A TEMPLATE FOR DESCRIBING THE “ILL-APPEARING” INFANT

Templates do not just facilitate documentation but also can guide bedside observations. The person taking a history who uses OLD-CARTS might be reminded to ask a dimension of a symptom that otherwise would not have been elicited.

 

What does it mean to say a child is “well-appearing” or “ill-appearing?” I find the GCS (Glasgow Coma Scale) categories to be helpful:

 

Eyes – is the child attentive with the eyes

Motor – is the child appropriately active/reactive

Verbal – is the level of social interaction appropriate for age (eg comforted by the arms of the mother).

 

Using GCS can stimulate a more detailed description of what we mean when we describe an ill-appearing child.

 

TAKE HOME POINTS

-Use the categories of GCS to detail what it means for a child to be “ill-appearing.”

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LUMBAR SPINE NEUROLOGICAL EXAMINATION TEMPLATE

The neurological examination is relative to the pathology you are investigating. This should not be used in a cut and paste fashion but rather for reference.

 

MOTOR

Hip flexion “pull your knee to your chest” (L2/3) 5/5

Hip adduction “pull your knees into each other” (L2/3) 5/5

Hip abduction “pull your knees apart” (L4/5/S1) 5/5

Hip extension “pull your thigh back” (L4/5) 5/5

Knee extension “hold your knee straight” (L3/4) 5/5

Knee flexion “pull your heel to your bottom” (L5/S1) 5/5

Ankle dorsiflexion “pull your foot up” (L4/5) 5/5

Ankle plantarflexion “step on the gas” (S1/S2) 5/5

Great toe dorsiflexion “pull your big toe up” (L5) 5/5

Great toe plantarflexion “squeeze your big tow down” (S1,S2) 5/5

Anal tone – (S2/3/4) 5/5

 

SENSORY

Light touch (pinprick vs ice vs proprioception vs vibration if evidence of pathology found)

L1 – inguinal ligament

L2 – medial thigh

L3 – distal thigh

L4 – medial leg and dorsal foot

L5 – 1st web space, lateral foot

S1 – plantar foot

S2 – popliteal fossa, posterior thigh

S3/4/5 – perianal area

 

REFLEXES

 

Patellar – L3/4

Medial hamstring reflex L5

Ankle – S1

PENETRATING NECK TRAUMA REQUIRES DETAILED EXAMINATION

A patient presents with a stab wound to the neck. You examine the wound and see a 1 cm laceration. The patient reports no other symptoms. How can we best identify injuries?

 

Through the neck run longitudinal blood vessels, nerves, as well as organs of the respiratory and gastrointestinal systems. The mechanism is important – what is the direction of the wound tract?

 

Below is a template of a thorough examination of penetrating neck trauma, with more detail on pertinent items. This is based on the 1997 article by Demetriades et al.

 

Airway: No subcutaneous emphysema, hoarseness, or stridor, no bubbling from wound

Esophagus: No odynophagia, no pharyngeal blood, no hematemesis

Vascular: Normal pulses, no bruit, no hematoma, no active bleeding

Neurologic:

Motor/Sensory/Reflexes normal

Cranial nerves:

II – pupils equally reactive (no Horner’s syndrome)

III, IV, VI – EOMI

V – normal facial sensation

VII – symmetrical facial movements

IX – normal soft palate

X – no hoarseness/dysphonia, normal cough

XI – symmetrical shoulder lift

XII – tongue midline

Brachial plexus:

normal radial, ulnar, median function of hand

musculocutaneous – normal forearm flexion

axillary  – normal arm abduction

 

Summary:

In penetrating neck trauma, evaluate the airway and esophagus, in addition to the vascular and neurologic functions.

COMA NEUROLOGIC EXAM TEMPLATE

An example of a comprehensive coma exam in a patient with psychogenic coma:

 

General:

-description – lying supine, well-dressed

-breathing pattern – normal

-breath odor – normal

Head atraumatic normocephalic

Eyes:

-eyes midline and conjugate without deviation

-pupils 2mm, equally reactive

-eyes squint to bright light

-fundoscopy – unable to perform due to eye movement

-purposeful movements detected

Oropharynx – mucus membranes moist

Neck – no meningismus

Chest cta bilat

Heart rrr no mrg

Abd soft, nt, no om

Extremities – warm, no atrophy

Neurologic examination:

Mental status:

-level of consciousness – unreactive

-no receptive or expressive language

Motor:

-muscle tone normal, not atonic, not increased

-not following motor commands

Sensory:

-withdraws to pain in all 4 extremities

Reflexes:

-DTRs symmetrical

-Babinski down bilaterally

Cranial nerves:

II – visual threat – blinks. Eye squints to bright light.

