A neurological exam attempts to answer the following questions:1.Are the findings symmetrical or unilateral?2.If unilateral, where do they originate?

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Five areas of nervous system exam:Mental status and

speechCranial nervesMotor systemSensory systemReflexes

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Appearance and behavior

Speech and language

Mood

Memory and attention

Thoughts and perceptions

Insight and judgment

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Mental Status and Speech

The Cranial NervesOriginate from the

base of the brain and provide sensory and motor innervation

Conduct parts of the cranial nerve exam when you assess other areas such as the eyes, ears, throat, and musculoskeletal system

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Assessing Cranial NervesTest the olfactory nerve by having your

patient identify common odors.Test the oculomotor, trochlear, and

abducens nerves by evaluating your patient's extraocular movements.

Test motor function of the trigeminal nerve by palpating the temporal and masseter muscles.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Assessing Cranial Nerves (cont.)Test sensory function of the trigeminal nerve

with sharp and dull objects.Test the glossopharyngeal and vagus nerves

with a tongue blade.Test the spinal accessory nerve by having

your patient shrug her shoulders against resistance.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Thirty-one pairs of nerves arise from the spinal foramina. Efferent or motor

tracts arise from the anterior root of the peripheral nerve.

If system is damaged:Function is lost below

the level of the injury Movements become

weak or paralyzed Bledsoe et al., Paramedic Care: Principles & Practice,

Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle

River, NJ

Assessing the motor system Inspect your patient’s general body

structure, muscle development, positioning, and coordination. Observe the size and contour of his muscles.

Assess muscle tone.Assess muscle strength.

Grip strength

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Assessing the motor system (cont.)Assess your patient’s

position sense and coordination. Gait Perform the Romberg

test Pronator drift To assess your patient’s

coordination, test for rapid alternating movements.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

The posterior root of the peripheral nerves carries the sensory, or afferent, nerve fibers to the spinal cord and brain.

A dermatome chart is a road map depicting bands of skin innervated by sensory nerve fibers.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

To assess the sensory system, test for pain, light touch, temperature, position, vibration, and discriminative sensations.

Ask your patient to close his eyes for each of these tests.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Assess pain. Dull or sharp?

Test for temperature sensation. Warm or cold?

Test for position sense. Up or down?

Test vibration sense. Tuning fork

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

The reflex arc connects some sensory impulses directly to motor neurons.Triggers immediate

responses Test your patient’s

superficial and deep tendon reflexes.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Biceps Triceps Brachioradialis Quadriceps

Achilles reflex Plantar reflex Abdominal

reflexes

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Physical Examinationof Infants and Children

Specific techniques same as adult Inspection, palpation, percussion, and

auscultationYou must be familiar with the anatomical

differences between children and adults. You must understand the physical and

psychological developmental stages of the different age groups.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Building patient and family rapportRemain calm and confident. Be direct and honest about what you are

doing. Do not separate the child from his/her

parents. Provide continuous reassurance and

feedback.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

General appearance and behaviorAsk the parents if his/her behavior seems

normal. Two questions:

Does your patient look and act like a normal child in the same age group?

Do actions appear normal to you and to his parents?

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Infants (newborn to 1 year)The arms and legs will

flex slightly and move equally.

Recognize their parents’ faces and voices

Frightened by loud noises and bright lights

Four to six months, they begin to sit up

Very distressed by separation from their parents

Toe-to-head examBledsoe et al., Paramedic Care: Principles & Practice,

Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle

River, NJ

Toddler (1–3 years)Able to walk by

their 18th monthTrust no one but

their parentsMost difficult age

group to examine Assess vital areas

first.Like to be distracted

with toysBledsoe et al., Paramedic Care: Principles & Practice,

Volume 2: Patient Assessment, 3rd Ed.© 2009 by Pearson Education, Inc. Upper Saddle

River, NJ

Pre-schooler (3–6 years)Distrusting of strangers

Speak with them to gain trust

Have a great fear of being hurt and of the sight of their own blood

Often feel guilty about their problem

Approach slowly and reassure

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

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School Age (6–12 years)Will cooperate with

you if you gain their trust

Want to participate Still fear

separation, pain, and punishment

Modesty becomes more important

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Adolescent (13–18 years)Can be treated

much the same as adults

Modesty is extremely important. Have person of the

same sex conduct exam, if possible.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

© Index Stock Imagery, Inc.

General AppearanceNote whether your patient looks toxic or

sick. A toxic child appears not to recognize or

respond to his parents. These children usually require rapid

transport. Provide aggressive support of vital functions.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

The Head and Neck The fontanelles Smaller airway

Greater risk of obstruction

Observe facial expression for signs of pain or discomfort.

Check for neck stiffness.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

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Chest and LungsObserve both the chest

and abdomen for movement. A child in severe

respiratory distress may exhibit a “see-saw” pattern.

Assess the rate, quality, and depth of respirations.

Auscultate for breath sounds with the bell of your stethoscope at the midaxillary line.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

CardiovascularHeart rate generally decreases with age.Measure pulse rate by listening to the heart.

Tachycardia or bradycardia can be a response to hypoxia

Blood pressure generally will rise as they grow older.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Normal Vital Signs for Various Pediatric Age Groups

AbdomenLiver and spleen

are proportionally larger and more vascular than an adult’s.

Inspect the abdomen for movement.

Palpate lightly first, then deeply.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

MusculoskeletalEvaluate pulses,

sensation, movement, and warmth in all four extremities.

Check for capillary refill. Accurately reflects

perfusion status Palpate the upper and

lower extremities.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Nervous SystemAssess the child’s general behavior, level of

consciousness, and orientation.Test specific functions such as language and

recall. Much of the nervous system exam is

conducted during other aspects of the physical exam.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Record the findings on your patient’s chart or permanent medical record.

The patient record is only as good as the accuracy, depth, and detail you provide.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

The patient’s chart is a legal document.Present the data legibly, accurately, and

truthfully. Follow a standard format when charting

patient information. The SOAP format

Universally accepted organization for patient charts.

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Physical Examination Approach and Overview

Overview of a Comprehensive Examination

Anatomical Regions Physical Examination of Infants and

Children Recording Examination Findings

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed.

© 2009 by Pearson Education, Inc. Upper Saddle River, NJ