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ATI Child Physical Assessment

Terms in this set (198)

Direct vs indirect percussion
Striking body part without vs with a finger placed between striking finger and area being examined.
Sinus dysrhythmia
Mild acceleration and slowing of heart rate that occurs with breathing, a normal finding in children.
Tangential lighting
Lighting from the side, used to make raised lesion cast shadow, for example.
Testing olfactory sense (CN I)
Use non-noxious odor like orange or mint (toothpaste). Noxious odor like alcohol wipe may stimulate trigeminal nerve (CN V).
Order of examining child
From least invasive or uncomfortable to most. If one part of exam produces anxiety, skip and return to it later. Examine older child before younger.
Examining an infant
Nonverbal communication important like holding, rocking, patting. Talk in quiet, unhurried tone of voice. Older infants have separation anxiety and stranger fear, so may help if parent holds infant. Let child hold stuffed animal and see parent at all times.
Examining a toddler
Toddlers are concrete and interpret what you say literally. Use short, concrete instructions and repeat them. Use dolls to demonstrate each step of exam and let toddler perform exam on doll. Let toddler play with equipment.
Examining a preschooler
Similar to toddler, but examination is easier because they like to please and conform. They know names of body parts, so can do some teaching. Begin to introduce medical terms. Use short, specific, simple language. Modest, so let them undress for exam. Rewards like stickers or small toys are effective.
Examining a school-age child
Still concrete, but more sophisticated. Explain each step of exam. Children respond well to reassurance and praise. For younger children in this group, speaking to them in third person can reduce anxiety and gain cooperation: "Little boys sometimes think it tickles when I listen to their tummies." They respond well when you explain what you are doing as you do it.
Examining an adolescent
Verbal skills may be more sophisticated than behavioral skills. Address fears verbally and directly. Avoid prying, confrontation, repetitive questioning, judgmental attitude. Refocus on nonthreatening subject if exam not going well. Respect privacy and emphasize confidentiality. When possible, do at least part of exam with parent not in room, but inform child if law requires some information to be told to parent. Share findings throughout exam and ask child to reiterate in own words to confirm understanding.
Components of exam
General survey/anthropometric measurements.
Vital signs.
Integument.
Head, face, neck.
Eye.
Ear, nose, throat.
Respiratory.
Cardiovascular.
Abdominal.
Musculoskeletal.
Neurologic.
General survey components
Body habitus.
Facial expression, presence or absence of distress.
Hygiene, grooming, dress.
Odors.
Affect.
Anthropometric measurements: Weight, height, head circumference, BMI.
Parent-child interaction.
Normal range for growth on growth charts
Between 5th and 95th percentile.
How to weigh infant
Platform scale. Place cloth or pad and then calibrate scale. Remove child's clothes and diaper. Weigh to the nearest 1/2 ounce.
How to weigh toddlers through adolescents
Upright scale. Child should only wear underwear if possible. If not, have them take off shoes and jacket. Weigh to the nearest 1/4 pound. For adolescents, look for signs of eating disorder.
How to measure length of infant or young toddler
For children up to age 24 months, use measuring board. May use tape measure, but less accurate. Place infant on surface with head midline and legs fully extended and flat on table. Mark top of head and heel of foot and measure distance between marks.
Measuring height of toddler through adolescent
Use a stadiometer. Have child stand straight and tall and look ahead. Head, shoulders, and heels should touch wall. Measuring device sits gently on head. Number just under device is height. Measure to nearest 1/8 inch.
Measuring head circumference
Usually measured at birth and every checkup up to 36 months, beyond only if there is suspicion of abnormality. Place tape measure around widest part of infant's head, slightly above eyebrows and pinna and around occipital prominence at back of skull.
Normal head circumference
32-38 cm for newborn. Increases 33% by 1 year, 1 inch from 1 to 2 years, 1/2 inch from 2 to 3 years, less than 1/2 inch per year from 3 to 5 years.
Taking vital signs of infant
Count respirations first before disturbing the infant. May want to do rectal temperature last.
Assessing temperature in children
More variable than in adults. Higher in infancy and early childhood with rectal temperature usually above 99. Fluctuates, especially with strenuous activity. Rectal best reflects core temperature, but it is invasive and may be poor choice. Oral only good if child can hold correctly and has clear nares. Axillary and tympanic are convenient, but may not be as accurate.
