Sunday, October 9, 2022

 


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Birth 1 year

Age (completed months and years)

WHO Child Growth Standards

WHO Child Growth Standards

2 years

Months Weight (kg)

Weight-for-age GIRLS

Fig. 15.17 Growth charts. World Health Organization standard centile charts for girls and boys. From WHO Child Growth Standards. http://www.who.int/

childgrowth/standards/weight_for_age/en/ © World Health Organization 2017. All rights reserved.

312 • Babies and children

If required, use a chart to stage puberty (Fig. 15.19). 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

Children usually present with a symptom. Children with acute

symptoms often have physical signs such as wheeze, but

examination is normal in the majority of children with 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 adults

The techniques used when examining children are the same as

those in adults, with some exceptions. Examining a child is a skill

that takes time to learn. The key skills involve being:

Observant of the child 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 for the child.

Opportunistic, to examine systems as the child presents

them. Chest and cardiac auscultation may be better earlier

in the examination in younger children before they become

restless or upset.

Adaptive to a child’s mood and playfulness. A skilled

practitioner can glean most examination findings from even

the most uncooperative child. Usually the history suggests

the diagnosis; the examination confirms it.

Differences in examination between

children and adults

The appropriate approach varies with the child’s age.

1–3 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 their 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, 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.

3–5 years

Some children in this age range have the confidence and maturity

to comply with some aspects of adult examination. They may

cooperate by holding up their T-shirts for chest examination

Puberty

This stage of adolescence, when an individual becomes

physiologically capable of sexual reproduction, is a time of rapid

physical and emotional development. The age at the onset and

end of puberty varies greatly but is generally 10–14 years for girls

and 12–16 years for boys (Fig. 15.18). The average child grows

30 cm during puberty and gains 40–50% in weight.

Female

8 1 9 1 0 12 14 16 18 2 1 13 15 17 19 0

Years

Male

8 1 9 1 0 12 14 16 18 2 1 13 15 17 19 0

Years

Height of growth spurt

12 years

Age of menarche

Breast stage

Pubic hair stage

121

/4– 121

/2 years

IV

III

II

IV

III

II

Height of growth spurt

14 years

Penis stage

Testicular volume

Pubic hair stage

12mL

4mL

IV

III

II

IV

III

II

Fig. 15.18 Timing of puberty in males and females.

The physical examination • 313

15

signs, they should ideally be reassessed in 1–2 hours if there

is a high level of parental or clinical anxiety that the signs are

out of keeping with a simple viral illness in a child of that age.

General examination

Height

Use a stadiometer (Fig. 15.20).

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.

5+ years

The child 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-to-toe walking, and

being asked to ‘sit forward’ and ‘take a deep breath in and hold it’.

The acutely unwell child

There are many non-specific 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).

Children become ill quickly. If a child has been unwell for less

than 24 hours and initial examination reveals only non-specific Male genital development Pubic hair MALE FEMALEBreast development

BI

Prepubertal

BII

Breast bud

BIII

Juvenile smooth

contour

BIV

Areola and papilla

project above breast

BV

Adult

PHI

Pre-adolescent

No sexual hair

PHIII

Dark, coarser, curlier

PHIV

Filling out towards

adult distribution

PHV

Adult in quantity and type

with spread to medial thighs

in male

GI

Pre-adolescent

GII

Lengthening

of penis

GIII

Further growth in length

and circumference

GIV

Development of glans penis,

darkening of scrotal skin

GV

Adult genitalia

PHII

Sparse, pigmented, long,

straight, mainly along

labia and at base of penis

Fig. 15.19 Stages of puberty in males and females. Pubertal changes according to the Tanner stages of puberty.

15.10 Serious signs requiring urgent attention

• Poor perfusion with reduced capillary refill and cool peripheries

(indicating shock)

• Listless, poorly responsive, whimpering child (suggesting sepsis)

• Petechial rash over the trunk (suggesting meningococcal sepsis)

• Headache with photophobia or neck stiffness (suggesting meningitis)

• Respiratory distress at rest (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

Knees straight

Heels touching back of board

Barefoot with feet flat on floor

Fig. 15.20 Stadiometer for measuring height accurately in children.

