Peds Test 2

Reflex grading

0 - Absent 1 - Decreased 2 - Normal 3 - Increased 4 - increased with Clonus Hyperactivity indicates upper motor neuron lesions, hypocalcemia, or hyperthyroidism.

Motor Strength Grading

0- no muscle movement 1- visible muscle movement but no mov at joint 2- mov without gravity 3- mov against gravity 4- move against gravity resistance 5- normal strength Muscle weakness is the most common presenting symptom of neuromuscular disease.

Tanner stages of pubic hair girls

1 - prepubertal - no pubic hair 2- sparse, long straight hair 3- darker, coarser, curly, sparse hair over the mons pubis 4- darker, curly, abundant hair over the mons pubis 5-adult triangle pattern, with hair growth on medial thighs.

Tanner Stages of pubic hair for boys

1- preadolescent - No pubic hair; penis and testes are same size and proportion as in childhood, 2-sparse pubic hair; slight enlargement of penis and testes 3-darker, coarser pubic hair, further enlargement of penis and testes 4-coarse and curly pubic hair covering more area; further enlargement of penis and testes 5-hair spread to medial surface of the thighs and adult in quality and quantity; penis and testes reach adult size and proportion

Tactile discrimination

> 5 yo. Graphesthesia: write number or letter on child's hand. Child ID letter or number. If unable = sensory, spatial or proprioceptive deficit. (can be cerebral palsy). Stereognosis: place familiar object in childs hand. Child ID's object. Two point discrimination: touch child with something in two different spots. First close to each other and then farther away. child ID locations of both points.

AVPU scale

A method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process of infants

Heel to toe walking (tandem walking)

Able to walk heel to toe in a straight line by age 6. If hemispheric lesion walking this way decreased support for the upper body. some swaying normal. ataxia, lack of coordination or impaired judgement of distance not normal.

Triceps Reflex (C7-C8)

Appears at 6 mo. Tell person to let arm "just go dead" as you strike triceps tendon directly just above the elbow Normal response is extension of forearm

Landau

Appears: 4-5 mo Disappears: 12 mo-2 years Elicit: Infant is placed prone on flat surface or suspended firmly supporting abdomen Response: Infant should raise head and legs and arch back Comments: absence of Landau reflex suggests problem with motor dev.

Protective Extension sitting position

Appears: 5-7 mo Disappears: never Elicit: The infant is placed in a sitting position, then gentle force is applied to displace infant's center of gravity. Response: Arms should abduct, and infant should ext3edn his or her arm outward on the side of the fall, palm open, to stop the fall. Comments: Asymmetrical response is often an early sign of hemiparesis.

Parachute Reflex

Appears: 8 mo Disappears: Persists throughout life Elicit: Infant is suspended prone and firmly supported, then quickly lowered toward flat surface Response: Infant should extend arms and legs in Protective manner Comments: Response should be symmetrical

Romberg test

Assess proprioception in school age and older. Child stands with feet together, arms to side of body and eyes closed. Minimal swaying normal, leaning to one side or losing balance not normal.

Sensory exam

Assessment of light touch, deep pressure, pain, proprioception temperature and vibration. Test in 3 and older. Only pain sensation tested in newborn to determine sensory fx.

Communication

Attentive listening, directing conversation, establishing rapport, and following up on important cue are the general guidelines to a successful interview. Begin with less sensitive topics, progressing to emotionally intense subjects once trust and rapport have been established. Any information regarding situations that are potentially harmful to the child's or adolescents health or safety, or to the safety of others, cannot be kept confidential

Sequence of neuro assessment

Begin at highest level of neurologic functioning and concluding with the lowest: cerebral functioning (behavior, language, speech and mental status), CN's motor function, sensory function, and reflexes.

Puberty in males

Begins between ages 9.3-13.5, at which time testicles begin to enlarge. Next pubic hair begins to grow, and lastly, penis size increases. Maturation lasts about 2-5 years. Puberty before 9 is premature adenarche, which includes other signs of early puberty, such as axillary hair, increased body odor, oily skin, and acne.

