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Behavior/Mental Status - Establishing Relationship
This 2.5 year old
is apprehensive about being examined and isn't quite sure she wants
to be there. The finger puppets are used in attempt to establish rapport
and involve the child in play. The child's social interactions
and motor skills are observed during this time. The child is also examined
on the mother's lap.
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Behavior/Mental Status - Follows Commands
At this age verbal instructions
without demonstration are understood. The child can follow two-step commands.
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Behavior/Mental Status - Points to Pictures
The girl is first asked
to name the pictures but doesn’t cooperate enough to determine
if she knows their names. So the examiner switches strategy and asks
her to point to the picture he names. She is able to do this for all
five pictures. She asserts her autonomy by using her foot instead of
her finger. These pictures are from the Denver II.
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Behavior/Mental Status - Names Pictures
Later on in the exam she cooperates
enough to demonstrate that she is able to name all five pictures that
are shown to her, which is the next developmental level above pointing
to them. The next level after naming would be identification by the action
of the picture, such as asking which one flies. Pointing to 4 pictures
should be accomplished by 2.5 years, naming by 3 years and identification
by action by 4 years.
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Behavior/Mental Status - Response to Questions
The girl is shown a picture
in an attempt to get her to talk. She is shy and doesn’t talk much
but responds to questions with yes and no. She is putting two words together
in a simple sentence. A child’s earliest sentences usually contain
important content words and lack grammatical words. A 3 year old forms
a 3 to 4 word sentence and uses pronouns and plurals.
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Behavior/Mental Status - Pointing to and Naming Body Parts
The girl
is able to point to 8 out of 9 body parts. She can identify them on herself
as well as others. A 2.5 year old should be able to point to 6 out of
8 body parts.
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Fine Motor/Coordination - Using Puppets
Using finger puppets facilitates coordination testing. First the girl
is asked to place the puppets on her finger, which shows that she accurately
reaches a target without ataxia. The girl is then taught how to do
finger to nose by having her touch the puppet’s nose then her
nose.
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Fine Motor/Coordination - Using
Measuring Tape
A measuring tape can also be used to test coordination.
As the girl reaches for the tip of the tape to pull it out and has to extend
the arm to reach the target, she is being tested for dysmetria. Having
her manipulate the tape measure and work the control button is testing
hand coordination. The examiner tries to get her to click the button but
she doesn’t do it. This was an attempt to test repetitive
movements.
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Fine Motor/Coordination - Block Tower
The girl is able to build a 5
block tower and almost gets to 6 blocks. She’s not sitting in the
best position nor does she have the most stable platform to build a tower.
A 2.5 year old should be able to build a 6-8 block high tower. At 3 years,
the child is able to build a 3-block bridge. Assessing if a child is
developmentally age appropriate is not based on one particular test but
rather how they do on several different tests as well as their overall
performance.
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Fine Motor/Coordination - Drawing
The girl imitates drawing a horizontal
line as well as making circular shapes. At 3 years of age a child should
be able to draw a circle and at 4 years old can copy a cross.
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Motor - Tone
Upper and lower extremity tone is tested using passive
range of motion. The girl is apprehensive about this but using the finger
puppet as part of the exam helps.
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Motor/Reflexes - Deep Tendon Reflexes
This segment of the exam illustrates
the problems associated with obtaining deep tendon reflexes. The reflex
hammer is turned into a horse and initially she allows the examiner to
test the right upper extremity. Notice that after testing for the brachioradialis
reflex she becomes uncooperative. One of the ways to reduce apprehension
in the child is to place your thumb or index finger over the tendon to
be examined and tap on it rather than directly tapping on the child’s
tendon. It's less threatening.
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Motor - Kicking and Throwing a Ball
At this age, the child is able to
kick the ball and throws the ball overhand to the examiner. A ball is
a good tool to use during the neurological examination because the child
enjoys playing with it and it allows the examiner to see both fine and
gross motor skills that the child has developed.
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Motor/ Gait - Walking, Running
At this age, the gait is steady, well
coordinated and no longer wide-based. The arms are down to the side and
there are normal associated movements. The hands are no longer used when
getting up off the floor or sitting down on the floor. The child is able
to run.
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