314 • Babies and children

Abnormal findings

Healthy tonsils and pharynx look pink; when inflamed, they are

crimson–red.

Inspecting the throat 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. 185).

Ears

Examination sequence

Ask the parent to:

Sit the child across their 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. 15.22).

Place their 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 toddler with no mastoid

development, or up and back in a child whose mastoid

process has formed.

Lymphadenopathy

Normal findings

Palpable neck and groin nodes are extremely common in children

under 5 years old. They are typically bilateral, less than 1 cm in

diameter, hard and mobile with no overlying redness, and can

persist for many weeks. In the absence of systemic 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).

Vital signs

Normal ranges for vital signs vary according to age (Box 15.11).

Ears, nose and throat

The preschool child

Throat

Examination sequence

Ask the parent to:

Sit the child on their knees, both facing you.

Give an older child the opportunity to open their 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. 15.21).

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.

Fig. 15.21 How to hold a child to examine the mouth and throat.

Fig. 15.22 How to hold a child to examine the ear.

15.11 Physiological measurements in

children of different ages

Age (years) Pulse (bpm)

Respiratory

rate (breaths

per minute)

Systolic blood

pressure (mmHg)

0–1 110–160 30–60 70–90

2–5 60–140 25–40 80–100

6–12 60–120 20–25 90–110

13–18 60–100 15–20 100–120

Child protection • 315

15

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 child

It can be difficult to identify a child with severe illness. With

experience you will learn to identify whether a child is just miserable

or really ill. Early-warning scores (such as PEWS or COAST, Fig.

15.23) can help. Certain features correlate with severe illness

(Box 15.13).

Child protection

Children who experience neglect or physical and/or emotional

abuse are at increased risk of health problems. At-risk children

are often already known to other agencies but this information

may not be available to you in the acute setting. Injuries from

physical abuse can be detected visually. Consider non-accidental

injury if the history is not consistent with the injury, or 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 dirty or is wearing dirty or torn clothes

that are too small or large. The parent–child relationship gives

insight into neglect; the child is apparently scared of the parent

(‘frozen watchfulness’) or the parent is apparently oblivious to

the child’s attention (Box 15.14).

Cardiovascular examination

Feel the brachial pulse in the antecubital fossa in children below

2–3 years. Do not palpate the carotid or radial pulses in young

children. Measure blood pressure using a cuff sized two-thirds

the distance 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’ – tracheal,

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.

Children’s small, thin chests transmit noises readily, and

their 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

In children aged 6 months to 3 years, examine the abdomen

with the child sitting upright on their parent’s knee. In the

young child, 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 children.

Neurological examination

Test power initially by watching the child 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 a child is usually apparent when you are

talking to them or their parents. A child with meningitis will not

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)

15.13 Clinical signs associated with severe

illness in children

• Fever >38°C

• 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)

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 non-mobile infants

• Posterior rib fracture

• Subconjunctival or retinal haemorrhage

• Dirty, smelly, unkempt child

• Bad nappy rash

316 • Babies and children

Date

Time

40

Doctor/Nurse/Family Concern?

39

38 Temperature

(°C)

Heart Rate

(bpm)

Resp Rate

(bpm)

Heart Rate (number)

Resp Rate (number)

GCS*

Pain Score*

Continue normal observations.

Nurse in Charge review. Hourly observations.

Nurse in Charge & Doctor to review patient. Half-hourly observations.

Nurse in Charge & SpR to review patient. Consider informing Consultant.

*nb: BP, GCS and Pain Score values do not contribute to the overall COAST score.

Nurse in Charge & Senior Doctor to see immediately.

If airway compromise, call ITU Registrar immediately.