Musculoskeletal Dev. Considerations

Bones grow till 19-20 Not fully ossified till adults - pliable, soft and often bend rather than break in the very young Until puberty - % cartilage is high - ribs pliable and pliant. Rib fractures are common; ribs provide minimal protection to organs and blood vessels Lordosis is normal in infants and toddlers - the appearance of pot belly (abdominal distention). Geny Varum (bowing of legs), normal in infants and toddlers - leg muscles bear the weight of a large trunk Genu Valgum (knock knee) normal beginning at 2-3 yo until 7-8 yo Pes Planus - normal in infants as they begin to walk and resolves as they grow Growth spurt at 12 (girls) and 14 (boys) skeleton grows faster than muscles = hands and feet grow faster than body.

Genu varum

Bowleg - normal until ages 3-4

Hoping in place

By 4, should hop in place without losing balance

Blunt's disease

Causes a varus deformity of both tibias. Genu Varum differs from Blount's disease in that both the femur and the tibia are involved with Genu Varum, while Blunt's dz affects only the tibia.

History

Children with mental disorders mya have physical comorbidities that are either the cause or results of their mental health problem.

Heel to shin test >8-9 yo

Coordination of lower extremities. Child supine, ask to place right heel on left shin near knee and slide down to floor. repeat action as fast as possible and test both legs.

Allergies

Especially allergic rhinitis. Diphenhydramine can cause drowsiness and sedation, but in some children it may have a paradoxical effect and results in hyperactivity.

Glasgow Scare > 1 yo

Eye-opening 4-open spontaneously 3-to verbal command 2- to pain only 1-no response Motor 6-obeys commands 5-localizes pain 4-flexion withdrawal to pain 3-Flexion involuntary and abnormal (decorticate rigidity) 2-Involuntary extension (decerebrate rigidity) 1-no response Verbal (2-5) 5-Appropriate words and phrases 4-inappropriate words; confused 3- cries and or screams 2-grunts 1- no response Verbal (>5yo) 5- oriented and converses 4-disoriented and converses 3-inappropriate words 2-incomprehensible nonspecific sounds 1-no response Scores = 13-15 mild head injury 9-12 Moderate injury < 8 severe injury

Glasgow Coma Scale for < 1 yo

Eye-opening: 4 - open spontaneously 3- to loud noise 2- To pain only 1-no response Motor response 6- movements purposeful and spontaneous 5-localizes pain 4-flexion withdrawal to pain 3-flexion involuntary and abnormal (decorticate rigidity) 2-involuntary extension (decerebrate rigidity) 1-no response Verbal (Birth to 23 months) 5- smiles, coos, cries, vocalize 4-cries 3-inappropriate crying and or screaming 2-grunts 1-no response Scores = 13-15 mild head injury 9-12 Moderate injury < 8 severe injury

Galeazzi Sign

Flex infants hips and knees with the soles of the feet placed on the examination table, near the infant's buttocks. Knee height is compared. Uneven knees indicated that one leg is shorter than the other, a sign of unilateral hip dislocation with shortening of the limp on the affected side. This is a positive Galeazzi Sign.

ROS

Focuses on determining whether there is a history of any past acute illnesses or current chronic illnesses that may have behavioral manifestations. Yellowish skin (anorexia); Scars on knuckles (Russell's sign - bulimia); Cuts, burns, bruises (self-injury) Conjunctival injection (marijuana use), watery eyes (narcotic use), dilated pupils (cocaine or hallucinogens). Hypotension, bradycardia, cardiac arrhythmia (eating disorders, inhalant or amphetamine use. Hypertension (obesity), tachycardia (stimulant use).

metatarus adductus

Forefoot adduction may be due to positional incurving of one of both feet caused by intrauterine positioning. Heel is in varus position, with a flexible forefoot that can be abducted beyong the midline. This condition usually resolves spontaneously, particularly with weight bearing.

Paraphimosis

Foreskin remains constricted and cannot be returned to the original position; the child has paraphimosis. This is considered a urologic emergency to avoid ischemia or infarction of the glans.

Brachioradialis reflex (C5-C6)

Hold the person's thumbs to suspend the forearms in relaxation. Strike the forearm directly, about 2 to 3 cm above the radial styloid process. The normal response is flexion and supination of the forearm.