How to take rectal temperature of infant
Have infant lie prone, preferably on parent's lap. Separate buttocks with thumb and index finger. Insert lubricated thermometer at 20-degree angle to the lap no more than 2 cm (3/4 inch). If not electric, keep in place 2-3 minutes. Do not use if diarrhea or anal lesions.
Taking tympanic temperature for different ages
Pull ear down and back for 3 years and younger, up and back for older children. Do not use if ear pain, excess wax, lesions, drainage.
Usual temperature ranges by age
Infants up to 1 year: 99.4-99.7 (37.5-37.7).
Ages 1-5: 98.6-99.7 (37.0-37.7).
Ages 5-11: 98.0-98.6 (36.7-37.0).
Ages 11 and above: 97.8-98.0 (36.6-37.0).
Why high heart rates are normal for ages 6 months and younger
They cannot stretch myocardial fibers to increase heart rate and are rate-dependent.
Causes of bradycardia in infants
First, hypoxia. Second, hypothermia.
Causes of tachycardia in children
Fever, pain, anxiety, dysrhythmia, CHF, medication effect.
Causes of bradycardia in children
Hypoxia, hypotehrmia, congenital heart problem, medication related (dig toxicity, opioid, sedative).
How to take pulse of infant
Apical pulse for 30 seconds (if regular), 1 minute if not. Most accurate measurement if child is asleep.
How to take pulse of toddler to adolescent
Radial pulse.
Usual heart rates by age
Birth to 2 months: 90-190.
2-6 months: 80-180.
6-12 months: 75-155.
2 to 10 years: 70-110 awake, 60-90 asleep.
Above 10 years: 55-90 awake, 50-90 asleep.
How to count respirations in infants and older children.
For infants, best early in exam and when child is asleep. Breathing is diaphragmatic, so watch abdomen. Breathing is irregular, so count full minute. For older children, same as adult.
Usual respiratory rates by age
Infants to 1 year: 30-35.
2-5 years: 22-25.
5-12 years: 19-22.
12 and above: 16-19.
How much fever raises respiratory rate of infant
10 breaths per minute for each degree Celsius of fever.
Causes of hypertension in children
Renal disease, coarctation of aorta, stress, medication effect. Essential hypertension also seen.
Causes of hypotension in children
Hemorrhage, sepsis, septic shock.
Choosing appropriate blood pressure cuff
Bladder width should be 40% of child's arm circumference halfway between olecranon and acromion. Bladder length should cover 80-100% of circumference.
Type of error from too small and too large blood pressure cuff
Too small: False high.
Too large: False low.
Blood pressure findings in coarctation of aorta
Lower extremity blood pressure lower than upper extremity blood pressure.
Measuring infant's blood pressure
Not done routinely, but should be done once in first year of life. Best to use Doppler. Another method is oscillometry.
Measuring blood pressure in toddler or preschooler
Explain it will be like an "arm hug." Position limb at heart level. Rapidly inflate cuff to 20 mmHg above where radial pulse disappears. Release cuff at rate of 2-3 mmHg per second. Record first Korotkoff sound as systolic and fourth as diastolic.
Measuring blood pressure in school age children and adolescents.
Same technique as adults. Record first Korotkoff sound as systolic. Record fourth sound as diastolic for children under 12 and fifth sound for children over 12.
Components of integument exam
Color, temperature, texture, moisture head to toe.
Turgor and edema.
Lesions: Location, distribution, size, shape, cloor, texture, surface characteristics, exudate, tenderness.
Hair: Quantity, distribution, texture, color, parasites.
Nails: Color, shape, thickness, adhesion to nailbed, lesions, clubbing, capillary refill.
Milia
Tiny white papules on cheeks, forehead, nose, and chin of infant. They will go away on their own. encourage parents not to rub them and break skin.
"Stork bite"
Irregular red or pink nevus on forehead or back of neck that usually fades during first year.
Mongolian spots
Bluish-gray macular areas on sacrum or buttocks of dark-skinned infants. These are not bruises.
Cafe au lait spots
Large round or oval patches that are light brown. Normal finding unless larger than 1.5 cm.
