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A. Physical Exam Key Points. A complete general physical exam is important in identifying a systemic disorder, beginning with ABCs.

1. Vital signs. Changes in heart rate and BP may reflect systemic infection, cardiac disease, intoxication, or an active seizure. Alteration of temperature may reflect an infection or effects from intoxication.

2. General appearance. Is patient appropriately developed and nourished? Growth and development problems may reflect an underlying medical or neurologic disorder. Is patient cooperative, interactive, or in distress?

3. Skin. Inspect for signs of trauma, rash, and birthmarks (ery-thematous, hypopigmented or hyperpigmented lesions). Rash may suggest infectious or vasculitic disorder. Neurocutaneous disorders (eg, neurofibromatosis, tuberous sclerosis, SturgeWeber syndrome, von Hippel-Lindau syndrome, and ataxia telangiectasia) may present with alteration of arousal.

4. Head and neck. Head circumference may reflect alteration in brain parenchyma (microcephaly or macrocephaly). Inspect for signs of head trauma. Neck stiffness (meningismus) may indicate meningitis or subarachnoid hemorrhage.

5. Heart and lungs. Cardiac murmur or altered cardiac dynamics may indicate cardiac dysfunction. Identify respiratory dysfunction by auscultation.

6. Abdomen. Hepatosplenomegaly may be seen in a variety of metabolic and neurodegenerative disorders.

7. Neurologic exam. Disorders of the cerebral cortex affect cognition, whereas lesions in the brainstem affect specific cranial nerves. Spinal cord lesions demonstrate motor or sensory levels, or both, on exam.

a. Mental status. Assess ability to interact with the environment by speaking with and listening to patient, evaluating at an age-appropriate level.

b. Cranial nerves. Pupil size and reactivity, in addition to eye movements, reflect function of upper brainstem. Symmetric movement of face, soft palate, and tongue demonstrates integrity of lower brainstem.

c. Motor system. Muscle bulk, tone, and strength demonstrate function of motor pathways. Fine motor skills may suggest developmental abilities. Involuntary movements may be seen in several neurologic disorders. Assess patient's gait.

d. Sensory system. Localized sensory deficits may reflect dysfunction of central or peripheral nervous system as well as functional disorders.

e. Deep tendon reflexes. Demonstrate integrity of specific reflex pathways from peripheral muscle through levels of the spinal cord; rarely affected by disorders that present as staring.

f. Cerebellar exam. Cerebellar dysfunction may be a sign of localized space-occupying, destructive, or degenerative disorders.

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