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 examination in the laboratory. However, clinicopathological

correlation is usually necessary.

Mycology

A fungal infection can be confirmed (or refuted) by scraping

scale from the surface of a rash with a scalpel blade, clipping

samples of nail or plucking hair, and undertaking microscopic

examination and culture.

Patch testing

Patch testing (Fig. 14.15) is performed to establish whether a

contact allergy is the cause of an individual’s rash. It involves

applying putative allergens to the patient’s skin, leaving the test

patches undisturbed for 2 days, removing them and then reading

the final result after 4 days. A positive result is indicated by an

inflammatory reaction at the site of the patch.

OSCE example 1: Pruritus

Mr Thomson, 45 years old, presents with a 4-month history of intense

itch disturbing his sleep.

Please examine his skin

• Introduce yourself to the patient and clean your hands.

• Ask him to undress to underwear.

• Carry out a general inspection, observing for scratch marks (and

whether they are symmetrical), colour and dryness of the skin,

presence of a rash, pallor, jaundice, exophthalmos or goitre.

• Palpate the pulse for tachycardia and atrial fibrillation.

• Examine the hands and insteps for scabietic burrows, fine tremor,

thyroid acropachy and koilonychia.

• Examine the abdomen for an enlarged liver or spleen.

• Examine the mouth for a smooth tongue or angular cheilitis.

• Test for dermographism.

• Examine for lymphadenopathy.

• Thank the patient and clean your hands.

Suggest a differential diagnosis

Intense pruritus may be caused by dermatoses such as scabies and

dermatitis herpetiformis, but also by systemic disorders such as

polycythaemia, iron deficiency, liver or renal dysfunction, hyper- or

hypothyroidism, and lymphoma.

Suggest investigations

Full blood count, renal, liver and thyroid function tests, ferritin level and

chest X-ray.

Investigations • 293

14

OSCE example 2: Pigmented lesion

Ms Forsythe, 55 years old, presents with a 6-week history of a

changing pigmented lesion on her right calf.

Please examine her skin

• Introduce yourself to the patient and clean your hands.

• Ask her to undress to underwear.

• Carry out a general inspection of the skin, estimating her Fitzpatrick

skin type, and observing for signs of actinic damage and for other

lesions that might require close assessment.

• Observe the lesion on her calf for size, symmetry, regularity of

margins, variation of pigmentation and ulceration.

• Palpate the lesion.

• Examine for enlargement of regional lymph nodes.

• Examine the abdomen for an enlarged liver.

• Undertake a similar examination of any other suspicious lesions.

• Thank the patient and clean your hands.

Suggest a differential diagnosis

Any changing lesion should raise suspicion of malignant melanoma,

although melanocytic naevi, seborrhoeic keratoses, dermatofibromas,

haemangiomas and pigmented basal cell carcinomas can cause

diagnostic confusion.

Suggested investigations

If, after examination, there is still suspicion regarding the malignant

potential of the lesion, it should be excised for histological examination.

Integrated examination sequence for the skin

• Prepare the patient:

• Arrange for privacy.

• Arrange for a chaperone, if necessary.

• Remove sufficient clothing.

• Remove makeup and wigs, if face and scalp are being examined.

• Carry out a general examination of the skin:

• Look for excoriations, xerosis (dry skin), actinic damage and

suspicious lesions, for example.

• Carry out a specific examination of a rash:

• Extent.

• Distribution: symmetry, pattern.

• Morphology.

• Colour.

• Erythema/purpura.

• Specific features, e.g. scale, signs of infection/infestation.

• Mouth, hair and nails.

• Regional lymph nodes.

• Carry out a specific examination of a lesion:

• Site, size, colour.

• Symmetry.

• Surface texture.

• Consistency.

• Mobility.

• Pattern of vasculature.

• Regional lymph nodes.

