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The physical examination • 359
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Female
Height of growth spurt
12 years
Age of menarche
1
12
/4– 121/2 years
Breast stage
Pubic hair stage
8 1012141618209 1113151719
Male
Height of growth spurt
Penis stage
IV
III
II
IV
III
II
Years
14 years
IV
If required, use a chart to stage puberty (Fig. 15.20). Pubertal
staging has a wide normal range, with abnormalities apparent
only on follow-up. Delayed or precocious puberty is not
uncommon.
Physical examination techniques in children
and young people
CYP usually present with a symptom. Those with acute symptoms often have physical signs such as wheeze, but examination
is normal in the majority who have chronic symptoms. Routine
screening examination after infancy is unhelpful, as many paediatric diseases only produce signs late in the illness.
Similarities in examination between children
and young people and adults
The techniques used when examining CYP are the same as
those in adults, with some exceptions. Examining CYP requires a
range of skills that take time to learn. The key skills involve being:
• Observant during discussion or play, to identify elements of
the examination that are naturally displayed and so can be
partitioned from the formal examination process, reducing the
duration of what is often a stressful encounter, particularly for
younger children.
• Opportunistic, to examine systems as CYP present them.
Chest and cardiac auscultation may be better earlier in the
examination in younger children before they become restless
or upset.
• Adaptive to CYP’s mood and playfulness. A skilled practi-
tioner can glean most examination findings from even the
most uncooperative CYP. Usually the history suggests the
diagnosis; the examination confirms it.
15
Testicular volume
Pubic hair stage
8 1012141618209 1113151719
Fig. 15.19 Timing of puberty in males and females.
4mL
Years
III
Differences in examination between children
II
12mL
IV
III
II
and young people and adults
The appropriate approach varies with CYP’s age.
1 to 3 years
All children at this age can be reluctant to be approached by
strangers and particularly dislike being examined. Early on, let
children gradually become used to your presence and see that
your encounter with their parents is friendly. Carefully observe the
child’s general condition, colour, respiratory rate and effort, and
state of hydration while taking the history: that is, when the child
is not focused on your close attention. For the formal examination, ask the parent to sit the child on the parent’s knees.
Examine the cardiorespiratory system and the abdomen with the
young child sitting upright on the parent’s knee. With patience,
abdominal examination can be done with the child lying supine
on the bed next to a parent or on the parent’s lap. Taking your
stethoscope from around your neck to use it can upset the child,
so make slow, non-threatening moves. If the child starts crying,
360 • BABIES AND CHILDREN
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Pubic hair
MALE FEMALE
BI
Prepubertal
Breast development
PHI
Pre-adolescent
No sexual hair
Male genital development
GI
Pre-adolescent
labia and at base of penis
BII
Breast bud
PHII
Sparse, pigmented, long,
straight, mainly along
GII
Lengthening
of penis
BIII
Juvenile smooth
contour
PHIII
Dark, coarser, curlier
GIII
Further growth in length
and circumference
BIV
Areola and papilla
project above breast
PHIV
Filling out towards
adult distribution
Development of glans penis,
GIV
darkening of scrotal skin
Fig. 15.20 Stages of puberty in males and females. Pubertal changes according to the Tanner stages of puberty.
BV
Adult
PHV
Adult in quantity and type
with spread to medial thighs
in male
GV
Adult genitalia
chest auscultation and abdominal palpation become very difficult; take a pause. Ear, nose and throat examination often
causes upset and is best left till last; suggesting that ear examination will tickle can help with older children.
3 to 5 years
Some children in this age range have the confidence and
maturity to comply with many aspects of adult examination. They
may cooperate by holding up their T-shirts for chest examination
and turning round; if so, comment warmly on this cooperation
and provide positive feedback on helpful behaviour. Children’s
social skills regress when they are unwell, and some are very
apprehensive of strangers.
5þ years
The CYP may comply with a full adult-style examination.
Although children under 11 years are often not able to express
themselves well, those over 5 years are able to understand and
comply with requests such as finger-to-nose pointing, heel-totoe walking and being asked to ‘sit forwards’ and ‘take a deep
breath in and hold it’. Young people may find examination
particularly embarrassing. Be aware and sensitive to this, and
request permissions before proceeding.