Assessing bruises
In infant, ask how child got them. In older children, bruises are common on knees, shins, lower arms. Ask about bruises in other places.
Assessing nails in infants and children
Nails should be firmly attached. Hold limb above heart for capillary refill (may also check heel). Normal is less than 2 seconds.
Part of hand to assess skin texture, moisture, temperature
Fingertips for texture and moisture, back of hand for temperature.
Checking skin turgor in children of different ages.
Pinch skin over abdomen and look for tenting in infants through school age children. In adolescents, pinch skin fold over clavicle.
Checking edema in children
Rare finding. Press over bony part of shin or ankle.
Components of head, face, neck exam
Inspect and palpate face and skull.
Test cranial nerve V and VII.
Inspect neck for contour and tracheal position.
Evaluate neck range of motion.
Palpate carotid arteries.
Palpate cervical lymph nodes.
Check cranial nerve XI.
Palpate trachea and thyroid gland.
Normal head shape of infant
Round with prominent occipital area that gets less prominent as child gets older. Adolescent no longer has prominent occiput.
Caput succedaneum
Swelling and ecchymosis of presenting part of head of newborn. It feels soft and may extend across suture lines. It usually resolves within a few days of birth.
Cephalhematoma
Subperiosteal hemorrhage in newborn that is soft and spongy and usually only extends over one bone. It usually reabsorbs within first few weeks of life.
Age at which infant can hold head erect and midline when sitting up
4 months.
What small head and large head mean in small child
Large head is usually hydrocephalus. Small head is microcephaly or genetic abnormality.
Age at which suture lines are no longer palpable
18 months.
Normal and abnormal findings for fontanels
Normal is flat and firm. Bulging indicates increased intracranial pressure. Sunken indicates dehydration. Larger than normal fontanels that do not close when they should may indicate hydrocephalus, Down syndrome, hypothyroidism. Small fontanels that close early may indicate microcephaly.
When fontanels close
Posterior may not be palpable. If it is, it is less than 1cm in diameter and closes at 2-3 months. Anterior is usually 5 cm at 6 months and closes by 18 months.
Cradle cap
Seborrhea, crusting of scalp.
What unusual hair growth pattern means
Examples: Low hairline on neck or forehead. Congenital disorder or hypothyroidism.
Significance of facial assymetry
May result from positioning in utero, swelling from infection or trauma, paralysis of CN V or VII.
How to inspect for facial symmetry in infant
When he cries, both sides of forehead should wrinkle and both sides of lips should turn up.
How to inspect for parotid enlargement in child
Have child look up at ceiling. Swelling will be seen at angle of jaw.
Testing cranial nerve V
Motor: Have child bite down and palpate temporal and masseter muscles.
Sensory: Cotton wisp on forehead, each cheek, and chin for sensation.
Significance of neck edema
Mumps or throat or mouth infection.
Significance of distended neck veins
Increased pressure from respiratory or cardiac disorder.
Significance of dimpling or sinus tract on neck of infant
Thyroglossal duct cyst or brachial cleft cyst.
Significance of webbing or extra skin folds on side of neck of child
Could be Turner syndrome.
Significance of limited horizontal range of neck motion
Could be torticollis, persistent tilting of head to one side.
Causes of torticollis
Sternocleidomastoid injury or unilateral hearing or vision impairment.
Significance of pain with neck flexion in adolescent
Could be injury or meningitis.
How to test cranial nerve XI
Turn head to each side against resistance and shrug shoulders against resistance.
Normal position of trachea
Midline or slightly to right.
Sequence of palpating lymph nodes of head and neck
Around ears, under jaw, occipital area, cervical chain of neck. Cervical lymph nodes in infant are not palpable even if inflamed.
Normal and abnormal lymph nodes in toddlers to adolescents
Firm, movable lymph nodes with clearly defined edges that are less than 1/2 inch in diameter are normal. Enlarged, firm, tender nodes indicate infection.
Components of eye exam
Inspect appearance of eye structures.
Pupillary response and EOM.
Vision screening.
Use ophthalmoscope to check for red reflex.
Epicanthal fold
Extra skin fold that extends over inner corner of eye. Common in Asian children. In others, usually disappears by age 10.
When lacrimal glands start to function
2-4 weeks.