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Section 3

Applying history

and examination skills

in specific situations

15 Babies and children 297

16 The patient with mental disorder 319

17 The frail elderly patient 329

18 The deteriorating patient 339

19 The dying patient 347

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15

Babies and children

Ben Stenson

Steve Cunningham

Babies 298

The history 298

Maternal history 298

Pregnancy history 298

Birth history 298

Infant’s progress 298

Presenting problems and definitions 298

The physical examination of newborns 299

Timing and efficacy of the routine neonatal examination 299

General examination 299

Cardiovascular examination 301

Respiratory examination 302

Abdominal examination 303

Neurological examination 304

Limbs 305

Weighing and measuring 306

Final inspection 307

The physical examination of infants beyond the newborn period 307

Older children 307

The history 307

Obtaining a history from children compared with adults 307

Common presenting symptoms 308

Past medical history 310

Birth history 310

Vaccination history 310

Developmental history 310

Drug history 310

Family and social history 310

Systematic enquiry 310

The physical examination 310

Normal growth and development 310

Physical examination techniques in children 312

The acutely unwell child 313

General examination 313

Ears, nose and throat 314

Cardiovascular examination 315

Respiratory examination 315

Abdominal examination 315

Neurological examination 315

Spotting the sick child 315

Child protection 315

OSCE example case 1: Cyanotic episodes 317

OSCE example 2: Asthma 317

Integrated examination sequence for the newborn child 318

298 • Babies and children

BABIES

15.1 Classification of newborn infants

Birthweight

• Extremely low: <1000 g

• Very low: <1500 g

• Low: <2500 g

• Normal: ≥2500 g

Gestational age

• Extremely preterm: <28 weeks

• Preterm: <37 weeks (<259th day)

• Term: 37–42 weeks

• Post-term: >42 weeks (>294th day)

15.2 Apgar score

Clinical score 0 1 2

Heart rate Absent <100 bpm >100 bpm

Respiratory

effort

Absent Slow and

irregular

Good: strong

Muscle tone Flaccid Some flexion of

arms and legs

Active movement

Reflex

irritability

No

responses

Grimace Vigorous crying,

sneeze or cough

Colour Blue, pale Pink body, blue

extremities

Pink all over

Add scores for each line; maximum score is 10.

bpm, beats per minute.

Reproduced with permission of International Anesthesia Research Society from

Current researches in Anesthesia & Analgesia Apgar V 1953; 32(4), permission

conveyed through Copyright Clearance Center, Inc.

A baby is a neonate for its first 4 weeks and an infant for its first

year. Neonates are classified by gestational age or birthweight

(Box 15.1).

The history

Ask the mother and look in the maternal notes for relevant

history:

Maternal history

Is there a family history of significant illness (e.g. diabetes,

hereditary illnesses)?

What were the outcomes of any previous pregnancies?

Pregnancy history

How was maternal health?

Did the mother take medications or other drugs?

What did antenatal screening tests show?

Birth history

What was the birthweight, gestation at birth and mode of

delivery?

Was there prolonged rupture of the fetal membranes or

maternal pyrexia?

Was there a non-reassuring fetal status during delivery or

meconium staining of the amniotic fluid?

Was resuscitation required after birth?

What were the Apgar scores (Box 15.2) and the results of

umbilical cord blood gas tests?

Infant’s progress

Has the infant passed meconium and urine since

birth?

In later infancy, what are the specific signs and systems

and developmental progress, depending on the presenting

problem?

Presenting problems and definitions

Infants cannot report symptoms, so you must recognise the

presenting problems and signs of illness, which are non-specific

in young infants. Always take the concerns of parents seriously.

Pallor

Always investigate pallor in a newborn, as it implies anaemia or

poor perfusion. Newborn infants have higher haemoglobin levels

than older children and are not normally pale. Haemoglobin levels

of <120 g/L (<12 g/dL) in the perinatal period are low. Preterm

infants look red because they lack subcutaneous fat.

Respiratory distress

Respiratory distress is tachypnoea (respiratory rate) >60 breaths

per minute with intercostal and subcostal indrawing, sternal

recession, nasal flaring and the use of accessory muscles.

