What is the proper procedure for performing a neurologic examination on a 13-year-old female?

Neurological Examination for a 13-Year-Old Female

The neurological examination for a 13-year-old female should follow a systematic approach focusing on age-appropriate assessment of mental status, cranial nerves, motor function, sensory function, reflexes, coordination, and gait.

Mental Status Assessment

• Assess level of consciousness using the following scale 1:

  • 0—Alert
  • 1—Drowsy
  • 2—Obtunded
  • 3—Coma/unresponsive

• Orientation assessment 1:

  • Ask age and month (both must be correct for full score)
  • Assess ability to follow commands (e.g., open/close eyes, grip/release hand)

Cranial Nerve Examination

1. CN I (Olfactory): Test smell identification if clinically indicated

2. CN II (Optic) 1:

   • Visual acuity
   • Visual fields by confrontation
   • Check for afferent pupillary defect
   • Fundoscopic examination for papilledema or optic atrophy

3. CN III, IV, VI (Oculomotor, Trochlear, Abducens) 1:

   • Pupillary response to light
   • Eye movements in all directions
   • Check for ptosis, nystagmus
   • Assess for diplopia

4. CN V (Trigeminal) 1:

   • Facial sensation in all three divisions
   • Corneal reflex
   • Jaw strength

5. CN VII (Facial) 1:

   • Facial symmetry at rest and with expressions
   • Score as:
     • 0—Normal
     • 1—Minor facial weakness
     • 2—Partial facial weakness
     • 3—Complete unilateral palsy

6. CN VIII (Vestibulocochlear) 1:

   • Hearing assessment (finger rub)
   • Assess vestibular function if indicated

7. CN IX, X (Glossopharyngeal, Vagus) 1:

   • Gag reflex
   • Voice quality
   • Palatal elevation

8. CN XI (Spinal Accessory):

   • Shoulder shrug strength
   • Head turning against resistance

9. CN XII (Hypoglossal):

   • Tongue protrusion and movement
   • Check for atrophy or fasciculations

Motor Examination

1. Tone 1:

   • Assess for normal tone, hypotonia, or hypertonia
   • Evaluate passive range of motion of extremities

2. Strength 1:

   • Test major muscle groups bilaterally using the 0-5 scale
   • For arms: Test shoulder abduction, elbow flexion/extension, wrist flexion/extension, grip
   • For legs: Test hip flexion/extension, knee flexion/extension, ankle dorsiflexion/plantar flexion
   • Score motor function as:
     • 0—No drift
     • 1—Drift before 5 seconds
     • 2—Falls before 5-10 seconds
     • 3—No effort against gravity
     • 4—No movement

3. Bulk:

   • Observe for muscle atrophy or hypertrophy

Sensory Examination 1

1. Light touch: Test using cotton wisp on face, trunk, and extremities
2. Pain: Test using sharp object (carefully)
3. Temperature: If indicated
4. Vibration: Test using 128 Hz tuning fork on distal phalanges and medial malleoli
5. Proprioception: Test joint position sense at fingers and toes
6. Score sensory function as:
   • 0—Normal
   • 1—Mild sensory loss
   • 2—Severe sensory loss

Reflexes

1. Deep tendon reflexes:

   • Biceps (C5-C6)
   • Triceps (C7-C8)
   • Brachioradialis (C5-C6)
   • Patellar (L2-L4)
   • Achilles (S1-S2)
   • Grade using 0-4 scale (0=absent, 4=hyperactive with clonus)

2. Pathological reflexes:

   • Babinski sign (plantar response)
   • Hoffman sign if indicated

Coordination and Cerebellar Function 1

1. Fine motor coordination:

   • Finger-to-nose test
   • Rapid alternating movements

2. Gross motor coordination:

   • Heel-to-shin test
   • Score limb ataxia as:
     • 0—No ataxia
     • 1—Ataxia in 1 limb
     • 2—Ataxia in 2 limbs

Gait and Station 1

1. Observe normal walking
2. Tandem walking (heel-to-toe)
3. Romberg test (standing with feet together, eyes closed)
4. Assess for abnormal gait patterns (ataxic, spastic, etc.)

Special Considerations for Adolescents

• Establish rapport before beginning the examination
• Explain each step before performing it
• Consider developmental milestones appropriate for a 13-year-old 1
• Assess for any signs of motor delays that might indicate underlying neurological issues
• Note any asymmetry in examination findings, which may be particularly significant

Red Flags Requiring Further Investigation 1

• Focal neurological deficits
• Asymmetric findings
• Abnormal reflexes
• Coordination difficulties
• Gait abnormalities
• Visual field defects
• Cranial nerve abnormalities

This systematic approach ensures a comprehensive neurological examination that is appropriate for a 13-year-old female, focusing on key elements that would identify any neurological abnormalities while being developmentally appropriate.