Eye color at birth
Dark-skinned babies usually have brown irises. Light-skinned babies usually have blue or gray, and they may change color at 6 months.
Vision development in infant
Peripheral vision is intact at birth, but not macula. Macula begins to develop at 4 months and is mature at 8 months. Infant can focus on object with both eyes simultaneously by 3-4 months.
"Sunset sign"
On eye exam, sclera is seen between upper eyelid and iris. May mean eyelid is retracted or child has hydrocephalus.
Significance of upward or "Mongolian" slant of eye
Normal in Asian children, may be Down syndrome in others.
Coloboma
Keyhole-shaped pupil caused by notch in iris that may indicate congenital anomaly.
How to test accommodation
Have child look at your finger or a toy then distant object like picture on wall. Pupil should dilate for distance and constrict for close object.
How to tell cranial nerves II and III are intact
PERRLA.
How to check for strabismus
EOM, corneal light reflex, cover-uncover test.
How to get infant to cooperate with eye exam
Often, they will open eyes if held over parent's shoulder.
How to test infant's visual acuity
Move hand quickly toward eyes and note blink reflex.
How to test vision from 18-23 months
Allen test. 7 cards contain familiar objects. Make sure child can identify them at close range. Then show at 15 feet. Normal is identifying 3 out of 7 cards within 3 to 5 attempts.
How to test vision from 3-6 years
Picture chart or Snellen E chart.
How to test vision in school-age children and adolescents
Snellen letter chart.
How to check red reflex
Hold ophthalmoscope 1 foot away and shine on pupils with patient looking straight ahead.
Significance of black spots or opacities on red reflex
May be congenital cataracts.
Significance of white instead of red reflex
May be retinoblastoma.
Components of ENT exam
Inspect ears for shape, placement, discharge, tenderness.
Check hearing.
Examine ear canal and tympanic membranes.
Inspect nose and test CN I.
Inspect lips and oral cavity.
Test CN XII, IX, X.
Significance of depression or protrusion in tissue around ear
Depression may be sinus. Protrusion may be mastoiditis.
"Comfort hold" for examining infant's and young child's ears
Sitting on parent's lap with side of head supported against parent's chest.
Which way to pull ear to use otoscope, give eardrops, take temperature
Younger than 3 years: Down and back.
3 years and older: Up and back.
Normal tympanic membrane
Shiny and pearly gray with cone of reflected light at nasal aspect ( 7 o'clock in left ear and 5 o'clock in right).
How to test hearing in child
Rub fingers together inches from ear or stand behind patient, ask him to plug ear, and test ability to hear whispered words.
How to test hearing in infant
Stand 2 feet behind infant and make soft noise with bell or rattle. Infant should turn to sound.
Significance of crease across nose between cartilage and bone
Common in allergies.
At what age are infants obligate nose breathers
6 weeks and younger.
How to test CN IX and X
Uvula is midline and child can swallow.
When not to inspect mouth during exam
If there are symptoms of epiglottitis, like high fever and drooling, or respiratory distress.
Components of respiratory exam
Observe respiratory rate and rhythm.
O2 saturation.
Skin color and nailbeds for color and clubbing.
Inspect chest configuration and work of breathing.
Palpate and percuss anterior and posterior.
Auscultate.
Pectus carinatum
Pigeon chest. Sternum protrudes, increasing AP diameter.
Pectus excavatum
Funnel chest. Lower part of sternum is depressed, decreasing AP diameter.
Chest shape of infant
Barrel-shaped or circular with AP diameter equal to lateral diameter. As child grows, lateral diameter increases.
Breast enlargement in newborn
For both boys and girls, maternal estrogen may cause breast enlargement on second or third day of life. White fluid may be expressed. This usually resolves in first week of life.
Breathing pattern of infant
Nose breathing with slight flaring. Abdomen bulges with inspiration. Little thoracic movement. Normally irregular rhythm.
Significance of barrel chest in toddler to school-age child
Indicates respiratory problem like asthma or cystic fibrosis.
Breathing pattern of toddler to school-age
Diaphragm is still primary respiratory muscle, so abdomen rises and falls. There should be no retractions.
Breathing pattern of adolescent
Chest has normal 1:2 AP to transverse diameter. Abdominal breathing is not usual.
