosa
- Alveolar process, gingivae

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Percuss out the boundaries of liver, spleen and other masses

in the abdomen,

Liver span –

• Infant : 5 – 6.5 cm
• 1 – 5 yrs : 6 – 7 cm
• 5 – 10 yrs: 7 – 9 cm
• 10 – 16 yra: 8 – 10 cm

Distended urinary bladder,

For demonstration of fluid by eliciting

- Shifting dullness,
- Fluid thrill and
- Puddle sign

Auscultation

- Bowel sounds and their nature,

- Arterial sounds (bruits),
- Venus hum,
- Succession splash and
- Peritoneal friction rubs.
- Forget not to replace the cloth after completion of
examination and complement the patient for the co-
operation.

The format of stating final diagnosis should be the clinical

diagnosis followed by the functional impairment and lastly the
probable etiology.

Eg Moderate splenomegaly, massive hematemesis with

circulatory failure and hepatocellular failure. Etiology – chronic
liver disease with portal hypertension.

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EXAMINATION OF NERVOUS SYSTEM

1. Neurological history
2. General examination
3. Head to foot examination.
4. Higher mental functions
5. Cranial nerves
6. Motor system
7. Sensory system
8. Cerebellar signs
9. Signs of meningeal irritation
10. Examination of spine
11. Soft neurological signs
12. Tests for autonomic functions
13. Analysis and localization of lesions.

[Link] HISTORY

Common presenting symptoms related to nervous system are:

1. Convulsions, headache, vertigo, abnormal movements, delirium, double vision, tinnitus

2. Paralysis, clumsiness, blurring or loss of vision, deafness
3. Vomiting in raised intracranial tension.
4. Urine retention in spinal cord lesions
5. Radiating pain in root compression
6. Post infective polyneuropathy presenting as general weakness in recovery phase of an illness
7. Neurological impairment following perinatal insult.
8. Genetic and chromosomal disorders

Other presentations are – History of –

▪ Fever, headache, vomiting ▪ Recent vaccination

▪ Altered sensorium ▪ Exanthematous illness
▪ High pitched cry/ irritability ▪ Toxin exposure
▪ Ear discharge ▪ Drug intake
▪ Trauma ▪ Dog bite

The following points should be elicited in the history:

Onset and duration: Acute – within 24 hours / Subacute – within few days / Chronic – within few weeks

Evolution

- Rapidly deteriorating
- Stepwise or gradually progressing
- Static
- Partially or gradually improving
- Relapsing or remitting
- Resolving
- Having residual disability

History taking in a case of cerebral palsy

I. H/o Delay in attaining milestones appropriate for age

1. If this is the presenting complaint, describe the developmental history in the history of present
illness itself. But in most of the cases, the child s a known case of CP now presented with
respiratory illness. seizure or diarrhea. In such cases the history of present illness should be
described first. Detailed developmental history should be enquired and noted later.
2. Developmental history in detail – Gross motor, Fine motor, Personal social, Language, Vision,
and Hearing.
3. Mention approximate developmental age in each domain.
4. Should be able to use TDSC to detect the developmental quotient if asked.
II. History related to motor involvement

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1. Stiffness / Frailness of limbs

- Stiffness as evidenced by h/o fisting of upper limbs / scissoring of lower limbs and
difficulty in changing the diapers
- Frailness as evidenced by h/o slipping through shoulders / lack of active flexion of
both lower limbs in vertical suspension.
2. Which limb is more involved – upper or lower?
3. Asymmetry in weakness – right vs left limb.
4. Predominant weakness in each limb – proximal vs distal
5. Upper limb –
- Proximal weakness – difficulty in raising the limb above the shoulder, difficulty in
combing the hair.
- Distal weakness – mixing food, taking objects from the floor.
6. Lower limb –
- Proximal weakness – getting up from sitting posture, climbing stairs.
- Distal weakness – slipper slipping.
7. History of involuntary movements
- Proximal / Distal
- Progressive / Static
- Continuous / Intermittent
- Disappears during sleep or not
8. Abnormal posturing of limbs
III. History suggestive of cranial nerve involvement
1. Ability to follow bright objects of different size / color (2 nd nerve)
2. H/o abnormal eye position / eye movements. H/o drooping of eyelids (3,4,6)
3. H/o difficulty in sucking / Ability to clench the teeth (5)
4. H/o deviation of ankle of mouth / difficulty in closing the eyes / drooling of saliva (7)
5. H/o not turning towards sound source (8)
6. H/o regurgitation of feeds / nasal twang of voice (9.10)
7. H/o difficulty in neck movements (11)
8. Ability to protrude the tongue (12)
IV. H/o associated comorbid illness
1. Seizures
- Duration
- Describe the first episode in detail
- Type of seizure
- Generalized – associated with upward gaze, tongue biting, loss of consciousness,
bladder and bowel incontinence.
- Focal
- Myoclonic
- Number of episodes of seizure
- Response to anticonvulsants
2. Vision. H/o not following objects
- Duration
- H/o abnormal positioning of eyes
3. Hearing. H/o not turning head towards sound
- What age it was noticed
- Any investigations / treatment
4. Microcephaly
5. H/o hyperactivity
6. H/o sleep disturbance
7. Feeding difficulties
- For solid / liquid
- Time taken for feeding
- Any tongue thrusting or spitting
- How mother manages the feeding problem
- How is the weight gain
8. Constipation
- Duration