Cyanosis

Bluish discoloration of the lips and mucous membranes due

to hypoxia is difficult to see in newborn infants unless oxygen

saturation (SpO2) is <80% (normal is >95%). Causes include

congenital heart disease and respiratory disease, and cyanosis

always needs investigation (p. 28).

Acrocyanosis

Acrocyanosis is a bluish-purple discoloration of the hands and feet

and is a normal finding, provided the newborn is centrally pink.

Jaundice

Many newborns develop jaundice in the days after birth. Look for

yellow sclerae in newborns with coloured skin or you may miss

it. Examine the baby in bright normal light. Normal physiological

jaundice cannot be distinguished clinically from jaundice from

a pathological cause. Do not use clinical estimates instead of

measurements to evaluate jaundice.

The physical examination of newborns • 299

15

but avoid an overly rigid approach as you may be unable to

perform key elements if you unsettle the baby. Do things that

may disturb the baby later in the examination.

Examination sequence

• Observe whether the baby looks well and is well grown.

• Look for:

• cyanosis

respiratory distress

pallor

plethora (suggesting polycythaemia).

Note posture and behaviour.

Note any dysmorphic features.

Auscultate the heart and palpate the abdomen if the baby

is quiet.

If the baby cries, does the cry sound normal?

Skin

Normal findings

The skin may look normal, dry, wrinkled or vernix-covered in

healthy babies. There may be meconium staining of the skin

and nails.

Prominent capillaries commonly cause pink areas called ‘stork’s

beak marks’ at the nape of the neck, eyelids and glabella (Fig.

15.1). Facial marks fade spontaneously over months; those

on the neck often persist. Milia (fine white spots) and acne

neonatorum (larger cream-coloured spots) are collected glandular

secretions and disappear within 2–4 weeks. Erythema toxicum

is a common fleeting, blanching, idiopathic maculopapular rash

of no consequence, affecting the trunk, face and limbs in the

first few days after birth.

Abnormal findings

Document any trauma such as scalp cuts or bruising.

Dense capillary haemangiomas (port wine stains) will not

fade. Referral to a dermatologist is advisable, as laser treatment

may help in some cases. Around the eye they may indicate

Sturge–Weber syndrome (a facial port wine stain with an

underlying brain lesion, associated with risk of later seizures,

cerebral calcification and reduced cognitive function). Melanocytic

naevi require follow-up and treatment by a plastic surgeon or

dermatologist. A Mongolian blue spot (Fig. 15.2) is an area of

bluish discoloration over the buttocks, back and thighs. Easily

mistaken for bruising, it usually fades in the first year.

Jitteriness

Jitteriness is high-frequency tremor of the limbs, and is common

in term infants in the first few days. It is stilled by stimulating the

infant and is not associated with other disturbance. If jitteriness is

excessive, exclude hypoglycaemia, polycythaemia and neonatal

abstinence syndrome (drug withdrawal). Infrequent jerks in light

sleep are common and normal; regular clonic jerks are abnormal.

Dysmorphism

Identifying abnormal body structure (dysmorphism) is subjective

because of human variability. Individual features may be minor and

isolated, or may signify a major problem requiring investigation

and management. A recognisable pattern of several dysmorphic

features may indicate a ‘dysmorphic syndrome’ such as Down’s

syndrome (p. 36). Use caution and sensitivity when discussing

possible dysmorphism with parents of a newborn child.

Hypotonia

Hypotonia (reduced tone) may be obvious when you handle an

infant. Term infants’ muscle tone normally produces a flexed

posture at the hips, knees and elbows. Hypotonic infants may

lack this flexion. Hypotonia can occur with hypoxia, hypoglycaemia

or sepsis, or may be due to a specific brain, nerve or muscle

problem. Preterm infants have lower tone than term infants and

are less flexed.