Neuro Dev Considerations

In term infants head size increases approximately sixfold in the first year of life, during which time the infant is very vulnerable to to head and spinal cord injuries, particularly shaking injuries. Any neuro injuries, infections or dz occuring at this time can permanently affect the growth of the brain. THe integrity of the blood brain barrier begins to form in utero and is complete by birth. Myelination begins in uterus and occurs rapidly mid-gestation until age 2 continuing until adulthood. the neurologic system is anatomically complete at birth, but because it is not fully myelinated, it is functionally immature until myelination is complete.

Foreskin adhesions

In the uncircumcised male, the foreskin of a child older than 3 should be gently retracted, and it should be easy. some foreskin adhesions are normal until approximately 4 years of age in most boys. Must not be forcefully retracted. Some smegma under the foreskin is a normal finding.

CN XI, Spinal accessory nerve

Infant lying supine, examiner turn infants head to one side. Normal; infant should bring head to midline. Abnormal: inability to bring head to midline may indicate CN XI dysfunction or torticollis.

CN XII Hypoglossal

Infant's ability to such and swallow is evaluated when feeding; infant's tongue is inspected for lateral deviation when crying or cooing. Normal: sucking and swallowing should be coordinated, and there should be no tongue deviation. Abnormal: difficulty sucking or swallowing is evident.

Muscle dev.

Infants muscles comprise 25% of weight; adults = 40% Infant less muscle tone and coordination during infancy = increased risk of injury Muscle growth rapid during adolescence due to presence of sex hormones, especially testosterone

Clonus

It is a rapid and rhythmic jerking movement of the foot caused by sudden stretching of a tendon. Clonus is normal in the newborn (28 days). Sustained clonus beyond 6-8 beats or clonus that continues past the neonatal period may indicate an upper motor neuron abnormality, such as cerebral palsy.

First step in neuro assessment

Just observe the child's spontaneous activity like feeding, talking, playing, walking, followed by a more purposefull examination.

Genu Valgum

Knock-knees - normal until age 7-8 years, after which time it can be caused by rickets, JRA, osteomyelitis, neoplasia or trauma.

Most sensitive indicator of a child's neuro status

LOC, assessed by the glasgow coma scale score. Assesses 3 main areas: eye opening, motor response and verbal response. Decreased response to commands or decreased pinprick or pain response in any age group indicates deteriorating LOC.

Pelvic exam

Not done in a routine basis in adolescents. If indicated, the american academy of pediatrics recommends that the gyn exam takes place in the primary care setting within the medical home. Only perform is something is wrong or concern (persistent vag d/c; dysuria or urinary tract sx in a sexually active female, dysmenorrhea (painful) unresponsive to NSAIDS, amenorrhea, abnormal vag bleeding, lower abd pain, contraceptive counseling for IUD or diaphragm, pap test (age 21), suspected or reported rape or sexual abuse, pregnancy.

Gait and Balance

Observe child walk across room, turns and walks back. Notice any limp or ataxia and easy alternate arm swing. Toddler has wide gait - lordosis. Wide gait abnormal after beyond toddler. Knock-knee is normal in preschool age child while walking. Cerebellar ataxia, scissor gait is abnormal. Toe walking normal until 2.

Sexual history

Obtain hx with teen fully clothed in a comfortable, non threatening environment. The questions must be age appropriate. Interview should be done in privacy with parent or support person out of the room. Matter of fact non judgemental approach. use open ended questions like "when did you? rather than "did you?" Make sure to state you would prefer the parents to leave so teen doesnt have to make the decision but ok if teen prefers parents to stay.

Onset of menarche

Occurs approximately 2 years after appearance of breast buds. Occurs in breast dev stages 3 or 4 around 12 years of age.

Risk factors for Developmental Dysplasia of the hip

Oligohydramnios Breech presentation Intrauterine position (also influences appearance of torticollis and metatarsus adductus - positional clubfoot).

Temperature

Only done when child's pain perception is abnormal. Use tube with hot and cold areas and touch child in different areas and ask child to tell if cold or hot.

Risk factors for mental disorders in children and adolescents

Poor quality of home life Minority groups/ discriminated groups Parental abuse or neglect Difficult relationships with peers Bullying Lack of access to quality support and services Adolescent pregnancy and parenthood Being in an early or forced marriage Being an orphan, having been institutionalized, Having autism, intellectual disability, or other neurological conditions.