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- Passing stools once in how many days

- Treatment taken
9. H/o contractures / deformities / bed sores
10. H/o recurrent respiratory illness / recurrent aspiration / GERD
V. History related with etiology of CP
1. Prematurity
2. IUGR
3. HIE as possible cause of CP – refer perinatal history
4. Toxic – H/o exchange transfusion / kernicterus
5. Trauma – H/o birth injury / accidental injury in neonatal period
6. Genetic – H/o dysmorphic features / multiple congenital anomalies
7. Metabolic
- H/o seizures / vomiting / sepsis like presentations / unusual odour (phenylketonuria,
mucopolysaccharidosis)
- Dysmorphic facies / delay n passage of meconium / constipation / excessive
sleepiness / dry skin (hypothyroidism)
8. Neuronal migration disorder – term baby / normal perinatal history
9. Infections
- Intrauterine infections – refer antenatal history
- Perinatal infections – birth history (maternal fever, UTI)
- Postnatal infections – meningitis
10. Perinatal and antenatal vascular events – congenital hemiplegic CP
VI. Treatment history
1. Details of investigations
2. Physiotherapy details
3. Speech therapy / hearing aids
4. Occupational therapy
5. Squint surgery / spectacles
6. Surgery for contractures
7. Special school training

Other usual details in history

• Contact history , H/o allergy

• H/o Past illness
• Antenatal, natal, neonatal history
• Nutritional history
• Immunization history
• Family history - Impact of the disease on other family members
• Socioeconomic and environmental history

Summarize the history.

By end of history, one should be able to categorize CP by etiology, topography, physiology, and functional
disability and associated co-morbidities. Clinical examination should confirm your history findings.

[Link] EXAMINATION

1. Sensorium
- AVPU score
- GCS score
2. Posture
3. Paucity of movements
4. Handedness
5. Involuntary movements.

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[Link] TO FOOT EXAMINATION In head to foot examination, head should be examined in detail.

Examination of Head

• Size • Percussion
• Shape • Transillumination
• Fontanelle • Auscultation of skull
• Sutures • Evidence of injury
• Swellings

Look for Café-au-lait spots.

[Link] MENTAL FUNCTIONS

In infants and toddlers observe

• The basic biologic functions (feeding, sleeping)

• Interaction with people and surroundings
• Playfulness

In young children (2-5 years) assess the response for age-appropriate questions

• Name
• Pointing to body parts
• Asking who gave the toy.

For the older child (5-10 years)

• Address
• Name of school
• Drawing a picture
• Counting numbers

Above 10 years formal HMF testing as in adults can be done.

HMF includes: -

1. Orientation in time, place, and person

2. Speech
• Aphasia
• Dysarthria
3. Memory – immediate, recent, past
4. Intelligence
5. Emotional state
6. Comprehension and attention span

[Link] NERVES

First Cranial Nerve – Olfactory nerve:

• Use familiar materials like orange peel, coffee powder, tooth paste etc.
• Pungent substances stimulate 5th nerve.
• Test each nostril separately with the other nostril and eyes closed.
• For infants and retarded children note the behavioral response.