The acutely unwell children and young
people
There are many nonspecific signs that are common to a range of
conditions, from a simple cold to meningitis. These include a
runny nose, fever, lethargy, vomiting, blanching rash and irritability. However, some signs are serious, requiring immediate
investigation and management (Box 15.10).
CYP become ill quickly. If they have been unwell for less than
24 hours and initial examination reveals only nonspecific signs,
they should ideally be reassessed in 1 to 2 hours if there is a high
level of parental or clinical anxiety that the signs are out of
keeping with a simple viral illness at that age.
General examination
Height
Use a stadiometer (Fig. 15.21).
Vital signs
Normal ranges for vital signs vary according to age (Box 15.11).
The physical examination • 361
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15.10 Serious signs requiring urgent attention
• Poor perfusion with reduced capillary refill and cool peripheries (indi-
cating shock)
• Listless, po orly responsive, whimpering child (suggesting sepsis)
• Petechial rash over the trunk (suggesting meningococcal sepsis)
• Headache with photophobia or neck stiffness (suggesting
meningitis)
• Respiratory distress at r est (rapid rate and increased respiratory
effort, indicating loss of respiratory reserve due to pneumonia or
asthma)
Calibration checked
Head straight, eyes and ears level
Gentle upward traction on mastoid process
Ears, nose and throat
The preschool child
Throat
Examination sequence
• Ask the parent to:
• Sit the child on the parent’s knees, both facing you.
• Give an older child the opportunity to open the mouth
spontaneously (‘Roar like a lion!’). If this is not successful,
proceed as described here.
• Place one arm over the child’s upper arms and chest (to
stop the child pushing you away, Fig. 15.22).
• Hold the child’s forehead with their other hand (to stop the
child pulling their chin down to their chest).
• Hold the torch in your non-dominant hand to illuminate the
child’s throat.
• Slide a tongue depressor inside the child’s cheek with your
dominant hand. The child should open their clenched teeth
(perhaps with a shout), showing their tonsils and pharynx.
Abnormal findings
Healthy tonsils and pharynx look pink; when inflamed, they are
crimson–red.
Inspecting the throat (see Fig 15.22) reveals the presence, but
not the cause, of the infection; pus on the tonsils and pharynx
does not differentiate a bacterial from a viral infection (p. 210).
15
Knees straight
Barefoot with feet flat on floor
Heels touching back of board
Fig. 15.21 Stadiometer for measuring height accurately in children.
15.11 Physiological measurements in children of
different ages
Respiratory rate
Age
(years)
0–1 110–160 30–60 70–90
2–560–140 25–40 80–100
6–12 60–120 20–25 90–110
13–18 60–100 15–20 100–120
bpm, Beats per minute.
Pulse
(bpm)
(breaths per
minute)
Systolic blood
pressure (mm
Hg)
Ears
Examination sequence
• Ask the parent to:
• Sit the child across the parent’s knees with the child’s ear
facing you.
• Place one arm around the child’s shoulder and upper arm
that are facing you (to stop them pushing you away,
Fig. 15.23).
• Place the parent’s other hand over the parietal area above
the child’s ear that is facing you (to keep the child’s head
still).
• Use an otoscope with the largest speculum that will
comfortably fit the child’s external auditory meatus.
• To straighten the ear canal and visualise the canal and
tympanic membrane, hold the pinna gently and pull it out
and down in a baby or to ddler with no mastoid development, o r up and back in a child whose mastoid proces s has
formed.
Lymphadenopathy
Normal findings
Palpable neck and groin nodes are extremely common in children under 5 years of age. They are typically bilateral, less than
362 • BABIES AND CHILDREN
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15.12 Causes of lymph node enlargement
Cervical lymphadenopathy
• Tonsillitis, pharyngitis, sinusitis
• ‘Glandular fever’ (infectious mononucleosis/cytomegalovirus)
• Tuberculosis (uncommon in developed countries)
Generalised lymphadenopathy
• Febrile illness with a generalised rash
• ‘Glandular fever’
• Systemic juvenile chronic arthritis (Still’s disease)
• Acute lymphatic leukaemia
• Drug reaction
• Mucocutaneous lymph node syndrome (Kawasaki disease)
symptoms such as weight loss, fevers or night sweats, these are
typically a normal, healthy immune response to infection. Only
rarely are they due to malignancy (Box 15.12).