Patellar Reflex (L2-C4)

Present at birth.

CN VIII (acoustic/vestibulocochlear)

Response to startle (up to 4 mo), and acoustic blink reflex (up to 12 mo) is assessed; objective hearing assessment is performed. Infant responds to sound by quieting to voice or blinking to hand clap; objective hearing assessment is wnl. Abnormal if there is no response. It may be conductive hearing loss, depending on the age of the infant and past medical hx.

CN IX Glossopharyngeal CN X Vagus

Sensory fx: gag reflex and ability to suck and swallow are assessed. abnormal is inability to suck or swallow Motor: normal cry is loud and lusty and not hoarse. Abnormal is shrill, high-pitched cry indicates increases ICP, high pitched cat like cry indicates cri-du-chat syndrome

CN III - Oculomotor CN IV - Trochlear CN VI - Abducens

Sensory: Direct and consensual pupillary response to light; pupil size and accommodation are assessed Normal: Sensory pupils are round, equal in size, and constrict directly and consensually in response to light and accommodation. Abnormal: Absence of pupillary constriction is a response to light or accommodation, indicating an abnormality in a sensory portion of CN 3. Physiologic Anisocoria (difference in pupil size by up to 20% is wnl. Motor: extraocular eye mov are tested through the 6 cardinal fields of gaze; upper eyelid elevation and convergence of eyes are assessed; dolls eye maneuver. Normal: no lid lag, no ptosis or nystagmus seen. Abnormal: inability to follow the finger; any ptosis or lid lag indicates an abnormality in CN III. The inability to gaze downward or inward is also caused by an abnormality on CN IV. The inability to move eyes laterally is an abnormality in CN CI. May have resulted from head trauma or space-occupying lesions. Diplopia is an abnormal finding attrib

CN 5 Trigeminal

Sensory: The cheek is touched with a wisp of cotton, and the corneal reflex is assessed Motor: the ability to suck and swallow (place a gloved finger in the child's mouth) Normal: Infant should turn cheek toward stimulus; corneal reflex elicits blinking or tearing (Abnormal corneal reflect associated with severe brain damage) Motor: The infant should suck vigorously on a gloved finger (abnormal - difficulty swallowing sucking

CN VIII (acoustic/vestibulocochlear)

Sensory: hearing and equilibrium. Whisper test, Weber and Rinne test, and audiometry as needed. Normal: Hearing is normal and correlates with language dev. no vertigo or dizziness was reported. Abnormal: sensorineural loss is caused by disorders of CN VIII. Lateralization to the unaffected ear occurs; vertigo can be caused by abnormalities in the vestibular branch off CN VI, such as tumors or ear infections Vestibular fx: Vertigo is assessed by performing the Romberg test

CN 3 (Oculomotor), 4 (throclear), 6 (Abducens)

Sensory: pupillary response to light and blink Motor: the ability to gaze in all directions is noted. Doll's eye maneuver (rotate infant head side to side=eyes should move in the opposite direction of rotation; blink reflex assessed. Normal: Sensory- PERRLA, blink in response to light (absent blink may be blind; MOTOR-disconjugate gaze wnl till 6 mo. Doll's eye maneuver normal brainstem intact. (disconjugate gaze or asymmetrical light reflex after 6 mo = referral. If fail Doll's eye maneuvers and eyes remain fixed, brainstem injury should be suspected.

CN VII Facial

Sensory: taste is not usually tested in infants. Infants prefer sweet. Motor: symmetrical facial mov is assessed when child cries or smiles; ability to suck and swallow assessed. Symmetrical facila mov is noted when child is crying or smiling: there is no difficulty suckin or swallowing. Abnormal if facial asymmetry is noted. Difficulty with suck or swallow.

CN IX glossopharyngeal CN X Vagus

Sensory: taste receptors are assessed by placing a familiar flavor on the post 1/3 of the tongue and also by eliciting the gag reflex. Abnormal: Aneusia (loss of taste), and loss of sensation on the palate or pharynx indicate CN IX dysfunction, which can be caused by intracranial lesions proximal to CN IX. Motor: assess tongue strength and swallowing mov; say ahhhh and inspect palate; voice quality, hoarseness, and stridor are noted. Abnormal: lesions to Cn X result in the absence of gag and palatal reflex. Unilateral CN IX and CN X paralysis result in deviation of the uvula to the unaffected side when the soft palate is touched; Mild difficulty swallowing is noted; bilateral paralysis of CN X results in severed dysphagia; there is no palate elevation with stimulation and hoarseness of voice.