Second Cranial Nerve – Optic Nerve

Components of examination are –

1. Field of vision
2. Acuity of vision
3. Color vision
4. Evaluation of pupil
- Size
- Shape

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- Reactions – direct & consensual, accommodation, cilio-spinal

5. Fundus examination

Third, Fourth and Sixth Cranial Nerve (Oculomotor, Trochlear and Abducens)

▪ Testing is as for field of vision in infants and young children by observing the eye movements when a
colored object (dangling red ring tied to a string) is moved in various directions in visual field.
▪ Above the age of 4 years, child is asked to look at a red pen as it is moved in the direction of action of
extra-ocular muscles. In non-cooperative and unconscious patients, dolls eye maneuver is adapted; but
is contraindicated when cervical spine injury is suspected.
▪ Gaze palsy – Conjugate lateral gaze palsy, Conjugate upward gaze palsy, Conjugate downward gaze
palsy
▪ Squint – Cover-Uncover test, Corneal light reflex.
▪ Opsoclonus
▪ Skew deviation
▪ External ophthalmoplegia
▪ Internal ophthalmoplegia
▪ Nystagmus

The fifth nerve (Trigeminal nerve)

Motor part

o Look for deviation of jaw as the infant opens the mouth or cries.
o For the older child ask the patient to clench the teeth and feel the temporal and masseter muscles
which stand out prominently.
o The pterygoids are tested by moving the jaw side-to-side against resistance, with mouth open.

Sensory part

o Sensations are tested as described in sensory system

o Examine atleast 3 medial and 3 lateral points on the face.
o Sense of position and movement are tested by passively moving the pinna with the patient’s eyes
closed.
o In small babies stimulate the nostrils with a cotton wisp and observe the expression.
o Corneal reflex
o Jaw jerk

The seventh cranial nerve (Facial nerve)

Test materials – saline, glucose, vinegar and quinine for sensory part.

Motor part

Face becomes expression less in 7th nerve paralysis.

Infants and young children –

- Observe the child while crying

- Mouth deviates to healthy side; there is inability to close the eye and flattening of nasolabial fold on the
affected side.
- Impaired wrinkling of forehead and drooling of fluid from weak side are less prominent findings.
- Condition has to be differentiated from hypoplasia of DAO muscle.

Older children

Formal testing is possible in older children. Examiner should sit opposite to the child.

- Ask the patient to look upwards without tilting the head. The wrinkles on the forehead are less prominent
on the affected side.
- Ask the patient to shut the eyes tightly. Affected eye is not closed. On attempted closure Bell’s
phenomenon (the normally present rolling up of eyeballs) becomes evident (Bell’s sign). Try to open the
closed eyes simultaneously on both sides by separating the eyelids with index and thumb of each hand.
The affected eye is easily opened.
- Ask the patient to say ‘eee’ and show the teeth. The angle of mouth deviates to healthy side. The
nasolabial fold on the affected side is flattened.
- Ask the patient to whistle. It is not possible in facial nerve paralysis.

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- Ask the patient to fill the oral cavity with air as attempted blowing. Examiner should feel the tone and
power of facial muscles on both sides by pressing the index and middle fingers simultaneously. The
affected side yields easily and air escapes.

Sensory part

- Testing is possible in older children. Salt, sweet, sour and bitter tastes should be tested in the order
respectively.

The eighth cranial nerve (Vestibulo-cochlear Nerve)

Hearing

(For infants and young children: Development assessment)

If hearing impairment is detected in an older child ascertain whether nerve disease or middle ear affection by
tuning fork tests for each ear.

- Rinne’s test
- Weber’s test

The ninth nerve (Glossopharyngeal nerve), The tenth nerve (Vagus nerve) and The eleventh nerve
(Accessory Nerve)

Test materials required are those for taste, a tongue depressor and a spatula. The 9 th nerve is rarely damaged
alone. Sensory examination is for taste in the posterior one-third of tongue and is the isolated test for 9th nerve.

Pharyngeal or Gag reflex

The afferent is the 9th nerve and efferent are 9th and 10th nerves and hence the test is common for both nerves.

Paralysis of 9th and 10th nerves are characterized by –

- Feeding difficulties
- Nasal tang of voice,
- Nasal regurgitation of fluids
- Pooling of secretions in the throat.
- Hoarseness of voice and respiratory distress develop due to vocal cord paralysis.

Examination of palate will reveal the nature and severity of paralysis.