Cardiovascular examination
Fig. 15.22 How to hold a child to examine the mouth and throat.
Fig. 15.23 How to hold a child to examine the ear.
To assess the pulse (rate and volume), the brachial pulse in the
antecubital fossa is best used for children below 2 t o 3 years
and the radial pulse in older CYP. Measure blood pressure
using a cuff sized two-th irds the dista nce from elbow to
shoulder tip. Repeat with a larger cuff if the reading is elevated.
If in doubt, use a larger cuff, as smaller cuffs yield falsely high
values.
Respiratory examination
Abnormal findings
The child under 3 years has a soft chest wall and relatively small,
stiff lungs. When the lungs are made stiffer (by infection or fluid),
the diaphragm must contract vigorously to draw air into the
lungs. This produces recession (ribs ‘sucking in’dtracheal,
intercostal and subcostal) and paradoxical outward movement of
the abdomen (wrongly called ‘abdominal breathing’). These
important signs of increased work of breathing are often noticed
by parents. Older children may be able to articulate the
accompanying symptom of dyspnoea.
In young children, their small, thin chests transmit noises
readily, and the smaller airways are more prone to turbulence
and added sounds. Auscultation may reveal a variety of sounds,
including expiratory polyphonic wheeze (occasionally inspiratory
too), fine end-expiratory crackles, coarse louder crackles transmitted from the larger airways and other sounds described as
pops and squeaks (typically in the chest of recovering patients
with asthma).
Abdominal examination
1 cm in diameter, hard and mobile with no overlying redness and
can persist for many weeks. In the absence of systemic
In children aged 6 months to 3 years, examine the abdomen with
the child sitting upright on the parent’s knee. In the young child,
The physical examination • 363
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15
Fig. 15.24 NHS Scotland National Paediatric Early Warning Chart (PEWS) for children aged 2 to 4 years. For each domain, observations in the coloured areas contribute
scores according to the legend in the R margin. The total score is recorded in the PEWS line. Used with the permission of Healthcare Improvement Scotland. https://
ihub.scot/improvement-programmes/scottish-patient-safety-programme-spsp/spsp-programmes-of-work/maternity-and-children-quality-improvement-collaborativemcqic/paediatric-care/pews/.
364 • BABIES AND CHILDREN
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splenic enlargement extends towards the left iliac fossa. In older
children the enlarged spleen edge moves towards the right iliac
fossa. Faecal loading of the left iliac fossa is common in constipation. Rectal examination is rarely indicated in CYP, but examination of the anus for fissures (common with constipation)
can be helpful where appropriate.
Neurological examination
Test power initially by watching the CYP demonstrate their
strength against gravity. Ask them to lift their arms above their
head, raise their leg from the bed while they are lying down and
stand from a squatting position. If appropriate, test power
against your strength.
Neck stiffness in CYP is usually apparent when you are talking
to them or their parents. CYP with meningitis will not want to
move, and if they are forced to do so, the neck remains aligned
with the trunk. With a young child, move a toy to catch their
attention and see if they move their head.
Spotting the sick children and young people
It can be difficult to identify CYP with severe illness, particularly
younger children. With experience you will learn to identify
whether CYP are just miserable or really ill. Early-warning scores
(e.g. Paediatric Early Warning Score (PEWS), Fig. 15.24) can
help. Certain features correlate with severe illness (Box 15.13).
Child protection
CYP who experience neglect or physical and/or emotional abuse
are at increased risk of health problems. At-risk CYP may already
be known to other agencies but do not assume this is the case
when interagency communications are not available to you.
15.14 Signs that may suggest child neglect or abuse
Behavioural signs
• ‘Frozen watchfulness’
• Passivity
• Over-friendliness
• Sexualised behaviour
• Inappropriate dress
• Hunger, stealing food
Physical signs
• Identifiable bruises (e.g. fingertips, handprints, belt buckle, bites)
• Circular (cigarette) burns or submersion burns with no splash marks
• Injuries of differing ages
• Eye or mouth injuries
• Long-bone fractures or bruises in nonmobile infants
• Posterior rib fracture
• Subconjunctival or retinal haemorrhage
• Dirty, smelly, unkempt child
• Bad nappy rash
Injuries from physical abuse can often be detected visually.
