1.  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

2.  Five areas of nervous system exam:  Mental status and speech  Cranial nerves  Motor system  Sensory system  Reflexes Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ

3.  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

4.  The Cranial Nerves  Originate 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

6.  Assessing Cranial Nerves  Test 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

7.  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

8.  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

9.  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

11.  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

12.  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

13.  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

14.  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

15.  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

16.  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

24. Physical Examination of Infants and Children

25.  Specific techniques same as adult  Inspection, palpation, percussion, and auscultation  You 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

26.  Building patient and family rapport  Remain 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

27.  General appearance and behavior  Ask 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

28.  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 exam Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ

29.  Toddler (1–3 years)  Able to walk by their 18th month  Trust no one but their parents  Most difficult age group to examine Assess vital areas first.  Like to be distracted with toys Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ

30.  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. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ

31.  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

32.  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.

33.  General Appearance  Note 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

34.  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. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ

35.  Chest and Lungs  Observe 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

36.  Cardiovascular  Heart 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

37. Normal Vital Signs for Various Pediatric Age Groups

38.  Abdomen  Liver 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

39.  Musculoskeletal  Evaluate 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

40.  Nervous System  Assess 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

42.  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

43.  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

44.  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