Ask the patient to keep the mouth open and put out the tongue and say ‘ah’. Watch the movements of the palate.

Examination of larynx is by direct laryngoscopy.

Accessory nerve testing

1. Sternomastoid muscle
2. Trapezius

The twelfth nerve (Hypoglossal nerve)

• The tongue should be relaxed inside the mouth and apparent deviation secondary to 5 th and 7th nerve
palsy should be excluded before testing.
• Look for symmetry, atrophy and fibrillations.
• Ask the patient to protrude the tongue in the cooperative age group
• In LMN lesions the affected side is atrophic, flaccid, reveals fibrillations and deviates to the paralyzed
side.
• Ask the patient to move the tongue from side to side and push the cheek from inside. Assess the
strength by pressing the cheek over the tongue with a finger during such movement.

Bulbar palsy

The symptoms are –

1. Pooling of secretions in throat

2. Sialorrhea

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3. Dysphagia
4. Dysarthria
5. Nasal regurgitation of liquids
6. Absent cough reflex
7. Frequent aspiration
8. Nasal twang of voice
9. Jaw hangs loosely
10. Jaw jerk and gag reflex are lost
11. Respiratory and cardiac irregularities and fluctuation in blood pressure may be seen due to vasomotor
and respiratory center involvement.

Pseudo-bulbar palsy

In pseudo or supra-bulbar palsy in which the upper motor neurons are affected, -

1. Jaw is stiff
2. Mouth is difficult to open fully
3. Sialorrhea is present
4. Jaw jerk is brisk and there may be jaw clonus
5. Tongue is small and stiff
6. Movements of tongue are difficult
7. Chewing and feeding become difficult
8. The gag and cough reflexes are preserved
9. Aspiration though present is not as frequent as in bulbar palsy

Cervical sympathetic

Paralysis of sympathetic fibers (Horner’s syndrome) is characterized by enophthalmos, ptosis and myosis and
absence of mydriasis, ciliospinal reflex and sweating over the same side of head and neck.

[Link] SYSTEM

Assessment parameters

1. Bulk of muscle
2. Tone
3. Power or strength
4. Locomotion and motility (gait)
5. Involuntary movements
6. Coordination of movements
7. Reflexes

[Link] of muscles is assessed by inspection, palpation and measurements of suspected part and then
comparing with the opposite side.

[Link] of muscle is the state of tension in muscle appreciated by the resistance of muscle to stretch. It can be
phasic or postural.

1. Phasic tone – Rapid contraction to high intensity stretch as in deep tendon reflexes.
2. Postural tone – prolonged contraction of antigravity muscles in response to low intensity stretch of
gravity.

Assessment of tone –

o Inspection
o Palpation
o Passive movements of joints
o Dropping of limb
o Posture against gravity
o Shaking the limb
o In newborns and infants’ traction response, ventral suspension, angles of joints, vertical suspension at
axilla are observed.
o Deformities secondary to hypo or hyper tonia

Abnormalities in tone are hypo or hyper tonia.

[Link] of muscle It is assessed by executing the function of the muscle at various joints and should be graded.

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Grading of muscle power

Grade Movement
0 Nil
I Trace of contraction. No joint movement
II After eliminating gravity
III Against gravity
IV Against gravity and resistance
V Full power

Since the testing needs much cooperation from the patient grading above IV and individual muscle power can be
applied only in children of older age group.

Ask whether the child can self feed, dress, comb hair and any difficulty in wearing chappals. In infants and non-
cooperative young children observe the spontaneous movements and in response to offering toys. In comatose
children spontaneous movements and the response to stroking the distal part of extremities can be tried.

Gross techniques of muscle strength testing are possible for shoulders, arms and pelvic girdle.

Shoulders and arms

- Vertical suspension at axilla will reveal shoulder girdle weakness in which infant slips through the
examiner’s hands. Hand power can be assessed by palmar grasp.

Pelvic girdle

- Observe the child climbing the stairs.

- Gower sign

Muscle power testing around joints.

1. Neck
2. Shoulder
3. Elbow
4. Wrist
5. Hand
6. Intercostals
7. Diaphragm
8. Erector spinae
9. Abdominal muscles
10. Abdominal muscles
11. Hip flexors
12. Hip extensors
13. Knee flexors
14. Knee extensors
15. Hip adductors and abductors
16. Ankle dorsiflexors, plantar flexors, supinator, pronator: ask the patient to do dorsiflexion, plantar flexion,
supination and pronation of foot against resistance.