Consider nonaccidental injury if the history is not consistent with
the injury or if the injury is present in unusual places such as over
the back. It may be difficult to detect neglect during a brief
encounter, but consider it if the child appears unkempt, has
unexplained pain/discomfort or is socially withdrawn. The
parent–child relationship gives insight into neglect; the child is
apparently scared of the parent (‘frozen watchfulness’) or the
parent appears oblivious to the child’s attention (Box 15.14).
Remote consultation in paediatric
practice
15.13 Clinical signs associated with severe illness in
children
• Fever >38C
• Drowsiness
• Cold hands and feet
• Petechial rash
• Neck stiffness
• Shortness of breath at rest
• Tachycardia
• Hypotension (a late sign in shocked children where blood pressure is
initially maintained by tachycardia and increased peripheral vascular
resistance)
The recent global pandemic has made necessary remote
consultation. While this may become part of normal practice in
future, it has significant limitations as well as advantages (see
Chapter 21). There is a risk that remote consultation can adversely
affect the appropriate assessment of CYP in communities or
households where technology and access to WiFi do not enable a
visual review of the child. Where video consultation is possible,
always ensure that CYP are present at least at the start of the
consultation so that you can ask specific questions of them and
observe any specific signs that may help your clinical decision
making. Younger CYP, in particular, get bored very easily during
video consultation and tend to disappear off camera.
Remote consultation in paediatric practice • 365
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OSCE example 1: Diarrhoea
Ismail, 4 months old, is brought in to see you by his mother. She is anxious as he has had diarrhoea for several days. He is breastfed.
Please perform a newborn examination, focusing on the cardiovascular system
• Introduce yourself to the mother. Wash your hands thoroughly and wear personal protective equipment (PPE) as per local guidance.
• Carry out a general inspection:
• Look at the general state of the infant. Are they alert and interested, or quiet and lethargic?
• Examine for signs of dehydration:
Sunken eyes, sunken fontanelle, reduced skin turgor, dry mucous membranes
Measure capillary refill by pressing on the midsternum for 5 seconds and counting the time for refill
Count the respiratory rate over 1 minute to identify tachypnoea
Count the pulse rate and pulse volume in the brachial artery.
Measure the child’s blood pressure.
Assess the child’s neurological status (AVPUdalert, verbal, pain, unresponsive).
• Is there any associated infection/condition that might be causing them to have diarrhoea. Perform an examination of the systems to exclude additional
diagnoses, i.e.
• respiratory crackles of pneumonia
• inflamed ear for otitis media
• bulging fontanelle of meningitis
• Dispose of any PPE you have used, wash your hands and thank the parent and child.
Suggest a diagnosis
Diarrhoea is common and, with it, dehydration. Most children can recover if an adequate assessment of dehydration is made and they are provided with
rehydration. Learn how to assess degrees of dehydration (commonly classified as 5, 10 or 15% dehydration) and how to calculate volume of fluid to replace
(body weight in kg  percent dehydration  10 ¼ volume in mL to be replaced). Fluid replacement is in addition to routine daily requirements. If there are
continued diarrhoeal losses, fluids may need recalculated every 4 to 8 hours to take account of this.
Suggest investigations
Heart rate, respiratory rate, blood pressure, pulse oximetry.
15
OSCE example 2: Chronic cough
Joanne, 2 years old, who has had a problem with cough. The cough has been present for the past 8 weeks following a severe viral infection. The cough
affects her sleep but not her appetite, weight or activities.
Please perform a chest examination, focusing on the respiratory system
• Introduce yourself to the parent and child. Wash your hands thoroughly, and wear PPE as per local guidance. Ensure that you use a stethoscope that has
been appropriately cleaned.
• Carry out a general inspection: are there any signs of acute or chronic respiratory distress?
• Look for chest wall deformity (pectus excavatum, Harrison ’s sulcus).
• Look for signs of respiratory distress (tachypnoea, indrawing, accessory muscle use).
• Count the respiratory rate over 1 minute.
• Look at the colour and perfusion of the patient (cyanosis, pallor, sweatiness).
• Look for finger clubbing and poor weight gain.
The respiratory rate is 20 per minute (normal), and there are no other abnormal findings on inspection except that you can hear the child have an
intermittent moist cough.
• Auscultate: warm the stethoscope.