Receiving O2 (L/min)

Resp. Mod/Severe

Distress None/Mild

Distress None/Mild

Level Decreased

TOTAL COAST SCORE

Number of shaded boxes

NB: Scores 3 should

be recorded overleaf

Observer’s initials

ACTIONS

O2 saturations (%)

Blood Pressure

(mmHg)*

*nb BP does not score

in COAST Scoring

(over 1 minute)

and

37

36

35

34

220

210

200

190

180

170

160

150

140

130

120

110

100

90

80

70

60

50

40

70

60

50

40

30

20

10

0–1

2

3

4

5–6

Patient details

Name

DOB

Hosp No

PRESCHOOL (1–4 years)

COAST: CHILDREN’S UNIT

CHILDREN’S OBSERVATION AND SEVERITY TOOL

CHILDREN’S

UNIT

SOUTH COAST CHILDREN’S EARLY WARNING SCORE: CHILDREN’S UNIT

Fig. 15.23 Rapid cardiopulmonary evaluation. BP, blood pressure; bpm, beats/breaths per minute; GCS, Glasgow coma scale score; ITU, intensive

treatment unit; SpR, specialist registrar. Courtesy Dr Sandell.

Child protection • 317

15

OSCE example case 1: Cyanotic episodes

Charlie, 4 months old, is brought in to see you by his mother Helen. She is anxious, as he has ‘turned blue’ on three occasions since discharge from

hospital. Two of the episodes have been during breastfeeding, when he has become agitated and breathless.

Please perform a newborn examination, focusing on the cardiovascular system

• Introduce yourself to the parent and clean your hands

• Carry out a general inspection: are there any signs of congenital heart disease?

• Look for signs of respiratory distress (tachypnoea, indrawing, accessory muscle use).

• Check for scars on the chest.

• Look at the colour and perfusion of the patient (cyanosis, pallor, sweatiness).

• Look for signs of dysmorphic features that might indicate an associated chromosomal abnormality.

• Look for signs of poor weight gain.

• Palpate: is the infant warm and well perfused? Are there any palpable cardiac abnormalities?

• Check central capillary refill. Feel the temperature.

• Palpate peripheral pulses (brachial, femoral).

• Palpate the precordium for palpable murmurs (thrills), ventricular heave or abnormal position of the apex.

• Assess whether there is palpable hepatomegaly or finger clubbing.

• Auscultate: is there a murmur?

• Auscultate the heart in a systematic fashion.

• Describe any murmur by documenting timing, grade (1–6), character, location, radiation, and variation with position and respiration.

• Auscultate the back to check whether the murmur radiates.

• Clean your hands and thank the parent.

Suggest a diagnosis

Congenital heart disease is possible with this presentation. There are many possible types and further investigation is needed for diagnosis. Tetralogy

of Fallot consists of four features: ventricular septal defect, right ventricular outflow obstruction, right ventricular hypertrophy and an overriding aorta. It

requires surgical correction. Children with tetralogy of Fallot are more likely to have chromosome disorders (Down’s syndrome or Di George syndrome).

Finger clubbing is not usually present in young infants.

Suggest investigations

Pulse oximetry, echocardiogram, electrocardiogram, chest X-ray.

OSCE example 2: Asthma

John, 8 years old, who has been diagnosed with asthma, is brought to see you by his parent. He has had more frequent episodes of wheeze and

night-time cough over the last 3 months, each lasting longer and responding less well to regular doses of bronchodilator.

Please perform a chest examination, focusing on the respiratory system

• Introduce yourself to the parent and patient, and clean your hands.

• 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.

• Palpate: consider palpation if there are chest-wall abnormalities or differential chest expansion on inspection, to look for differential chest-wall

movement.

• Auscultate: warm the stethoscope.

• Auscultate the respiratory system in all lung regions, anteriorly and posteriorly, with the chest fully exposed.

• Wheeze is auscultated in all lung regions. No crepitations are heard. Air entry is reduced to all lung regions. The respiratory rate is raised at 40

breaths per minute.

• Heart sounds are normal with no murmur.

• Clean your hands and thank the parent and patient.

Summarise your findings

This child has tachypnoea and a widespread, loud, polyphonic wheeze on expiration.