CN V trigeminal

Sensory: touch child's face with cotton ball with child's eyes closed. Repeat with safety pin and cotton ball and ask child to distinguish sharp from soft. tubes of hot and cold water to assess temp perception. Corneal reflex assessed by gently touching childs cornea with cotton ball (this test is often avoided) NORMAL: child moves away from stimuli. Child blinks and tears with corneal reflex. Abnormal: decreased/absent corneal reflex may be caused by a sensory (CN V) or motor (CNVII) abnormality. Loss of sensation on either cheek indicates compression of CN V Motor: OBserve the child chew or swallow or ask the child to make a mean face (masseter muscle). Palpate masseter and temporal muscles while child bites down. Normal: Jaw strong and symmetrical. Abnormal deviation of the mandible to one side when the mouth is open or inability to chew, bite down, or swallow indicated paralysis of CN V.

CN VII, facial

Sensory; ask child to ID a familiar taste by placing it in anterior 2/3 of tongue. Abnormal: ageusia (loss of taste) on the anterior 2/3 of tongue indicates damage to CN VII (space occupying lesion proximal to that CN) Motor: inspect face at rest, not asymmetry and drooping; Ask child to smile, raise eyebrows, make a funny face, puff out cheeks or show their teeth. Normal mov is symmetrical; no facial drooping, tics or eyelid sagging is noted. Abnormal: paralysis of facial muscles (Bell's palsy), facial asymmetry or impairment of eye closure indicates abnormality in CN VII

Autism

Severe and pervasive impairment in. several areas of development, such as reciprocal social interaction skills, maintaining relationships, and difficulties with non verbal communication, such as poor eye contact, abnormal facial expressions, tone of voice or gestures, or the presence of stereotypical behavior and speech, interests and activities. The onset is usually before 3 years but parents can note signs starting at 6 mo. The parents and caregivers are often the first to notice the atypical behavior, when the infant often does not appear to be interested in others or socially responsive through facial gestures and eye contact. Common behaviors include head banging, biting, aggression and hair pulling.

Tanner stages of breast development

Stage 1: prepubertal - nipple elevation begins Stage 2: breast bud stage with elevation of breast and papilla; enlargement of areola. Small mound Stage 3: further enlargement of breast and areola; no separation of their contour Stage 4: areola and papilla for a secondary mound above the level of the breast as areola and nipple project. Stage 5: mature stage: projection of papilla only, related to recession of areola. The nipple projects, and the areola becomes part of the breast contour. In some healthy women the areola continues to form a secondary mound.

Mental health assessment

Start at age 12 at all well-child visits. Screen for depression and tobacco, alcohol, or drug use.

Approach to menstrual history

Start at around 8-9 years, girls should be sensitively questioned about whether or not they have begun menstruating. Adolescent girls have irregular cycles. Ask about: Age of menarche, LMP, Regularity of periods, duration of a normal period, any skipped periods, irregularity, dysmenorrhea, metrorrhagia, or amenorrhea longer than 3 months. Presence of PMS, presence of other symptoms with menses such as HA, migraines, cramps, bloating, tender breasts, or mood changes.

CN in toddlers and Older children CN I, olfactory

Start at preschool age. nares re checked to be sure not occluded with mucus. With one nostril occluded and eyes closed, the examiner asks the child to smell something familiar such as soap, bubble gum, chocolate or mint. This is repeated on both nostrils using different odors. Normal: child can identify familiar smell. Abnormal: anosmia in children may be temp or permanent.; upper respiratory infections, allergies, sinusitis, nasal polyps or deviated septum may cause temporary anosmia; permanent anosmia may be due to Kallman's sundrome, head injury, brain tumor or CHARGE syndrome.

Anal Wink reflex (L4-S1)

Stimulation of the perianal area with a cotton tip applicator. A normal response is quick contrx of the anal sphincter.