III, IV, VI – does not track.  Oculocephalic reflexes reveal intact motor movements.

V – corneal reflex intact, nares tickling provokes grimace

VII – supraorbital nerve compression yields symmetrical facial grimace

VIII – voice stimulation in ear provokes flinch

IX/X – gag reflex intact

XI/XII – not possible to reliably examine

GCS:

Motor: purposeful movement to pain

Verbal – no response

Eyes – closed

Coma tests:

Cold calorics reveal nystagmus with fast phase away from the ice

EYE TEMPLATE

Acuity:

Extraocular movements: intact and painless

Visual fields: intact

Lids/Lacrim: nl, no edema

Conjunctivae/sclera: nl, no injection

Cornea: clear, no ulcers, no uptake of fluorescein

Anterior chamber: clear

Pupils: equally round, reactive to light, no direct or consensual photophobia. No afferent pupillary defect

Fundoscopy: intact red reflex, sharp disc

Intraocular pressure:

NEONATAL NEUROLOGIC EXAMINATION

Here is an outline of the neonatal neurologic examination followed by a listing of some reflexes that might be of value in demonstrating intact neurologic function.

 

GENERAL OBSERVATION/BEHAVIOR

 

CRANIAL NERVES

CN II – responds to light

CN III/IV/VI – vestibulo-ocular reflexes intact to cardinal directions of gaze

CN V – rooting reflex intact

CN VII – facial symmetry during crying

CN VIII – responds to sound

CN IX/X/XII – normal sucking

CN XI – sternocleidomastoid movement noted

 

MOTOR

Tone normal in all 4 extremities, no hypotonia, no hypertonia. Spontaneously moves all extremities.

 

REFLEXES

Symmetrical reflexes knee, ankle, biceps, triceps

 

SENSATION

Responds to touch in all 4 limbs

 

 

—-

PRIMITIVE REFLEXES

Primitive reflexes can be used to evaluate motor function in the neonate.  These are listed below:

 

Fetal position – After 36 weeks the fetus assumes a flexed position.  If the neonate is moved to extension, it will pull back to flexion. This lessons with time and is most present the first 48 hours after birth

 

Pull to sitting -the child will spontaneously open the eyes when pulled to a sitting position (fpnotebook.com)

 

Walking reflex – stand the baby up and he or she will exhibit a walking reflex

 

Rooting reflex – scratch the cheek and the baby will root for a nipple

 

Suckling reflex – front of tongue latches on finger/nipple, back of tingue massages it, pharynx/esophagus pulls on the finger.

 

Fencing reflex – turn head to the side, that arm extends and the opposite arm flexes above the head

 

Moro startle reflex – an abrupt drop causes the arms to outstretch and flex forward.

 

Swimmer’s (Gallant)- hold baby prone, stroke spine on one side, that side will flex

 

Crawling reflex – place baby prone, will try to crawl briefly.

 

Rotation test – hold baby up, rotate to one side, baby will turn head to that side

HAND MUSCLE AND TENDON CHART

Movement Muscle Nerve Nerve root Remarks
Thumb flexion IP FPL (flexor pollicis longus) Median (AIN branch) C8, T1
Finger flexion DIP 2/3 FDP (flexor digitorum profundus) Median (AIN branch) C8 In forearm the FDP is superficial to the FDS
Finger flexion DIP 3/4/5 FDP (flexor digitorum profundus) Ulnar C8 Digits 3,4,5 FDP are banded together.  Flexion of one flexes all. Hold the rest of the digit in extension during the exam
PIP flexion FDS (flexor digitorum superficialis) Median C7 Because FDP of digits 3-5 are linked, can examine one FDS by holding the other digits in extension.
Finger abduction Dorsal interossei Ulnar T1
Finger adduction Palmar interossei Ulnar T1
Thumb adduction ADP (Adductor Pollicis) Ulnar C8 Froment’s sign (pt holds paper tight between thumb and index, absent ADP, the distal thumb will flex)
Thumb palmar abduction APB (Abductor pollicis brevis) Median C8/T1 Also serves opposition.  Affected by carpal tunnel syndrome
Thumb radial abduction APL (Abductor pollicis longus) Radial (Posterior IO) C6C7 Unites with extensor pollicis brevis to form radial side of snuffbox
MCP extension digit 1 (thumb) EPL (extensor pollicis longus) Radial nerve (posterior interosseus branch) C7 On ulnar side of snuff box. Place hand on table, have patient lift thumb up
MCP extension digit 2 EI (extensor indicis proprius) Radial (deep radial) C7
MCP extension digits 2-5 EDC (extensor digitorum communis) Radial (deep radial) C7
MCP extension digit 5 EDM (extensor digiti minimi) Radial (posterior IO branch of deep radial) C7

