Physical Exam Key Points

1. Level of consciousness. Assess using GCS.

2. Ocular and motor responses. Assess the following to help determine whether illness has a structural or medical cause. Asymmetry points to a structural lesion.

a. Pupillary size. Normal or asymmetric?

b. Pupillary reflex. Fixed or reactive?

c. Extraocular movements. Normal, asymmetric, or absent?

d. Motor response to pain. Decorticate, decerebrate, or flaccid?

3. Respiratory pattern. Identification of abnormal patterns can help differentiate structural from medical causes of altered mental status.

a. Cheyne-Stokes respiration. Implies dysfunction of structures deep in both cerebral hemispheres or diencephalon; usually seen in metabolic encephalopathy.

b. Central neurogenic hyperventilation. May occur with lesions of midbrain and pons.

c. Cluster breathing. May result from primary or secondary brainstem lesions.

d. Ataxic breathing. May result from primary disruption of medullary respiratory centers.

4. Toxidromes (see Table I-4).

5. Neurologic findings. Perform a thorough neurologic exam.

6. Smell of patient's breath. May reveal alcohol intoxication or diabetic ketoacidosis.

7. Signs of trauma. Boggy scalp swelling, Battle sign, raccoon eyes, retinal hemorrhages, hemotympanum, bruises, hematomas.

8. Abdomen. Tenderness and palpable sausage-shaped mass are consistent with intussusception.

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