Plantar reflex (L4-L5, S1-S2)

Stroke the lateral side of the sole of each foot with the end of the reflex hammer. Toes should flex. Fanning of toes abnormal. For children who are not walking, the Babinski sign is normal for the age group.

Biceps reflex (C5-C6)

Support the person's forearm on yours; place your thumb on biceps tendon and strike a blow on your thumb Normal response is contraction of biceps muscle and flexion of forearm

Cerebellar function

Test preschool age and older. Assess gait, romberg test, hoping in place, heel to toe, walking (tandem walking), the heel to shin test and finger to nose test.

Dev considerations reproductive and Gu system

Testicles descend in the later months of gestation so premature babies are more prone to cryptorchidism and inguinal hernia. Teticles enlarge between 9-13 years. Term female infants have enlarged laabia majora due ot the effects of maternal estrogen. Until 2-4 years, the hymen comprises redundant folds of epithelial tissue that is pale pink. Both the make and female breasts may be swollen at birth and the neonate may secrete colostrum (witch's milk) as a result of the exposure to maternal estrogen .

Trendelenburg Test for Developmental dysplasia of the Hip in older child

The child is asked to hold a chair or the parents' or providers' hands and bear weight on each foot. one at a time. When bearing weight on the affected hip, the pelvis will drop on the contralateral side. This is a positive trendelenberg sign. When pt lifts R foot, L hip abductors are being tested When pt lifts L foot, R hip abductors are being tested.

Social HX

The mental health of the parents or any other adults living in the home is also a crucial part of the social history. Important to note any verbal discipline that could be characterized as verbal abuse.

Talipes Equinovarus

True clubfoot. = Rigid deformity involving muscles, tendons and bone. .Forefoot adduction, forefoot supination and equinus of the ankle (plantar flexion of the foot at the ankle) Internal torsion of the tibia may also be seen. Requires serial casting and possible surgery to correct. .

Vibration

Use low pitch tuning fork placed on bony prominence. Child asked when vibration stops.

Chordee

Ventral (downward) curvature of the penis due to a fibrous band along the corpus spongiosum seen congenitally with hypospadias, or a downward curvature seen on erection in disease conditions causing a lack of distensibility in the tissues.

CN II Optic

Visual acuity. Fundoscopy, visual fields and pupillary response on both eyes are assessed. Normal: visual acuity normal; no papilledema, peripheral vision intact. Child able to fix on object and follow 60-90 degrees. Pupils constrict in response to light. Abnormal: Abnormalities in vision may be caused by cataracts, conditions that cause ICP or uncorrected strabismus.

Barlow Sign

With hips adducted, slight, gentle pressure is applied to the posterior hip. If the hip is dislocated, a clunk is palpable, but not audible, as the hip dislocates out of the acetabulum. This is a positive Barlow sign.

Symmetry of thigh folds

With the infant prone, the provider assesses symmetry of thigh folds. Asymmetric thigh and gluteal folds also indicate hip dislocation, with an extra skinfold on the affected side.

Epispadias

a congenital defect in which the urinary meatus is located on the upper (dorsal) surface of the penis

Hypospadias

abnormal congenital opening of the male urethra on the undersurface (ventral) of the penis

Postural reflexes Positive support

appears: 3-4 mo Disappears: never Elicit: hold infant upright supported under arms with feet touching a flat surface. Response: Infant should extend legs in a attempt to bear weight. By 5-6 mo, infant is able to fully support own weight; By 7 mo, infant is able to bounce. Comments: Absent with corticospinal tract disease

CN XI spinal

ask child to lower chin agains resistance, shrug shoulder with and without resistance. Nod head and turn side to side against resistance to assess trapezius. Normal: child able to apply resistance using SCM; normal strength of SCM and trapezius. Abnormal head or neck trauma, CNS tumors or infections can cause paralysis fo SCM or trapezius

Proprioceptive sensation

assess motion and position of limbs by gasping child's toe and moving it up and down and ask child the position

Decorticate posturing

characterized by upper extremities flexed at the elbows and held closely to the body and lower extremities that are externally rotated and extended. occurs when the brainstem is not inhibited by the motor function of the cerebral cortex. Injury to corticospinal tract.