[Link] (Locomotion and motility)

Observe the gait with bare feet. Spinal abnormalities, musculoskeletal abnormalities of lower limbs and painful
conditions of feet should be excluded. Ask the patient to:

▪ Walk forwards, turn round and come back

▪ Walk around a chair in one direction and reverse the direction
▪ Walk on toes and heels
▪ Tandem walking (heel toe walking along a straight line)
▪ Run
▪ Climb up and down stairs.

The following are common abnormal gait in children:-

• Spastic paraplegic gait

• Hemiplegic gait
• Ataxic (cerebellar) gait
• Waddling gait

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• High stepping gait

• Hysterical gait

[Link] movements

1. Convulsions are nonpurposive, rapid, stereotyped contractions in a part or whole of the body associated
with electrical discharges from brain.
2. Chorea – Irregular, nonrepetitive semi-purposive dancing movements involving the face, head and limbs
associated with emotional instability. The movements not obvious can be augmented by the following
methods:-
▪ Extension of limbs
▪ Milk maid sign
▪ Pronator sign
▪ Lizard sign – Jack in the box tongue
3. Athetosis
4. Dystonia
5. Ballismus
6. Tremor
7. Myoclonus
8. Tics
9. Asterixis
10. Tetany (Accoucher’s hand , Troussau’s sign).
11. Chvostek’s sign
12. Erb’s sign
13. Oculogyric crisis
Except tics and tetany, the involuntary movements mentioned are produced by the inactivity or
degeneration of inhibitory neurons of extrapyramidal system.
14. Cramp
15. Fasciculations
16. Fibrillations

[Link] of movements

The classic signs of cerebellar dysfunction are –

1. Hypotonia
2. Ataxia
3. Nystagmus
4. Wide based gait
5. Titubation

Tests of ataxia in upper limbs

▪ Finger-to-nose test
▪ Finger-to-finger test
▪ Finger-to-finger-to-nose test
▪ Dysdiadokokinesia
▪ Exaggerated rebound

Tests of ataxia in lower limbs

▪ Heel to shin test

▪ Draw a circle test
▪ Watching the patient approaching the toys, picking up small pellets or dressing and undressing are more
sensitive than these formal tests especially in infants and young children.
▪ Romberg’s sign
▪ Pendular knee jerk

Note that weak muscles can mimic ataxia.

Truncal ataxia – the patient says or even falls when made to sit.

Gait ataxia – patients with ataxia walk with wide base. Minimal gait ataxia can be uncovered by asking the
patient to walk in tandem.

Titubation – is involuntary nodding movements of the head while sitting.

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[Link]

o Superficial
o Deep
o Organic

Superficial spinal reflexes

1. Abdominal reflex
2. Cremasteric reflex
3. Anal reflex
4. Plantar reflex
- Oppenheim’s sign
- Gorden’s sign
- Chaddock sign

Deep tendon reflexes (DTR)

Grading is done as

0 Absent
I Reduced
II Normal
III Exaggerated
IV Clonus

When there is difficulty in eliciting the reflex, try reinforcement by asking the patient to clench the teeth or by
distracting attention.

1. Jaw jerk
2. Biceps jerk
3. Radial supinator
4. Triceps
5. Knee jerk
6. Ankle jerk
7. Clonus
- Ankle clonus
- Patellar clonus
8. Palmo-mental reflex
9. Hoffmann sign

Organic reflexes mediate respiration, deglutition, micturition and defecation. They are ascertained from history.
Anal sphincter can be assessed by anal reflex and tone.

Primitive reflexes: Most important are Moro reflex, Grasp reflex and Glabellar tap reflex.

Urinary bladder: urgency, frequency and inappropriate voiding of urine.

Defecation disorders: bowel emptying. control of defecation, fecal retention, fecal incontinence.

[Link] SYSTEM

In children below 3 years and patients who are non-cooperative, only pain sense can be tested by observing
facial expression or withdrawal of limb. Six parameters are to be tested:

1. Touch
2. Pain
3. Temperature
4. Vibration
5. Stereognosis
6. Position sense.

The latter two are less important in children. All sensory examinations should be done when the patient is alert
and quickly from the abnormal to normal area.

