Gathering neurologic history follows the traditional medical model with two additions: the pace of the process and the localization of the problem. The symptom evolution provides clues to the underlying process as symptoms may evolve in a progressive, static, or episodic fashion. Progressive symptoms may evolve suddenly (seizures, stroke); acutely over minutes or hours (epidural hemorrhage); subacutely over days or weeks (brain tumor); or slowly over years (hereditary neuropathies). Static neurologic abnormalities are observed early in life and do not change in character over time (cerebral palsy). Static lesions are often caused by congenital brain abnormalities or prenatal/perinatal brain injury. Intermittent attacks of recurrent, stereotyped episodes suggest epilepsy or migraine syndromes, among others. Episodic disorders are characterized by periods of symptoms, followed by partial or complete recovery (demyelinating, autoimmune, vascular diseases).
Observation of the child’s appearance, movement, and behavior begins at the start of the encounter. For example, the child may display an unusual posture, abnormal gait, or lack of awareness of the environment.
Because the brain and skin have the same embryonic origin (ectoderm), abnormalities of hair, skin, teeth, and nails areassociated with congenital brain disorders (neurocutaneousdisorders) such as neurofibromatosis (NF type 1) in which café au lait macules (flat, light brown macules) are characteristic.
Adenoma sebaceum, fibrovascular lesions that look like acne on the nose and malar regions, nail fibromas, ash-leaf spots(hypopigmented macules), and Shagreen patches (flesh-coloredsoft plaques with prominent follicular openings) are commonlyseen in older children and adults with tuberous sclerosis.
The head circumference is measured in its largest occipitofrontal circumference and plotted against standard growth curves (Chapter 5). Microcephaly and macrocephaly represent an occipitofrontal circumference 2 standard deviations (SDs) below or above the mean, respectively. Measurements plotted over time may show an accelerating pattern (hydrocephalus) or decelerating pattern (brain injury, degenerative neurologic disorder). The anterior fontanelle is slightly depressed and pulsatile when a calm infant is placed upright. A tense or bulging fontanelle may indicate increased intracranial pressure (ICP) but may also be seen in a crying or febrile infant. Premature closure of one or more sutures (craniosynostosis) results in an unusual shape of the head. Abnormal shape, location, and condition of the face, eyes, nares, philtrum, lips, or ears are found in many genetic syndromes.
A careful ocular examination is essential and should include a search for epicanthal folds, coloboma, conjunctival telangiectasias, and cataracts. Direct ophthalmoscopy assesses the optic disks and macula for abnormalities such as papilledema or a cherry-red spot. A complete examination of the retina involves dilating the pupil and use of indirect ophthalmoscopy, typically requiring ophthalmologic consultation.
Examination of the hands and feet may reveal abnormal creases or digits (Chapters 50, 201). The neck and spine should be examined for obvious (myelomeningocele) or subtle (cutaneous dimples, sinus tracts, hair tufts, subcutaneous lipomas) midline defects. Nervous system abnormalities may result in kyphosis or scoliosis (Chapter 202).
Because of the developmental immaturity of infants, the neonatal neurologic examination primarily assesses the function of the basal ganglia, brainstem, and more caudal structures. The plasticity of the developing nervous system means that examination results should be used cautiously in predicting developmental outcomes.
A healthy newborn infant should have periods of quiet, sustained wakefulness interspersed with active and quiet sleep.