HAND EXAMINATION TEMPLATE: FUNCTIONAL ANATOMY

 

VASCULAR

 

Palpation – “extremity warm”

 

Color – “healthy pink”

 

Pulses – radial pulse normal

 

Capillary refill < 2 seconds

 

 

 

NEUROLOGIC – MOTOR (AND MUSCULOTENDINOUS)

 

THUMB

 

FPL distal thumb flexion 5/5

 

ADP thumb apposition 5/5

 

APB palmar abduction 5/5

 

APL radial abduction 5/5

 

EPL thumb dorsal extension 5/5

 

 

 

FLEXORS

 

FDP distal phalanx flexion 5/5

 

FDS proximal phalanx flexion 5/5 (with DIP and other digits in extension)

 

 

 

EXTENSORS

 

EIP extension of forefinger proximal phalanx 5/5

 

EDC extension proximal phalanx 5/5

 

EDM extension 5th digit proximal phalanx 5/5

 

 

 

OTHER MUSCLES

 

IO finger adduction/abduction 5/5

 

 

 

WRIST

 

FCU wrist ulnar deviation 5/5

 

FCR wrist radial deviation 5/5

 

PL intact to palpation

 

ECRB wrist extension 5/5

 

ECU ulnar deviation/extension 5/5

 

 

 

NEUROLOGIC – SENSORY

 

ulnar – volar tip 5th digit nl

 

median – volar tip 2nd digit nl

 

radial – dorsal 1st webspace nl


TEMPLATE: NEUROLOGICAL MENTAL STATUS EXAMINATION

 

FUNCTIONAL ANATOMY TEMPLATE: NEUROLOGICAL MENTAL STATUS EXAMINATION

 

Having a structured, systematic approach to the neurological mental status examination can greatly improve our diagnostic acumen.  Because this examination is long and complex, it helps to have a template. Unlike the mini-mental status examination, this template is organized by functional anatomy.

 

 

  1. GLOBAL BRAIN FUNCTION
    1. Arousal – alert (lethargy = drifts off, obtunded = difficult to arouse, stupor = requires constant vigorous stimulation, coma = unarousable.  If you can’t remember this, just document what stimulation is necessary for arousal)
    2. Attention – counts the months backward, spells globe backward (a problem with attention means delirium, assuming no dementia)
    3. Orientation – year, month, date, situation
  2. LOCAL BRAIN FUNCTION
    1. Frontal – no kinetic apraxia (test rock, paper, scissor), no disinhibition (naming Fs)
    2. Temporal
      1. Memory – 5 minute recall (note whether memory jogging required)
      2. Language – Naming items nl, receptive and expressive language nl (can test visual comprehension with reading aloud).  Test writing if you are unclear on aphasia vrs dysarthria.
    3. Parietal
      1. Constructional praxis – nl copy of cube, nl clock drawing
      2. Right inferior parietal lobe (+/- left): Double simultaneous stimulation – can check visual, tactile
      3. Left parietal: math (subtracting 7 from 100 serially)

 

 

References: Strub and Black’s The Mental Status Examination in Neurology

TEMPLATE: THE PSYCHIATRY EXAM

Here is a template that helps one document encounters with psychiatric overtones.  I included pertinent negatives that help prompt one to use the right terms.  These can be deleted during actual encounters.  Although I hear many express less enthusiasm for psychiatric emergencies, I believe that being able to systematically assess a patient’s psychiatric state goes a long way toward understanding the difficult patient encounter.

 

Arousal: Alert

Attentiveness: fully attentive

Appearance: well-dressed and well-groomed

Attitude: cooperative, not guarded

Activity: calm, not restless, no abnormal movements, good eye contact

Orientation: Fully oriented

Mood: euthymic, not dysphoric, euphoric, apathetic, anxious or angry

Affect: normal range, not restricted, flat, or labile

Verbal: nl expressive and receptive language function

Thought process: organized, goal-directed. Pt did not require redirection.

Thought content: no delusions, no suicidal/homicidal ideation

Perceptions: not responding to internal stimuli

Insight/Judgment: good insight, judgment appears to be good

 

 

References for this include Trzepacz’ excellent textbook, The Psychiatric Mental Status Examination.