ex neurologic-neuro cris oct 2015
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neuro-ped obregiaTRANSCRIPT
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EXAMENUL NEUROLOGIC
COPILUL MARE
CLINICA DE NEUROLOGIE PEDIATRICA
SPITALUL CLINIC DE PSIHIATRIE “AL. OBREGIA”
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Credeti ca e simplu?
Si totul se schimba in timp!!
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SCOPUL ACESTEI PREZENTARI1. Trecerea in revista a testelor pentru
evaluarea sistemului nervos:- Rezultate normale;- Rezultate patologice – 4 sindroame principale
neurologice;- Date specifice copilului;
Cum se completeaza FO in neurologia pediatrica!
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Examenul neurologic
CEL MAI COMPLEX EXAMEN CLINIC;
Efectuat corect + date anamnestice Putem avea date despre localizarea & tipul leziunii!!
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Exemplu
Produce0
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Particularitati ale examenului neurologic la copil Maturitatea cerebrala:
Dezvoltarea psiho-motorie normala; Schimbarea semnelor clinice;
Comunicarea cu copilul! Momentul ales; Cooperarea cu medicul; Dezvoltarea psihica a copilului;
EXAMEN CLINIC NECONVENTIONAL!(multe jucarii, la parinti in brate etc)
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ETAPELE DIAGNOSTICULUI NEUROLOGIC
Anamneza → Copil cu tulburari neurologice↓
Examenul neurologic = dg semiologic (depistarea semnelor neurologice);
↓ Dg sindromologic (semn neurologic1 + 2 + 3 = sindrom)
↓ Dg topografic (nivelul leziunii)
↓EXAMENE PARACLINICE
Dg etiologic↓
TRATAMENT
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ANAMNEZA
1) MOTIVELE INTERNARII;
2) ANTECEDENTELE PERSONALE;
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ANAMNEZA (neurologie pediatrica) Motivele internarii - maxim 3;
Istoricul bolii: Ce s-a intamplat? Cum? Cand? Copilul stie? Cine l-a vazut? Ce s-a facut? Si multe altele…
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ANAMNEZA (neurologie pediatrica) Antecedentele:
HEREDO-COLATERALE: Mama, tata, sora / fratele? Exista boli neurologice / psihice / genetice in familie?
PERSONALE FIZIOLOGICE: Sarcina; Nastere: fiziologica / cezariana, GN, Apgar-?, maternitate, icter
fiziologic; Vaccinari - ? DPM
PERSONALE PATOLOGICE: ?
Conditii de viata si munca: Scoala / gradinita; Rezultate?;
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ETAPELE EXAMENULUI NEUROLOGIC Anamneza → copil cu acuze neurologice
↓ Examenul neurologic = dg semiologic (depistarea semnelor
neurologice);↓
Dg sindromologic (semn neurologic1 + 2 + 3 = sindrom)↓
Dg topografic (nivelul leziunii)↓
EXAMENE PARACLINICE Dg etiologic
↓
TRATAMENT
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EXAMENUL NEUROLOGIC LA COPILUL MARE
Inspectie:- Anomalii ale craniului;- Modificari cutanate;- Atitudini particulare;- Miscari involuntare;
+ EXAMENUL CLINIC GENERAL!+ consulturi interdisciplinare…
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EXAMENUL NEUROLOGICcopilul > 4 ani;1. Examenul sindromului meningian;2. Examenul nervilor cranieni;3. Examenul motilitatii;4. Examenul sensiblitatii;5. Examenul reflectivitatii;6. Examenul psihic (vs < 6 ani);
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Examenul sindromului meningianAnsamblu de simptome obiective & subiective care
apar secundar afectarii invelisurilor cerebrale; OBIECTIVE (redoare de ceafa)
SUBIECTIVE: Cefalee + foto/fonofobie+greata+/- varasaturi
COPII MARI ~ ADULTI!