• Auscultate the respiratory system in all lung regions, anteriorly and posteriorly, with the chest fully exposed.
• Low-pitch rhonchi are auscultated in all lung regions. No crepitations are heard. Air entry is normal.
• Heart sounds are normal with no murmur.
• Palpate: consider palpation if there are chest-wall abnormalities or differential chest expansion on inspection, to look for differential chest-wall movement.
• Dispose of any PPE you have used, wash your hands and thank the parent and child.
Summarise your findings
This child has moist cough with low-pitch rhonchi on auscultation but a normal respiratory rate and no respiratory distress.
Continued
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OSCE example 2: Chronic coughdcont'd
Suggest a diagnosis
Postviral cough is common in young children. Cough usually resolves within 6 weeks. A prolonged cough, particularly if moist requires clinical review.
Persistent bacterial bronchitis often self resolves in many children, but for some the recovery can be aided by a course of broad-spectrum antibiotics (i.e.
amoxicillin). If the moist cough resolves but recurs on stopping antibiotics or fails to stop with antibiotics, then further investigation may be required.
Suggest initial investigations
Chest x-ray if recurrence or non-improvement.
Integrated examination sequence for the newborn child
• Perform a general examination:
• Looks well and is well grown? Dysmorphic features? Posture and behaviour? Does the cry sound normal?
• Skin: note cuts, bruising, naevi (haemangiomas or melanocytic), blisters or bullae.
• Head: check shape, swellings, anterior fontanelle, cranial sutures.
• Eyes: check for jaundice, ocular movements and vestibular function; perform ophthalmoscopy.
• Nose: check patency.
• Mouth: check mucosa, tongue, palate, jaw and any teeth.
• Ears: note size, shape and position; check the external auditory meatus.
• Neck: inspect and palpate for asymmetry, sinuses and swellings.
• Examine the cardiovascular system:
• Inspect: pallor, cyanosis and sweating.
• Palpate: apex, check for heave or thrill, count heart rate, femoral pulses, feel for hepatomegaly.
• Auscultate: heart sounds I and II, any additional heart sounds or murmurs.
• Examine the respiratory system:
• Inspect: chest shape, symmetry of movement, respiratory rate, respiratory distress: tachypnoea, suprasternal, intercostal and subcostal recession,
flaring of nostrils.
• Auscultate anteriorly, laterally and posteriorly, comparing sides.
• Examine the abdomen:
• Inspect: abdomen, umbilicus, anus and groins, noting any swellings.
• Palpate: superficial, then deeper structures. Spleen, then liver.
• Examine the perineum:
• Both sexes: check normal anatomy.
• Male: assess the penis, noting shape; check the urethral meatus is at the tip. Do not retract the foreskin. Palpate the testes, and the inguinal canal if
the testes are not in the scrotum. Transilluminate scrotal swellings.
• Examine the spine and sacrum:
• With the infant in the prone position, inspect and palpate the entire spine for neural tube defects.
• Examine the neurological system:
• Inspect: asymmetry in posture and movement, any muscle wasting.
• Pick the baby up to note any stiff or floppy tone.
• Sensation: does the baby withdraw from gentle stimuli?
• In dim light, the eyes should open; in bright light, babies screw up their eyes.
• Check the primitive reflexes:
• Check grasp responses, ventral suspension/pelvic response to back stimulation, place-and-step reflexes, Moro reflex, root-and-suck responses.
• Inspect the limbs:
• Inspect: limbs, counting digits and checking feet are, or can be, normally positioned.
• Check hips for developmental dysplasia/dislocation.
• Weigh and measure:
• Weigh the infant to the nearest 5 g.
• Measure: occipitofrontal circumference, crown–heel length (neonatal stadiometer).
• Record on a centile chart.
Stephen Potts
https://t.me/med1917
16
Patients with mental illness
and learning disability
The history 368
General approach 368
Sensitive topics 368
The uncooperative patient 368
The mental state examination 368
Appearance 369
Behaviour 369
Speech 369
Mood 369
Thought form 370
Thought content 370
Perceptions 371
Cognition 372
Insight 373
Risk assessment 373
Capacity 373
The physical examination 373
Collateral history 374
Psychiatric rating scales 374
Putting it all together: clinical vignettes 374
OSCE example 1: Assessing suicidal risk 376
OSCE example 2: Assessing delirium 377
Integrated examination sequence for the psychiatric assessment 377
368 • PATIENTS WITH MENTAL ILLNESS AND LEARNING DISABILITY
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Mental disorders are very common, frequently coexist with
physical disorders and cause much mortality and morbidity.