Suggest a diagnosis

Acute asthma attack on the background of unstable asthma is the likely diagnosis with these symptoms and signs. This requires treatment of the acute

episode with bronchodilator and oral glucocorticoids, and consideration of how to improve background control. Stabilising background control includes

an assessment of adherence and technique for current therapies, consideration of new triggers and how exposure may be reduced (by history and/or

skin-prick testing) and, if required, a trial of a stepwise increase in baseline asthma therapy.

Suggest initial investigations

Peak expiratory flow or spirometry, and oxygen saturation.

318 • Babies and children

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.

16

The patient with

mental disorder

Stephen Potts

The history 320

General approach 320

Sensitive topics 320

The uncooperative patient 320

The mental state examination 320

Appearance 320

Behaviour 320

Speech 321

Mood 321

Thought form 321

Thought content 322

Perceptions 323

Cognition 323

Insight 324

Risk assessment 324

Capacity 324

The physical examination 325

Collateral history 325

Psychiatric rating scales 325

Putting it all together: clinical vignettes 325

OSCE example 1: Assessing suicidal risk 327

OSCE example 2: Assessing delirium 328

Integrated examination sequence for the psychiatric assessment 328

320 • The patient with mental disorder

death) or incriminating (illicit drug misuse, other crime, homicidal

ideas). For interviews undertaken in non-clinical settings such as

police stations or prisons, or for the provision of court reports,

the latter is obviously especially pertinent, and it is important to

be clear with the patients about any limits to confidentiality in

your interview.

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.

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 and staff is paramount, so your initial assessment

of an agitated or hostile patient may be only partial.

The mental state examination

The mental state examination (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 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 is

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.

Appearance

Think of this as a written account of a still photograph, prepared

for someone who cannot see it. Observe:

general elements such as attire and signs of self-neglect

facial expression

tattoos and scars (especially any that suggest recent or

previous self-harm)

evidence of substance misuse (such as injection tracks

from intravenous drug use; spider naevi and jaundice from

alcoholic liver disease)

possibly relevant physical disease (such as exophthalmos

from thyrotoxicosis).

Behaviour

Think of this as a written account of a video, observing such

features as:

cooperation, rapport, eye contact

social behaviour (such as aggression, disinhibition, fearful

withdrawal)

apparent responses to possible hallucinations or

unobserved stimuli

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: the history, mental state examination, 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 accident and emergency department with a first episode of

psychosis, the focus is on symptoms, recent changes of 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).

Sensitive topics

Some subjects require 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, gender identity), distressing (major traumatic

experiences, such as rape, childhood sexual abuse, witnessing a

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

The mental state examination • 321

16

any aspect of life, and at interview appear downcast, withdrawn

and tearful, with little brightening even when talking about their

much-loved children.

Pervasive disturbance of mood is the most important

feature of depression, mania and anxiety, but mood changes

commonly occur in other mental disorders such as schizophrenia

and dementia. You might ask patients ‘How has your mood

been lately?’, ‘Have you noticed any change in your emotions

recently?’ and ‘Do you still enjoy things that normally give you

pleasure?’ Abnormalities of mood include a problematic pervasive

mood, an abnormal range of affect, abnormal reactivity and

inappropriateness or incongruity. Some terms relating to mood

are defined in Box 16.5.

Some patients prompt affective responses in the interviewer,

via the process of countertransference. The elated gaiety of some

hypomanic patients can be infectious, as can the hopeless gloom

of some people with depression. Recognising these responses in

yourself can be helpful in understanding how the patient relates

to others and vice versa.

Thought form

As with speech, this is a not an assessment of what the patient

is thinking about, but how they think about it. Assess it by

observing how thoughts appear to be linked together, and the

speed and directness with which the train of thought moves,

considering rate, flow, sequencing and abstraction. Some terms

relating to thought form are defined in Box 16.6.

Thinking may appear speeded up, as in hypomania, or

slowed down, as in profound depression. The flow of subjects

over-activity (agitation, pacing, compulsive hand washing)

under-activity (stupor, motor retardation)

abnormal activity (posturing, involuntary movements,

Box 16.3).