Significance of unequal chest expansion on palpation in infant
May be diaphragmatic hernia or pneumothorax.
Significance of increased or decreased tactile fremitus
Decreased may be air trapping as in asthma. Increase may be consolidation as in pneumonia.
Normal chest percussion in children
Hyperresonant in infants, toddlers, preschoolers because of thin chest wall. Resonant in older children.
Types of lung sounds
Bronchial: Loud, high-pitched, hollow, over trachea, only anterior.
Bronchovesicular: Medium-pitched, quieter, over mainstem bronchi anterior and posterior.
Vesicular: Soft, fine, breezy, low-pitched, over peripheral lung tissue.
Adventitious sounds
Crackles (rales): Wet, popping sounds, usually at end of inspiration.
Wheezes: Continuous sounds that can be high-pitched as in asthma or low-pitched. May be only expiratory or throughout cycle. May clear with coughing.
Friction rub: Scratching or squeaking sound that persists through cycle and does not clear with cough.
Whispered pectoriloquy
Whispered sounds are heard distinctly on auscultation rather than as muffled and indistinct.
Broncophony
Increased intensity and clarity of spoken sounds on auscultation, but words are indistinct.
Egophony
"Eee" sound is transmitted as "ay" for spoken words on auscultation.
Components of cardiovascular exam
Review vital signs.
Look for signs of cardiovascular problems.
Inspect and palpate carotid pulses.
Inspect and palpate precordium for pulsations.
Auscultate.
Significance of petechiae and purpura
Petechiae: Low platelets. Purpura (larger nonblanching purple discolorations): Septic shock.
When do fetal blood flow shunts close?
Normally within 10-15 hours of birth.
Signs of heart problem in infant
Persistent tachycardia, tachypnea, enlarged liver may mean heart failure. Cyanosis may indicate congenital abnormality. History of poor feeding, increased work of breathing, and diaphoresis during feeding may be from heart problem.
Signs of heart problem in toddler to school-age child
Poor weight gain, developmental delay, persistent tachycardia, tachypnea and dyspnea on exertion, cyanosis. Precordial bulge may indicate enlarged heart.
Location of apical impulse in infants and children
In infant, 4th intercostal space just lateral to midclavicular line because heart is positioned more horizontally than adult. Moves to 5th intercostal space, midclavicular line by age 7 years.
Where S1 and S2 are loudest
S1 (tricuspid and mitral closing) at apex. S2 (pulmonic and aortic closing) at base. S1 = S2 at Erb's point.
Components of abdominal exam
Inspect skin, contour, umbilicus.
Auscultate bowel sounds and bruits.
Percuss abdomen and costovertebral angles.
Palpate.
Normal findings on abdominal inspection in infant
Rounded appearance with veins visible. Umbilical hernia often appears at 2-3 weeks and disappears in first year. Diastasis recti usually disappears in early childhood.
When does umbilical stump fall off?
Turns black, dry, and hard in a few days and falls off in 7-14 days. Covered by skin in 3-4 weeks.
Normal abdominal inspection of toddler to young child's abdomen
Protrudes lying and standing up until 4 months and then protrudes only when standing. Moves with respirations until age 6.
Normal frequency of bowel sounds
Every 10-30 seconds.
Sounds heard when percussing abdomen
Tympany: Areas that contain gas.
Dullness: Solid organs.
Resonance: Lung tissue.
Usual location of liver dullness in children
Inferior edge 1 inch below right costal margin in infants and children. Closer to costal margin in adolescents.
How to palpate infant's abdomen
Flex knees with one hand to relax muscles. Palpate with other hand.
How to palpate toddler's to adolescent's abdomen
Have them raise knees. If ticklish, start palpating with child's hand under yours, then switch positions. Ask child to take deep breath to relax abdomen.
Is spleen palpable?
Normally no. Usually only palpable when enlarged to 3 times normal size.
Are kidneys palpable?
Left is usually not. Right may be.
Components of musculoskeletal exam
Peripheral vascular assessment.
Gait.
Posture, movement, general body symmetry.
Inspect and palpate spine for contour and tenderness.
Inspect limbs for skin changes and symmetry.
Palpate limbs for muscle mass, tone, strength, joint range of motion, crepitus.
