During the child's clinic visit, the physician inquires about the child's detailed history of the symptoms; other problems the child may have; which medications the child is taking; and whether there are other family members with the same or related problems.
The basic list of questions that every doctor seeks to answer is as follows...
Current complaint (CC): What is the major problem(s) affecting the child?
History of present illness (HPI): What are the symptoms? When did they start? How have they progressed, what makes them better or worse?
Past medical history (PMH): Does the child have any other medical problems? Have there been medical problems in the past? Which medications does the child take, and are there any known medication allergies?
Has the child been developing normally with good early developmental milestones and age-appropriate school performance?
Family history (FH): Are there any other family members with similar symptoms, other neurological disorders, or other major medical disorders? Is there any particular trait that "runs in the family"? In some cases, the doctor will need to construct a complete family tree, indicating family members with any disorders.
Social history (SH): Where does the child live? Who is the primary caretaker? What school does the child attend?
Review of Systems (ROS): Are there any other ongoing problems? Is there any difficulty with feeding or growth? Has there been any decline in cognitive, memory, or language function?
If there are any relevant prior medical records, x-rays, laboratory tests, or other pertinent information, these will be reviewed. If the doctor does not have easy access to this information, copies of all the medical reports as well as copies of the actual EEG, MRI, CT scan, or other information should be given to the physician so that these records may be reviewed, if needed.
Following this thorough history, the evaluating physician performs a general physical examination. This examination may include examining the back of the eyes, listening to the heart, feeling the liver, looking for birthmarks on the skin, and examining the limbs. In addition, a neurological examination, which involves testing the major functions of the brain, spinal cord, nerves, and muscles, is performed. The details of the examination differ depending on the child's age and particular symptoms. Not all tests are possible for all children. The most important aspect is to challenge the child to determine how much they can do and whether there are any limitations relative to other children of the same age.
Mental status examination:
Is the child awake, alert, and responsive?
Does the child behave in an appropriate manner?
Are speech, language, reading, and writing skills appropriate for the child's age?
Are spatial recognition and reasoning skills intact?
Is judgment intact?
Is memory for objects and numbers appropriate for the child's age?
Often a child's behavior in the doctor's office is very different from behavior at home or at school, so interpretation must be guided by the history as well.
Cranial nerve function:
Are eye, facial, mouth, and tongue movements intact?
Is sensation on the face normal?
Are hearing and balance functions intact?
Are smell and taste normal?
Sensation:
Is the child able to feel light touch, temperature, pinprick, and the position of joints throughout the body?
Is the sensation the same on both sides of the body and the same in the face, arms, and legs?
Motor function:
Is strength normal in all parts of the body?
Can the child easily stand up from the floor?
Are there any areas of unusually reduced muscle bulk?
When relaxed, can the examiner move the limbs and neck easily?
Is there a change with the speed of movement or a "spastic catch"?
Is there a change when a distant part of the body is moved or when the child is lying down, seated, or standing?
Are there any abnormal postures of the limbs, trunk, or face?
Are there excess involuntary movements such as chorea, choreoathetosis, myoclonus, tremor, or tics?
Coordination:
Can the child reach accurately to touch an object far from their body?
Are movements appropriately rapid?
Can the child manipulate objects with two hands and pick up small objects between the fingers?
Can the child perform rapidly alternating movements such as opening and closing the hands or fingers?
Reflexes:
When a rubber hammer is used to tap the tendons, is there normal movement at the knees, ankles, and elbows?
Do the toes go upwards or downwards when the bottom of the foot is stroked with a metal object?
Are there any persistent neonatal-type reflexes including the asymmetric tonic neck reflex (arm straight or bent when the childŐs head is turned) and Moro reflex (arm extension when startled)?
Gait:
How does the child support his or her weight against gravity?
How does the child respond to a loss of balance?
Can the child stand and walk stably (depending on the child's age)?
Is it possible to walk on the toes or heels, to walk on a narrow line, or to walk backwards?
Is the child unsteady while standing with eyes closed?
Is there any unusual posturing of the arms, legs, or face while walking or running?