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[Link]

Tactile sensibility includes light touch and pressure, tactile localization and discrimination.

▪ Light touch
▪ Deep touch (pressure):
▪ Tactile localization
▪ Two point discrimination

[Link]

Use a sterilized or disposable pin and prick the skin from affected to normal area. Compare with the opposite
side.

Pressure pain: Squeeze a distal muscle or Achilles tendon. It is a poorly localized pain.

[Link]

Two test tubes with hot (440C) and cold (300C) water are applied alternately to the skin. Patient responds by
saying warm or cold. As a bedside test the cold metallic sensation of the touch of a key can be used.

[Link]

The handle of a vibrating tuning fork of 128 Hz per second is applied over the skin of a bony prominence (medial
malleolus of tibia, olecranon process of ulna, etc).

[Link] (recognition of size, shape, weight and form)

Place common objects like coin, key, pencil, etc in patient’s one hand and ask to identify the object. Repeat the
test on opposite side.

[Link]

- Position sense
- Sense of joint movement:
- Sensory inattention

[Link] OF MENINGEAL IRRITATION

[Link] rigidity

[Link] sign .

[Link] sign

[Link] sign

[Link] OF SPINE

Look for

- Congenital deformities
- Defects
- Dimple
- Tuft of hair
- Swelling
- Tenderness
- Gibbus deformity

[Link] NEUROLOGICAL SIGNS

It is a deviant performance on a motor or sensory test abnormal for a particular age. Some of them are:

• Minimal choreoathetoid movements beyond 8 years of age.

• Synkinetic (mirror) movements
• Associated unnecessary movements
• Dysdiadokokinesia.

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• Finger agnosia
• Stimulus extinction
• Lateral dominance
• Left right discrimination

The persistence of two or more soft neurologic signs indicates neurologic dysfunctions like cerebral palsy,
attention deficit disorder, learning disability, etc.

[Link] FOR AUTONOMIC DYSFUNCTION

The autonomic nervous system has sympathetic and parasympathetic divisions and is concerned with
cardiovascular, gastrointestinal, respiratory and temperature regulation and bowel and bladder control and sexual
reflexes.

Features of autonomic disorders are:-

1. Pupillary immobility
2. Postural hypotension
3. Resting tachycardia
4. Incontinence of urine
5. Poor urine stream
6. Impotence
7. Constipation
8. Fecal incontinence
9. Gastrointestinal dysmobility
10. Impaired sweating
11. Snoring
12. Sleep apnea.

Resting tachycardia is made out by the Valsalva test – the patient blows into a sphygmomanometer maintaining
40 mm of HG pressure for 15 seconds. The ratio of the highest pulse rate in the preliminary test period to the
lowest pulse rate during the test is more than 1.5 in normal subjects and less than 1.1 in patients with autonomic
dysfunction.

Other points to be remembered are:

- Examination of carotids
- Palpation of peripheral nerves
- Observation for trophic ulcers

[Link] of and Localization of Lesions of Nervous System

The following points are to be analyzed regarding the neurological lesion:

1. Is there a neurologic problem?

2. Is it trivial or significant?

3. Is it acute, subacute or long standing?

4. Is it recovering, progressing, remitting and relapsing or static?

5. Which part of nervous system is affected, ie. UMN or LMN or combined?

6. Where is the lesion?

7. Can all the features be explained with a single lesion?

8. What may be the pathological nature of the lesion?

9. What is the probable etiology?

LMN lesions – characteristic features

1. Severe and early wasting

2. Hypotonia

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3. Weakness

4. Absent superficial and deep tendon reflexes

5. Fibrillations and fasciculations

6. Distribution of weakness depends on the site of lesion – spinal, nerve root or peripheral nerve.

Pyramidal lesions – characteristic features

1. Muscle wasting due to disuse may occur in long standing situations.

2. Spasticity and weakness of cortical nature will be seen – shoulder abduction, finger movements, hip
flexion and ankle dorsiflexion more affected.

3. Abnormal gait (hemiplegic, scissoring),

4. Absent superficial reflexes,

5. Extensor plantar response

6. Exaggerated deep tendon reflexes.

Extrapyramidal lesions – characteristic features

1. Abnormal postures

2. Involuntary movements

3. Rigidity

Cerebellar lesions – characteristic features

1. Hypotonia

2. Intension tremor

3. Dysmetria

4. Nystagmus

5. Titubation

6. Trunkal ataxia

7. Pendular knee jerk

Babinski’s rising up sign is useful to distinguish spastic and hysterical paralysis. The patient in supine posture
with extended leg is asked to rise up without the support of hands. In spastic paralysis affected limb rises first
which is not seen in hysterical paralysis.