Apgar score

This first clinical assessment of a neonate is made immediately

after birth. Tone, colour, breathing, heart rate and response

to stimulation are each scored 0, 1 or 2 (Box 15.2), giving a

maximum total of 10. Healthy neonates commonly score 8–10 at

1 and 5 minutes. The score predicts the need for, and efficacy of,

resuscitation. A low score should increase with time; a decreasing

score is a cause for concern. Persistently low scores at 10

minutes predict death or later disability. Neonates with scores

of less than 8 at 5 minutes require continued evaluation until it

is clear they are healthy.

The physical examination of newborns

Timing and efficacy of the routine

neonatal examination

Examine a newborn with the parents present. There is no ideal

time. If it is performed on day 1, some forms of congenital heart

disease may be missed because signs have not developed. If

it is delayed, some babies will present before the examination

with illness that may have been detectable earlier. Around 9%

of neonates have an identifiable congenital abnormality but most

are not serious. Always record your examination comprehensively

to avoid problems if illness or physical abnormality is identified

later. Fewer than half of all cases of congenital heart disease

or congenital cataract are detected by newborn examination.

General examination

Examine babies and infants in a warm place on a firm bed or

examination table. Have a system to avoid omitting anything, Fig. 15.1 Stork’s beak mark.

300 • Babies and children

Separated cranial sutures with an obvious gap indicate raised

intracranial pressure. Rarely, the cranial sutures are prematurely

fused (synostosis), producing ridging, and the head shape

is usually abnormal. Abnormal head size requires detailed

investigation, including neuroimaging.

Eyes

Examination sequence

Inspect the eyebrows, lashes, lids and eyeballs.

• Gently retract the lower eyelid and check the sclera for

jaundice.

Test ocular movements and vestibular function:

Turn the newborn’s head to one side; watch as the

eyes move in the opposite direction. These are called

doll’s-eye movements and disappear in infancy (see

Fig. 8.15).

Hold the infant upright at arm’s length and move in a

horizontal arc. The infant should look in the direction of

movement and have optokinetic nystagmus. This

response becomes damped by 3 months.

Normal findings

Harmless yellow crusting without inflammation is common after

birth in infants with narrow lacrimal ducts.

Term infants usually fix visually.

Abnormal findings

Eye infection gives a red eye and purulent secretions. An abnormal

pupil shape is usually a coloboma (a defect in the iris inferiorly

that gives the pupil a keyhole appearance, Fig. 15.4). This can

also affect deeper structures, including the optic nerve, and lead

to visual impairment. It can be associated with syndromes, as

can microphthalmia (small eyeballs). Large eyeballs that feel hard

when palpated through the lids suggest congenital glaucoma

(buphthalmos).

Ophthalmoscopy

Examination sequence

Hold the baby in your arms. Turn your body from side to

side so that the baby will open their eyes.

Subcutaneous fat necrosis causes palpable firm plaques, often

with some erythema under the skin. If extensive, there can be

associated hypercalcaemia that may require treatment. Blisters

or bullae are usually pathological.

Head

Examination sequence

Note the baby’s head shape (Box 15.3) and any swellings.

Feel the anterior fontanelle (Fig. 15.3). Is it sunken, flat or

bulging?

Palpate the cranial sutures.

Normal findings

Transient elongation of the head is common from moulding

during birth. Caput succedaneum is soft-tissue swelling over

the vertex due to pressure in labour. Overriding cranial sutures

have a palpable step.

Abnormal findings

Cephalhaematoma is a firm, immobile, usually parietal swelling

caused by a localised haemorrhage under the cranial periosteum.

It may be bilateral, and periosteal reaction at the margins causes

a raised edge. No treatment is required. Do not confuse this

with the boggy, mobile, poorly localised swelling of subgaleal

haemorrhage (beneath the flat sheet of fibrous tissue that caps the

skull), which can conceal a large blood loss and is life-threatening

if unrecognised.

Fig. 15.2 Mongolian blue spot.

