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A. Physical Exam Key Points. Complete general physical exam is important in identifying a systemic disorder. Assess ABCs to avoid missing an emergency condition.

1. Vital signs. Heart rate and BP changes may reflect systemic infection, cardiac disease, or intoxication, or even suggest increased intracranial pressure. Alteration of temperature may reflect infection or effects of intoxication.

2. Skin. Inspect for signs of trauma, rash, and birthmarks (erythe-matous, hypopigmented, or hyperpigmented lesions). Rash may suggest infectious or vasculitic disorder. Look for signs of a neurocutaneous disorder such as neurofibromatosis (café au lait spots and family history), tuberous sclerosis (hypopigment-ed macules on trunk or limbs, café au lait spots, and seizures, in addition to cysts or tumors of kidney, cardiac rhabdomyomas, and retinal tumors), hypomelanosis of Ito (large hypopigmented lesion), or linear nevus sebaceous syndrome (unilateral linear nevus on face or scalp with ipsilateral hemihypertrophy).

3. Head and neck. Head circumference may reflect alterations in brain parenchyma (microcephaly and macrocephaly), hydrocephalus, or even skull thickening. Inspect for signs of head trauma. Neck stiffness (meningismus) may indicate meningitis or subarachnoid hemorrhage.

4. Heart and lungs. Listen for cardiac murmur or altered cardiac dynamics. Respiratory dysfunction or abnormal breathing patterns may be a sign of neurologic disease.

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

6. Neurologic exam. Detailed neurologic exam allows clinician to localize the condition to specific regions of central and peripheral nervous systems. Disorders of the cerebral cortex affect cognition, whereas lesions in the brainstem affect specific cranial nerves. Spinal cord lesions demonstrate motor or sensory levels on examination, or both.

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

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

c. Motor system. Muscle bulk, tone, and strength demonstrate function of the motor pathways. Fine motor skills may suggest developmental abilities. Assess patient's spontaneous, voluntary, and involuntary movement. Involuntary movements may be seen in a variety of 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. These reflex arcs demonstrate integrity of specific reflex pathways from the peripheral muscle through the levels of the spinal cord.

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

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