Speech

This is not a description of what the patient says (that is, content),

but of how they say it (form). Assess:

articulation (such as stammering, dysarthria)

quantity (mutism, garrulousness)

rate (pressured, slowed)

volume (whispering, shouting)

tone and quality (accent, emotionality)

fluency (staccato, monotonous)

abnormal language (neologisms, dysphasia, clanging,

Box 16.4).

Mood

Mood is the patient’s pervasive emotional state, while affect is the

observable expression of their emotions, which is more variable

over time. Think of mood as the emotional climate and affect

as the weather. Both have elements of subjective experience

(that is, how the patient feels, according to their own report and

your specific questions) and how the patient appears to feel,

according to your own objective observation. So a depressed

patient might describe feeling sad, hopeless and unable to enjoy

16.3 Behaviour: definitions

Term Definition

Agitation A combination of psychic anxiety and excessive,

purposeless motor activity

Compulsion A stereotyped action that the patient cannot

resist performing repeatedly

Disinhibition Loss of control over normal social behaviour

Motor retardation Decreased motor activity, usually a combination

of fewer and slower movements

Posturing The maintenance of bizarre gait or limb positions

for no valid reason

16.4 Speech: definitions

Term Definition

Clang associations Thoughts connected by their similar sound

rather than by meaning

Echolalia Senseless repetition of the interviewer’s words

Mutism Absence of speech without impaired

consciousness

Neologism An invented word, or a new meaning for an

established word

Pressure of speech Rapid, excessive, continuous speech (due to

pressure of thought)

Word salad A meaningless string of words, often with loss

of grammatical construction

16.5 Mood: definitions

Term Definition

Blunting Loss of normal emotional sensitivity to experiences

Catastrophic

reaction

An extreme emotional and behavioural over-reaction

to a trivial stimulus

Flattening Loss of the range of normal emotional responses

Incongruity A mismatch between the emotional expression and

the associated thought

Lability Superficial, rapidly changing and poorly controlled

emotions

16.6 Thought form: definitions

Term Definition

Circumstantiality Trivia and digressions impairing the flow but

not direction of thought

Concrete thinking Inability to think abstractly

Flights of ideas Rapid shifts from one idea to another,

retaining sequencing

Loosening of

associations

Logical sequence of ideas impaired. Subtypes

include knight’s-move thinking, derailment,

thought blocking and, in its extreme form,

word salad

Perseveration Inability to shift from one idea to the next

Pressure of thought Increased rate and quantity of thoughts

322 • The patient with mental disorder

The main difference between them is that delusions either

lack a cultural basis for the belief or have been derived from

abnormal psychological processes.

Overvalued ideas

These are usually beliefs of great personal significance. They

fall short of being full delusions but are abnormal because of

their effects on a person’s behaviour or wellbeing. For example,

in anorexia nervosa, people may still believe they are fat when

they are seriously underweight – and then respond to their belief

rather than their weight, by further starving themselves.

Delusional beliefs

These beliefs also matter greatly to the person, resulting in

powerful emotions and important behavioural consequences;

they are always of clinical significance. They are classified by

their content, such as:

paranoid

religious

grandiose

hypochondriacal

of guilt

of love

of jealousy

of infestation

of thought interference (broadcasting, insertion and

withdrawal)

of control.

Bizarre delusions are easy to recognise, but not all delusions

are weird ideas: a man convinced that his partner is unfaithful

may or may not be deluded. Even if a partner were unfaithful,

it would still amount to a delusional jealousy if the belief were

held without evidence or for some unaccountable reason, such

as finding a dead bird in the garden.

may be understandable but unusually rapid, as in the flight of

ideas that characterises hypomania, or unduly ‘single track’ and

perseverative, as in some cases of dementia. Sometimes thinking

appears to be very circumstantial, and the patient hard to pin

down, even when asked simple questions.

More severe disruption of the train of thought is termed

loosening of associations or formal thought disorder, in which

the patient moves from subject to subject via abrupt changes of

direction that the interviewer cannot follow. This is a core feature

of schizophrenia. Concrete thinking, in the sense of difficulty

handling abstract concepts, is a common feature of dementia,

and can be assessed by asking the patients to explain the

meaning of common proverbs.