15.3 Neonatal head shapes

Head shape Description

Microcephalic (small-headed) Small cranial vault

Megalencephalic (large-headed) Large cranial vault

Hydrocephalic (water-headed) Large cranial vault due to

enlarged ventricles

Brachycephalic (short-headed) Flat head around the occiput

Dolichocephalic (long-headed) Head that looks long relative to

its width

Plagiocephalic (oblique-headed) Asymmetrical skull

Anterior fontanelle

Posterior fontanelle

Sagittal suture

Frontal bone

Frontal suture

Sinciput

Occiput

Parietal bone

and eminence

Lambdoid suture

Fig. 15.3 The fetal skull from above.

The physical examination of newborns • 301

15

Cleft palate may involve the soft palate or both hard and soft

palates. It can be midline, unilateral or bilateral and may also

involve the gum (alveolus). Cleft lip can appear in isolation or

in association with it. Refer affected infants early to a specialist

multidisciplinary team. Micrognathia (a small jaw) is sometimes

associated with cleft palate in the Pierre Robin syndrome,

with posterior displacement of the tongue and upper airway

obstruction.

A ranula is a mucous cyst on the floor of the mouth that

is related to the sublingual or submandibular salivary ducts.

Congenital ranulas may resolve spontaneously but sometimes

require surgery.

Teeth usually begin to erupt at around 6 months but can be

present at birth.

Ears

Examination sequence

Note the size, shape and position.

The helix should attach above an imaginary line through

the inner corners of the eyes.

Check that the external auditory meatus looks normal.

Normal findings

The helix can be temporarily folded due to local pressure in utero.

Preauricular skin tags do not require investigation.

Abnormal findings

Abnormal ear shape and position is a feature of some syndromes.

Neck

Examination sequence

Inspect the neck for asymmetry, sinuses and swellings.

Palpate any masses. Use ‘SPACESPIT’ (see Box 3.8) to

interpret your findings.

Transilluminate swellings. Cystic swellings glow, as the

light is transmitted through clear liquid. Solid or blood-filled

swellings do not.

Normal findings

One-third of normal neonates have palpable cervical, inguinal

or axillary lymph nodes. Neck asymmetry is often due to fetal

posture and usually resolves.

Abnormal findings

A lump in the sternocleidomastoid muscle (sternomastoid

‘tumour’) is caused by a fibrosed haematoma with resultant

muscle shortening. This may produce torticollis, with the head

turned in the contralateral direction.

Cardiovascular examination

Examination sequence

Observe the baby for pallor, cyanosis and sweating.

Count the respiratory rate.

Palpate for the apex beat with your palm in the

mid-clavicular line in the fourth or fifth intercostal space.

Note if the heart beat moves your hand up and down

(parasternal heave) or if you feel a vibration (thrill).

Count the heart rate for 15 seconds and multiply by 4.

Look at each pupil from about 20 cm through the

ophthalmoscope. You should see the red reflex of

reflected light from the retina.

Normal findings

Puffy eyes in the first days after birth impede the examination.

If this happens, always examine again later because failure to

detect and treat a cataract will cause permanent amblyopia.

Abnormal findings

An absent red reflex suggests cataract; refer to an ophthalmologist.

Nose

Examination sequence

Exclude obstructed nostrils (choanal atresia) by blocking

each nostril in turn with your finger to check that the infant

breathes easily through the other.

Mouth

Examination sequence

Gently press down on the lower jaw so that the baby will

open their mouth. Do not use a wooden tongue

depressor, as this may cause trauma or infection.

Shine a torch into the mouth and look at the tongue and

palate.

Palpate the palate using your fingertip.

Normal findings

Epstein’s pearls are small, white mucosal cysts on the palate

that disappear spontaneously.

White coating on the tongue that is easily scraped off with a

swab is usually curdled milk.

Abnormal findings

Ankyloglossia (tongue tie) is when the lingual frenulum joining the

underside of the tongue to the floor of the mouth is abnormally

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