Psychiatric assessment is, therefore, a required skill for all clinicians. It consists of four elements: history, mental state examination (MSE), selective physical examination and collateral
information. Each element can be expanded considerably, so the
assessment must be adapted to its purpose. Is it a quick
screening of a patient presenting with other problems, a confirmation of a suspected diagnosis or a comprehensive review for a
second opinion?
The history
General approach
The distinction between symptoms and signs is less clear in
psychiatry than in the rest of medicine. The psychiatric interview,
which covers both, has several purposes: to obtain a history of
symptoms, to assess the present mental state for signs and to
establish rapport that will facilitate further management.
A comprehensive history covers a range of areas (Box 16.1),
but the nature of the presenting problem and/or the referral
question, and the setting in which the history is being taken, will
determine the degree of detail needed for each. When seeing
someone in the Emergency Department with a first episode of
psychosis, the focus is on symptoms, recent changes in function, family history and drug use; when interviewing someone in
an outpatient clinic with a possible personality disorder,
assessment concentrates instead on their personal history,
which is essentially a systematised biography (Box 16.2).
16.1 Content of a psychiatric history
• Referral source
• Reason for referral
• History of presenting symptom(s)
• Systematic enquiry into other relevant problems and symptoms
• Past medical/psychiatric history
• Prescribed and non-prescribed medication
• Substance use: illegal drugs, alcohol, tobacco, caffeine
• Family history (including psychiatric disorders)
• Personal history
16.2 Personal history
• Childhood development
• Losses and experiences
• Education
• Occupation(s)
• Financial circumstances
• Relationships
• Partner(s) and children
• Housing
• Leisure activities
• Hobbies and interests
• Forensic history
Sensitive topics
Some subjects require a particular skill. The common theme is
reluctance to disclose, which can arise because the information is
private and disclosure is potentially embarrassing (such as sexual
dysfunction), distressing (major previous traumatic experiences,
such as rape, childhood sexual abuse, witnessing a death) or
incriminating (illicit drug misuse, other crimes, homicidal ideas). For
interviews undertaken in non-clinical settings, such as police stations or prisons, or for the provision of court reports, potentially
incriminating disclosures are obviously especially pertinent, and it
is important to be clear with the patient about any limits to
confidentiality in your interview. Some disclosures, such as those
relating to sexual orientation or gender identity, may expose patients to the real or perceived risk of hostility or discrimination.
Try to develop rapport early in the interview, if possible, and to
consolidate it before raising a sensitive topic, although sometimes you must cover such material without delay. It is particularly
important to ask about suicidal thoughts.
While clinicians should be able to interview patients regardless
of their age, gender, ethnic origin or sexual orientation, the skills
required may vary because patient attitudes may differ. For
example, it may be more difficult for a male patient to discuss
erectile dysfunction with a female than a male interviewer, or for
an adolescent patient to relate to an interviewer in their late
middle age than someone closer to their own years. Clinicians
need to be aware of the potential effects of demographic and
other differences between themselves and their patients.
The uncooperative patient
Adapt your approach to a patient who is mute, agitated, hostile
or otherwise uncooperative during the interview by relying more
on observation and collateral information. The safety of the patient, other patients, staff and the wider public is paramount, so
your initial assessment of an agitated or hostile patient may be
only partial.
The mental state examination
The MSE is a systematic evaluation of the patient’s mental
condition at the time of interview. The aim is to establish signs of
mental disorder that, taken along with the history, enable you to
make, suggest or exclude a diagnosis. While making your specific enquiries, you need to observe, evaluate and draw inferences in the light of the history. This may be daunting, but with
good teaching, practice and experience, you will learn the skills.
The MSE incorporates elements of the history, observation of
the patient, specific questions exploring various mental phenomena, and short tests of cognitive function. Like the history, its
focus is determined by the potential diagnoses. For example,
detailed cognitive assessment in an elderly patient presenting
with confusion is crucial; similarly, you should carefully evaluate
mood and suicidal thoughts when the presenting problem is
depression.
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