Syndactyly
Webbing between digits.
Simian crease
Single crease rather than multiple creases across palm, may indicate Down syndrome.
How to inspect infant hips for dislocation or subluxation
Ortolani-Barlow maneuver.
Significance of number of skin folds on leg of infant
Equal number of folds on each leg is normal. Difference may be limb length discrepancy.
Significance of forefoot inversion in infant
If flexible, it is from positioning in uterus and probably will resolve in 1-2 years. If not flexible, it is abnormal finding.
How to check for hip dislocation in toddlers to adolescents
Have child stand on one foot and then other. If iliac crest opposite the weightbearing leg appears lower, the hip of the weightbearing leg may be dislocated.
At what age bow legs go away
Age 4 years.
Genu varum
Bowlegs.
Genu valgum
Knock-knees.
How to assess for bowlegs or knock-knees
Have child stand on flat surface and measure distance between knees when ankle are together. More than 1.5 inches (3.5 cm) indicates bowlegs. Measure distance between ankles when knees are together. Greater than 2 inches (5 cm) indicates knock-knees.
Significance of crepitus on palpation of clavicles in infant
Likely fracture at birth.
Significance of bump palpated on long bone
Likely recent fracture with callus formation.
Normal spine curvature of infant
C curve. Concave cervical curve begins to develop at 2 months when infant can lift head when in prone position.
Normal spine curvatures of older children and adolescents
Cervical: Concave.
Thoracic: Slightly convex.
Lumbar: Concave.
Sacral: Convex.
(Double S.)
Significance of hair tufts and dimples on spine exam of infant
Tuft of hair over dimple may be spina bifida. dimple without hair may be dermoid cyst.
Normal spine curvature of younger children
Lumbar lordosis until age 6. After age 6, thorax is convex and lumbar concave.
How to check for scoliosis
In toddlers to school-age children, look for symmetry of shoulders, iliac crests, waist creases. At age 10-12 start with forward bend test. Spine should be straight and posterior ribs symmetric when child bends to touch toes.
Meaning of 3+, 1+, and 0 muscle strength
3+: Able to move against gravity, not resistance.
1+: Visible muscle contraction, but no limb movement.
0: Paralysis.
How to test infant's muscle strength
Hold between axillae. If infant slips, shoulders may be weak.
How to test muscle strength in toddler to school age
Note ability to climb on table, throw ball, clap hands, move around bed.
How to test muscle strength in adolescents
Like adult, movement against resistance and grip.
How to assess range of motion in infant
Do while checking Moro reflex. Child with clavicle fracture will only respond with one side on Moro. Watch for spontaneous movement of other extremities.
How to assess range of movement of toddlers through school age
Watch movement during play, reaching for object, climbing on exam table, and walking.
Significance of pain and inability to suppinate hand while arm is flexed in 2- to 4-year-old
Suspect elbow subluxation from being lifted by hands.
How to test shoulder range of motion in adolescent
Reach over shoulder to touch opposite shoulder. Reach behind back over and under shoulder.
Components of neurological exam
Mental status: Level of consciousness, eye contact, mood, affect, memory.
Motor function, balance, coordination.
Cranial nerves.
Sensory function.
Reflexes.
Best way to evaluate level of consciousness in younger patients
Ask parents and correlate with your observations.
Normal mental status of infant
Interacts and bonds with parents. Shuts out negative stimuli like background noise. Tracks high-contrast objects. Turns to voices.
How to test motor function of infant
Denver II test (developmental milestones). Movements while lying on table should be smooth and symmetric. Check head control by grasping wrists and pulling to sitting position. Or lift infant from prone position while supporting chest. Newborn holds head at 45 degrees with back straight or slightly arched. By 3-4 months, infant lifts head with back arched. This is Landau reflex and is present until 18 months.
Testing motor function, balance, and gait in toddler to adolescent
Have child walk 5 or 6 steps across room to check normal gait, then heel to toe for balance, then toe walking and heel walking for motor function and balance. May also do 20-second Romberg. A little swaying is OK, not more than a couple of inches.
Testing coordination in toddler to adolescent
Rapid alternating movements. Finger-to-nose (should come within 1-2 inches of nose. Heel-to-toe.