Ortolani maneuver

check hips for congenital dislocation, done until 1 yr old, should be smooth with no sounds. Abduct leg 90 degrees with gentle pressure over greater trochanter. Palpable but not audible clunk felt when hip dislocation reduced with DDH. Abnormal= feels like a clunk as head of femur pops back into place- not audible sound. positive ortolani sign

Finger to toe test >8-9 yo

close eyes, hold arms out in front of body. touch nose with right and left finger rapidly.

Pes planus

congenital condition of the foot involving laxity of the ligaments supporting the foot's longitudinal arch, causing fattening of the foot arch. Convex medial border of the foot is present. May be permanent or occur only when the child bears weight.

Achilles tendon reflex (S1-C2)

dorsiflex his or her foot slightly at the ankle; strike achilles tendon. Plantarflexion is the normal response.

Onset of puberty in females

first signs of puberty in girls are breast development and the growth of pubic hair. these usually occur between ages 8-13.5. menarche usually occurs about 2 years after the appearance of breast buds. Axillary hair appears around 2 years after the onset of pubic hair. Menarche occurs in reast dev stage 3 or 4. At thelarche (beginning of breast at puberty around 11), the presence of the hormone estrogen stimulates the dev of breast tissue. Puberty before 8 is abnormal and should be investigated.

Superficial reflexes Abdominal reflex (T8, T9 and T 10, T11 and T12)

handle of hammer, gentlys stroke abd toward umbilicus. Muscles contract and umbilicus should move toward the stimulus. May be hard in obese children or children with abd surgery (normal)

Primitive reflexes

involuntary reflexes found in the infant. Present at birth, and most dissapear by 4-6 mo. Asymetrical, absent or persistent primitive reflexes indicate a neurologic abnormality. Tested on children <1 yo. Postural reflexes replace primitive reflexes by 5-6 mo. assessment of these reflexes should begin at this time.

Light touch

light touch skin in different areas with stretched cotton ball. child should ID area being touched.

CN XII: Hypoglossal Nerve

mov of tongue. Ask child to stick out his or her tongue and move it from side to side; Listen to child speak and note articulations; tongue strength (press tongue against tongue blade) Eval ability to say letter R. Note if tongue deviates to one side. Lesions of CN XII cause tongue deviation or paralysis, resulting in difficulty articulating lingual sounds .

Retractile testes

move between the scrotum and the inguinal ring by cremasteric reflex (normal until puberty). Only refer if it has never been documented that the testes were ever descended. Positioning the child in a squatting position, asking him to sit with his legs crossed in front of him, or placing the infant supine with his legs raised and spread are maneuvers that help to move the testicles into the scrotum. If not in the sac, the provider should search for the testicles along the inguinal canal and try to milk them down. If the sac has remained empty past 6 months of age, refer.

Rapid Alternating mov >8-9 yo

palms face down and up on thigh and rapidly alternating.

Decerebrate posturing

posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out, a more ominous sign of brain stem damage. Most Severe.

CN in neonates and infants = CN 1 Olfactory

rarely tested in neonates if tested strong smell under baby's nose normal=startles, grimaces, sniffs or cries abnormal= congenital anosmia (kallman's syndrome)

CN2, optic

response to bright light, test pupillary reaction with an ophthalmoscope Normal: blink and pupils constrict equally. Able to fix and follow for 60-90 sec. Abnormal: may indicate congenital blindness or retinoblastoma.

Phimosis

stenosis or narrowing of the foreskin so that it cannot be retracted over the glans penis

Adam's forward bend test

test for scoliosis. Child strand straight, facing away from the examiner, feet together and knees straing. the examiner then asks the child to bend forward at the waist, armas dangling and touch his or her toes. Inspect eh teh child's back for spinal alignment. deformity, curvature or visible hump. Prominent scapula on the affected side when bending indicates scoliosis.

Cyrptorchidism

the failure of the testes to descend from the abdominal cavity where they develop during fetal life to the scrotum. this is associated with testicular cancer and sterility

Cremasteric reflex (T12-L1)

upward pull of testicles and scrotum due to touch to inner thigh.

Pain

use sharp and dull end of reflex hammer. Kid ID sharp vs dull sensation.