It may help to illustrate your assessment with verbatim examples

from the interview, chosen to illustrate the patient’s manner of

thinking and speaking.

Thought content

Thought content refers to the main themes and subjects occupying

the patient’s mind. It will become apparent when taking the history

but may need to be explored further via specific enquiries. It

may broadly be divided into preoccupations, ruminations and

abnormal beliefs. These are defined in Boxes 16.7 and 16.8.

Preoccupations

Preoccupations occur in both normal and abnormal mood states.

Sadly dwelling on the loss of a loved one is entirely normal in

bereavement; persisting disproportionate guilty gloom about the

state of the world may be a symptom of depression.

Ruminations

These are preoccupations that are in themselves abnormal –

and therefore symptoms of mental disorder – by reason of

repetition (as in obsessional disorders) or groundlessness (as

in hypochondriasis).

Abnormal beliefs

These beliefs fall into two categories: those that are not diagnostic

of mental illness (such as overvalued ideas, superstitions and

magical thinking) and those that invariably signify mental illness

(that is, delusions).

16.7 Thought content: definitions

Term Definition

Hypochondriasis Unjustified belief in suffering from a particular

disease in spite of appropriate examination and

reassurance

Morbid thinking Depressive ideas, e.g. themes of guilt, burden,

unworthiness, failure, blame, death, suicide

Phobia A senseless avoidance of a situation, object or

activity stemming from a belief that has caused

an irrational fear

Preoccupation Beliefs that are not inherently abnormal but which

have come to dominate the patient’s thinking

Ruminations Repetitive, intrusive, senseless thoughts or

preoccupations

Obsessions Ruminations that persist despite resistance

16.8 Abnormal beliefs: definitions

Term Definition

Delusion An abnormal belief, held with total conviction, which

is maintained in spite of proof or logical argument to

the contrary and is not shared by others from the

same culture

Delusional

perception

A delusion that arises fully formed from the false

interpretation of a real perception, e.g. a traffic light

turning green confirms that aliens have landed on

the rooftop

Magical

thinking

An irrational belief that certain actions and outcomes

are linked, often culturally determined by folklore or

custom, e.g. fingers crossed for good luck

Overvalued

ideas

Beliefs that are held, valued, expressed and acted

on beyond the norm for the culture to which the

person belongs

Thought

broadcasting

The belief that the patient’s thoughts are heard by

others

Thought

insertion

The belief that thoughts are being placed in the

patient’s head from outside

Thought

withdrawal

The belief that thoughts are being removed from the

patient’s head

The mental state examination • 323

16

when going to sleep (hypnagogic) or waking up (hypnopompic).

Hallucinations are categorised according to their sensory modality

as auditory, visual, olfactory, gustatory or tactile.

Any form of hallucination can occur in any severe mental

disorder. The most common are auditory and visual hallucinations,

the former associated with schizophrenia and the latter with

delirium. Some auditory hallucinations are characteristic of

schizophrenia, such as voices discussing the patient in the

third person or giving a running commentary on the person’s

activities (‘Now he’s opening the kitchen cupboard’). Ask, for

example, ‘Do you ever hear voices when nobody is talking?’

and ‘What do they say?’

Pseudohallucinations are common. The key distinction from

a true hallucination is that they occur within the patient, rather

than arising externally. They have an ‘as if’ quality and lack the

vividness and reality of true hallucinations. Consequently, the

affected person is not usually distressed by them, and does

not normally feel the need to respond, as often happens with

true hallucinations.

Cognition

If the history and observation suggest a cognitive deficit, it must

be evaluated by standard tests. History, observation, MSE and

rating scales (see later) are then used together to diagnose and

distinguish between the ‘3Ds’ (dementia, delirium and depression),

which are common in the elderly and in hospital inpatients.

Core cognitive functions include:

level of consciousness

orientation

memory

attention and concentration

intelligence.

Level of consciousness

Mental disorders are rarely associated with a reduced (or clouded)

level of consciousness, such as drowsiness, stupor or coma.

The exception is delirium (which is both a physical and a mental

disorder), where it is common.

Orientation

This is a key aspect of cognitive function, being particularly

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