A. Physical Exam Key Points. Complete general physical exam is important for identification of systemic disorders. Evaluate ABCs to avoid missing an emergency condition.

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

2. General appearance. Growth and development problems may reflect underlying medical or neurologic disorder.

3. Skin. Inspect for signs of trauma, rash, and birth marks (erythematous, 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. Respiratory dysfunction may be identified by auscultation.

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

7. Neurologic exam. Detailed exam allows clinician to localize condition to specific regions of central and peripheral nervous systems. Cerebral cortex disorders affect cognition; brainstem lesions affect specific cranial nerves. Spinal cord lesions demonstrate motor or sensory deficits, or both.

a. Mental status. Ability to interact with environment is assessed by speaking with and listening to patient. This must be carried out at an age-appropriate level.

b. Cranial nerves. Pupillary size and reactivity, in addition to eye movements, reflect function of portions 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 various neurologic disorders.

d. Sensory system. Localized sensory deficits may reflect dysfunction of central or peripheral nervous system, or they may be seen in functional disorders.

e. Deep tendon reflexes. Reflex arcs demonstrate integrity of specific reflex pathways from peripheral muscle through levels of spinal cord and are rarely affected.

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

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