Localization of Lesions

Localize the 5th nerve lesion analyzing the divisions involved, other cranial nerves affected and associated
findings.

Level of lesion Associated findings Parts of 5th nerve ffected

Pons Long tracts Motor part ± compete sensory part
Cerebellopontine angle 7,8 cranial nerves Motor part ± compete sensory part
Floor of middle cranial fossa 3,4,6 cranial nerves All 3 divisions
Cavernous sinus 3,4,6 cranial nerves Ophthalmic and maxillary divisions
Superior orbital fissure 3,4,6 cranial nerves Ophthalmic division
Apex of petrous temporal bone 6,7 cranial nerves All divisions

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Localization of LMN facial nerve lesion

Level of lesion Muscle paralysis Taste Hyperacusis Lacremati
on
Motor nucleus Present Normal Present Normal
Pons distal to motor nuclei Present Normal Present Normal
Geniculate ganglion Present Affected Present Absent
Proximal to nerve to Present Affected Present Normal
stapedius
Distal to nerve to stapedius Present Affected Absent Normal
Stylomastoid foramen Present Normal Absent Normal
Facial nerve branches Partial paralysis Normal Absent Normal

Differentiation between UMN and LMN facial palsy

Clinical feature UMN LMN
Affection of upper part of face Spared due to Present
bilateral
innervations
Spontaneous blinking Present Absent
Bell’s phenomenon Not seen Seen
Lacrimation Present Present except for lesion in the geniculate
ganglion
Affection of lower part of face Present Present
Atrophy of facial muscles Absent Present
Taste sensation over anterior Preserved Lost when the lesion is between
two-third of tongue brainstem and origin of chordate tympani
Hyperacusis Absent Present when the lesion is between
brainstem and nerve to stapedius
Emotional movements Preserved Lost
EMG and nerve conduction Normal Abnormal

Common causes of facial palsy in children

Unilateral UMN Unilateral LMN Bilateral LMN
Meningitis Bell’s palsy GBS
Encephalitis Otitis media Brainstem glioma
Brain abscess Basal meningitis Leukemic infiltrates
Cerebrovascular accidents GBS Motor neurone diseases
Brain tumors Poliomyelitis Post diphtheritic paralysis
Aneurysms Hansen disease
CP angle tumor Systemic hypertension
Secondary deposits Syringobulbia
Hansen disease

Cortical lesions

The common features are

1. Altered sensorium of varying degrees

2. Convulsions

3. Contralateral paralysis ( usually monoplegia, not dense if hemiplegia)

4. Cortical sensory loss and aphasia

Frontal lobe lesions – features

1. Weakness

2. Disinhibition

3. Incontinence

4. Appearance of grasp reflex.

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Temporal lobe lesions – features

1. Complex hallucinations

2. Dysphasia

3. Psychomotor seizures

Parietal lobe lesions – features

1. Cortical sensory loss

2. Dysphasia

3. Visual field defects

Occipital lobe lesions – features

1. Visual hallucinations

2. Visual field defects

Subcortical lesions

The differentiating features from cortical lesion are

1. Absence of convulsions

2. Absence of altered sensorium

Internal capsule lesions

1. Contralateral dense hemiplegia

2. Sensory involvement if the posterior one-third of posterior limb of internal capsule is also involved.

3. May also have homonymous hemianopia.

Thalamus lesions

1. Contralateral sensory loss or hyperalgesia.

Brainstem lesions

1. Midbrain upper level

▪ Ipsilateral 3rd nerve palsy with contralateral hemiplegia – Weber’s syndrome.

2. Midbrain lower level

▪ Due to involvement of red nucleus. Ipsilateral 3rd nerve palsy with contralateral hypertonia, tremor
and ataxia – Benedict’s syndrome.

3. Pons

▪ Ipsilateral nuclear 7th nerve palsy with contralateral hemiplegia.

▪ Ipsilateral 6th and 7th nerve palsy with contralateral hemiplegia - Fovelle’s syndrome.