COPII MICI (< 3 ani = FA + suturi deschise)- semne de HIC la copilul mic ( PC + alterarea starii generale)
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SEMNE DE IRITATIE MENINGEALA
Redoarea cefei
KERNIG I
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2. Examinarea nervilor cranieni
12 nervi periferici care inerveaza structurile extremitatii cefalice si gatului;
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2. EXAMENUL NV CRANIENII. OLFACTIV:
• B inhaleaza cu fiecare nara diferite mirosuri;• Modificari cantitative / calitative;
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2. EXAMENUL NV CRANIENIII. OPTIC:
• Acuitatea vizuala: de la 5 m;• Camp vizual;• FO – oftalmoscop;
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2. EXAMENUL NV CRANIENIIII. NV OCULOMOTOR COMUNIV. NV TROCHEARVI. NV ABDUCENS- oculomotricitate;
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Paralizie nv abducens stg;
(VI)
Paralizie nv oculomotor
comun dr (III);
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Particularitati la copil
Strabismul: Congenital: - diplopie;
Dobandit: + diplopie;
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2. EXAMENUL NV CRANIENIV. NV. TRIGEMEN;- Senzitiv - Sensibilitatea la nivelul fetei;- Motor - mm.masticatori;- R. cornean;
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2. EXAMENUL NV CRANIENIVII. NV. FACIAL:
- Motor - mm. faciala;
- R. nazopalpebral;- Examenul gustului (2/3 ant – dulce, acru,
sarat);
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VII
Produce2
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2. EXAMENUL NV CRANIENIVIII. NV. ACUSTICOVESTIBULAR;- P. acustica: acuitatea auditiva;
- P. vestibulara:- Pb. Romberg;- Pb. bratelor intinse
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2. EXAMENUL NV CRANIENIIX. NV . GLOSOFARINGIAN + X. NV. VAG:- Inervatia palatului, faringe, laringe;- Tulb de deglutitie pt solide (IX) si lichide (X);- RFG + velopalatin;
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2. EXAMENUL NV CRANIENIXI. NV. SPINAL / ACCESOR:- Mm. SCM & trapez;
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2. EXAMENUL NV CRANIENIXII. NV. HIPOGLOS:- Mm. limbii;
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Produce1
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3. EX MOTILITATII
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3. EX. MOTILITATIIa. Motilitatea activa, voluntara - apreciază viteza şi
amplitudinea mişcărilor.Copilul va executa toate mişcările posibile din toate segmentele articulare: flexie/extensie,pronaţie/supinaţie, abducţie/adducţie
• MAS & FMS mb superioare / inferioare;• Bilateral / simetric;
• Pb pareza:• Mb superioare – supinatie fortata;• Mb inferioare – Mingazzini;
• Pb de coordonare – cerebeloase;• Indice-nas / calcai-genunchi;
b. Motilitatea pasiva – tonusul muscularc. Tonusul muscular este starea de contracţie bazală a muşchiului
aflat în repaus.d. Motilitatea involuntara?;
• Tremor, atetoza, coree, balism, ticuri etc..
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4. EX SENSIBILITATII
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4. EX. SENSIBILITATII
A. S. superficiala – tactila, termica, dureroasa;
B. S. profunda• probe la inchiderea ochilor (Romberg);• MAK;
C. S. obiectiva inalta – lob parietal;• Ex – dermolexie;
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5. EX. REFLECTIVITATII
A. R. OSTEOTENDINOASE;• R. rotulian (L2-L4);• R. achilian (L5-S2);• R. bicipital (C5-C6);• R. tricipital (C7-C8);
B. R. OSTEO-PERIOSTALE;• R. stilo-radial (C5-C6);• R. cubitopronator (C6-T1);
C. R. CUTANATE;• Abdominale (superior T6-T7; mijlociu T8-T9; inferior T10-
T12);;• R. cutanat plantar (Babinski);
D. R. POSTURA;• R. postura a gambierului anterior (afectarea paleostriatului);
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Principalele sindroame neurologice(afectarea motilitatii)1. Sdr neuron motor periferic;2. Sdr neuron motor central (piramidal);3. Sdr extrapiramidal;4. Sdr cerebelos;
SI MULTE ALTELE!!
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1. Sdr neuron motor periferic
1. Tulb. de motilitate;- Activa – deficite motorii;- Pasiva – hipotonie musculara;
2. Tulb de reflectivitate;- ROT abolite;
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Produce3 Produce4 Produce5
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2. Sdr neuron motor central (piramidal);1. Tulb de motilitate;
• Activa – deficite motorii;• Pasiva – hipertonie;
2. Tulb de reflectivitate;• ROT – vii;• RCP- Babinski;• Clonus plantar;
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Particularitati ale sdr piramidal la copil Leziuni congenitale:
Fara pareza faciala centrala; Fara abolirea RCA de partea afectata; Hipotrofie mb afectate;
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Produce6
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Produce7
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3. Sdr extrapiramidal
“Bloc” format din 3 etaje util pentru initierea si modularea miscarilor voluntare + tonus musc;
1. Cortical scoarta frontala-
prefrontala>temporala>parietala>occipitala;2. Subcortical:
Nc lenticular (pallidum & putamen); Nc caudat;
3. Diencefalo-mezencefalic: Corpul Luys (diencefal); Nc rosu (mezencefal); Subst neagra Soemmering (mezencefal);
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3. Sdr extrapiramidal
1) Afectarea miscarilor:o Hipo / hiperkinezia;
2) Afectarea tonusului muscular:o Distonia;
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Produce8
Film2
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4. Sdr cerebelos
Centru de coordonare care: Mentine echilibru; Controleaza tonusul muscular;
INCONSTIENT!
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4. Sdr cerebelos
1. Tulb de motilitate:• Tulb de coordonare – ataxia / dismetria;• Tulb de motilitate pasiva – hipotonia;
2. Tulb de reflectivitate:• ROT vii;
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Produce
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SCLEROZA TUBEROASA
Pete acrome de la nastere; Spasme infantile → Crize epileptice focale rezistente la
tratament hemipareza dreapta; Intarziere mentala medie; AHC (+) mama cu pete acrome;
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EXAMENUL NEUROLOGIC
1. Sdr meningian.2. Nv. cranieni3. Ex motilitatii
4. Ex sensibilitatii5. Ex reflectivitatii