Cranial nerve I function and test
Olfactory (sensory).
Infant: Not tested.
Toddler and up: Smell test for common scents.
Cranial nerve II function and test
Optic (sensory).
Infant: Shine light in eyes to get blink reflex.
Toddler and up: Test visual acuity.
Cranial nerve III function and test
Oculomotor (motor). EOM, elevation of upper lid, pupil constriction and dilation.
Infants: Tracking of light.
Toddler and up: Test 6 cardinal fields of gaze.
Cranial nerve IV function and test
Trochlear (motor).
Infants: Tracking of light.
Toddler and up: Test 6 cardinal fields of gaze.
Cranial nerve V function and test
Trigeminal (sensory and motor).
Infants: Root and suck reflex.
Toddler and up: Sensory perception on forehead, cheeks, chin. Test jaw strength, teeth alignment.
Cranial nerve VI function and test
Abducens (motor).
Infants: Tracking of light.
Toddler and up: Test 6 cardinal fields of gaze.
Cranial nerve VII function and test
Facial (motor and sensory). Facial muscles and taste on anterior tongue.
All ages: Check facial features and expression.
Cranial nerve VIII function and test
Acoustic (sensory).
Infants: Blink response to sound.
Toddlers and up: Test hearing soft sounds and startle to loud noises.
Cranial nerve IX and X function and test
Glossopharyngeal and vagus (motor and sensory). Swallowing, gag, and taste on back of tongue.
Infants: Swallow test.
Toddlers and up: Test gag reflex.
Cranial nerve XI function and test
Spinal accessory (motor). Sternocleidomastoid and trapezius.
Infants: Not tested.
Toddlers and up: Strength in neck and shoulders.
Cranial nerve XII function and test
Hypoglossal (motor).
Infants: Check suck and swallow.
Toddlers and up: Test speech accuracy and articulation.
Sensory testing in infant
Not routinely done. However, can observe response to pain. Should cry and withdraw all limbs. Localizes pain more by 7-9 months.
Sensory testing of toddlers to adolescents
Light touch with cotton wisp. May also do sharp-dull discrimination in adolescents with broken tongue blade.
When to start testing DTRs
About age 5.
Reflexes most often tested in infants
Rooting, palmar grasp, tonic neck, Moro, Babinski.
How to test rooting reflex
Stroke cheek near mouth. Infant turns to that side and opens mouth. Present from birth to 3-4 months.
How to test palmar grasp reflex
Place your index finger in infant's hand from ulnar side. Infant grasps tightly with all fingers. Present at birth, strongest at 1-2 months, disappears at 3-4 months.
How to test tonic neck reflex
With infant supine, turn head to one side with chin over shoulder. Arm and leg on side head is turned to extend. Opposite arm and leg flex. Reflex appears at 2-3 months, decreases at 3-4 months, and disappears at 4-6 months.
How to test Moro (startle) reflex
Gently jar the crib, make loud noise, or support infant's head and back in semi-sitting position and then quickly lower to about 30 degrees. Infant abducts and extends arms and legs symmetrically, fans fingers, and curls index finger and thumb into C position. Then arms and legs come back in close to body. Present at birth and disappears at 1-4 months.
How to test Babinski (plantar) reflex
Trace upside-down J on sole of foot with reflex hammer handle starting at heel and moving up and across ball of foot. Normal is no response or slight curling of toes. Positive Babinski is fanning of toes and dorsiflexion of great toe.
Significance of positive Babinski
In infants up to 2 years, may be normal. In older children and adults, associated with upper motor neuron disease.
Reflexes to test in older children
Biceps: Indirect percussion of tendon in antecubital fossa. May feel response more than see it.
Brachioradialis: Patient rests forearm in lap with palm up. Strike above wrist medial to radius. Forearm flexes and arm suppinates.
Triceps: Support arm. Strike just proximal to point of elbow. Patient extends elbow.
Patellar.
Achilles: Support foot in dorsiflexion and strike just above heel. Foot should plantar flex.
Babinski.
3 developmental assessment tools
Ages & Stages Questionnaire (ASQ), Denver Developmental Screening Test II (Denver II), Parents' Evaluation of Development Status (PEDS).
THIS SET IS OFTEN IN FOLDERS WITH...