▪ Lateral gaze palsy – Millard Gubler syndrome.

4. Medulla

▪ Ipsilateral 12th nerve palsy with contralateral hemiplegia – Jackson syndrome.

▪ Varying combinations of vertigo, ataxia, nystagmus, ipsilateral facial anesthesia and intension
tremor and contralateral loss of position and vibration sense may be present.

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▪ In lateral medullary syndrome ( Wallenberg syndrome) there is ipsilateral loss facial pain and
temperature with preservation of light touch and corneal reflex. It is due to infarction of lateral
medulla secondary to vertebral or posterior inferior cerebellar arterial occlusion.

Spinal cord lesions

Physiologically spinal cord is made up of a series of superimposed segments with a pair of nerve roots arising
from each segment.

To locate the spinal segment, add –

- 1 for cervical vertebrae

- 2 for thorasic 1-6,

- 3 for thorasic 7-9,

- 10th thorasic arch overlies lumbar 1st and 2nd,

- 11th thorasic over lumbar 3rd and 4th

- 1st lumbar arch over sacral and coccygeal segments.

The common symptoms are back pain, gait disturbance, sphincter disturbances and weakness depending upon
the level of lesion.

The type of myelopathy can be compressive or non-compressive.

Causes of compressive myelopathy are –

- Trauma

- Tumors

- Caries spine

- Abscess

- Hemorrhage

Compressive myelopathies are extramedullary and intramedullary.

Extramedullary – features are –

- Asymmetric weakness,

- Root pain,

- Complete sensory loss,

- Late bladder involvement,

- Trophic changes.

Intramedullary – features are –

- Symmetrical weakness,

- Early bladder involvement,

- Trophic changes

- Descending pattern of sensory loss

- LMN paralysis at the level of lesion.

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Non-compressive myelopathies are produced by –

- Demyelination,

- Degeneration,

- Toxic and nutritional factors

In acute lesions of spinal cord, in initial spinal shock stage (variable period from few days to few weeks) there is
flaccid paralysis. Typical localizing signs appear after some days and will be present in slowly evolving lesions.

Localization of spinal cord lesions

Cord segment Clinical features Reflexes
C3, C4 Spastic tetraplegia upper limb more affected
Diaphragm paralysis
C5 Spastic tetraplegia Loss of biceps jerk
C7 Spastic paraplegia Loss of triceps jerk
C8, T1 Spastic paraplegia, paralysis of flexion of Upper limb DTR normal
hand and wrist
T6 Spastic paraplegia, intercostals paralysis Loss of upper abdominal
reflex
T9, T10 Spastic paraplegia Upper abdominal reflex
present. Loss of lower
abdominal reflex.
T12, L1 Spastic paraplegia Abdominals present. Loss of
cremasteric reflex.
L2,L3,L4 Spastic paraplegia Loss of knee jerk, ankle jerk
brisk
S1, S2 Paraplegia with flexion at hips and extension Knee jerk normal, absent
at knees, ankle dorsiflexion ankle jerk and plantar
response
S3, S4 No paraplegia. Retention of urine and feces. Loss of anal reflex. Normal
DTR

▪ Combined picture of UMN, LMN and root involvement is seen in spinal arachnoiditis.

▪ In Brown-Sequard syndrome transection of spinal cord produces pyramidal weakness on the same
side with spinothalamic sensory loss on the opposite side.

▪ Anterior horn cell disease is characterized by gross wasting, flaccid weakness, loss of DTR and
preservation of sensations. Fasciculations may be observed, eg. Spinal Muscular Atrophy.

▪ Radiculopathy (spinal root disease): Features are root pain, paraesthesia , sensory dulling and LMN
weakness of mainly proximal muscles, eg. Guillain-Barre syndrome.

▪ Peripheral nerve disease is characterized by distal symmetrical LMN weakness and distal sensory loss
or paresthesia (glove and stocking anesthesia).

▪ Neuromuscular junction disease – Symmetrical predominantly proximal muscle weakness with

diurnal variation and fatigability on exertion. Ptosis is characteristic. No change in muscle tone, DTR
and sensory capacity, eg. Myasthenia gravis.

▪ Muscle disease – Symmetrical proximal muscle weakness. No sensory loss. Muscle wasting and loss
of DTR are late, eg. Myopathies.

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dr ravikumar department of pediatrics gmc kannur kerala