and pubic, axillary and beard areas.
Abnormalities in hair distribution can occur when there is
transitioning between vellus and terminal hair types (for example,
hirsutism in women) or vice versa (androgenic alopecia). Hairs
undergo regular asynchronous cycles of growth and thus, in
health, mass shedding of hair is unusual. Hair loss can occur as a
result of disorders of hair cycling, conditions resulting in damage
to hair follicles (such as purposeful removal in trichotillomania),
or structural (fragile) hair disorders.
The nail is a plate of densely packed, hardened, keratinised cells
produced by the nail matrix. It serves to protect the fingertip
and aid grasp and fingertip sensitivity. The white lunula at the
base of the nail is the visible distal aspect of the nail matrix (Fig.
14.2). Fingernail regrowth takes approximately 6 months, and
toenail regrowth 12–18 months.
The possible diagnoses in dermatological conditions are broad
and some diseases have pathognomonic features. Thus, in order
to ensure that your history taking is focused and relevant, it
may be appropriate to ask to glimpse the lesion or rash before
embarking on detailed enquiry.
• a rash: scaly, blistering or itchy
• hair loss or excess hair (hirsutism, hypertrichosis)
• When did the lesion appear or the rash begin?
• Has the rash spread, or the lesion changed, since its
• Is the lesion tender or painful? Is the rash itchy? Is the itch
intense enough to cause bleeding by scratching or to
disturb sleep, as in atopic eczema and lichen simplex? Are
• Do the symptoms vary with time? For example, the
pruritus of scabies is usually worse at night, and acne
and atopic eczema may show a premenstrual
• Were there any preceding symptoms, such as a
sore throat in psoriasis, a severe illness in telogen
effluvium, or a new oral medication in drug
• Are there any aggravating or relieving factors? For
example, exercise or exposure to heat may precipitate
• What, if any, has been the effect of topical or oral
medications? Self-medication with oral antihistamines may
ameliorate urticaria, and topical glucocorticoids may help
• Are there any associated constitutional symptoms,
such as joint pain (psoriasis), muscle pain and
weakness (dermatomyositis), fever, fatigue or
• Very importantly, what is the impact of the rash on the
Ask about general health and previous medical or skin conditions;
a history of asthma, hay fever or childhood eczema suggests
atopy. Coeliac disease is associated with dermatitis herpetiformis.
Take a full drug history, including any recent oral or topical
prescribed or over-the-counter medication. Enquire about allergies
not just to medicines but also to animals or foods.
Fig. 14.2 Structure of the nail. A Dorsal view. B Cross-section.
Proximal nail fold (paronychium)
286 • The skin, hair and nails
Enquire about occupation and hobbies, as exposure to chemicals
may cause contact dermatitis. If a rash consistently improves
when a patient is away from work, the possibility of industrial
dermatitis should be considered. Ask about alcohol consumption
Document foreign travel and sun exposure if actinic damage,
tropical infections or photosensitive eruptions are being considered.
The risk of squamous cell and basal cell cancers increases
with total lifetime sun exposure, and intense sun exposures
leading to blistering burns are a risk factor for melanoma. The
susceptibility of an individual to sun-induced damage can be
determined by defining their skin type using the Fitzpatrick scale
Ask about a family history of atopy and skin conditions.
The history of a skin disorder alone rarely enables a definite
diagnosis, with perhaps the occasional exception: an itchy eruption
that resembles a nettle rash, the individual components of which
last less than 24 hours, is very likely to be urticaria; and an
intensely itchy eruption that affects all body areas except the
head (in adults) and is worse in bed at night should be considered
to be scabies until proved otherwise.
Proper assessment of the skin involves all the human senses,
with the exception of taste. Once we have listened to the
patient’s history, we look at the rash or lesion, touch the skin,
and occasionally use our sense of smell to diagnose infection
and metabolic disorders such as trimethylaminuria (fish odour
Examination of the skin should be performed under conditions
of privacy in an adequately lit, warm room with, when appropriate,
a chaperone present (p. 20). The patient should ideally be
undressed to their underwear. Routinely, the hair, nails and oral
cavity (p. 187) should be examined, and the regional lymph
nodes (p. 33) palpated. Assess skin type using the Fitzpatrick
In documenting the appearance of a lesion or rash, use the
correct descriptive terminology (Box 14.3); doing so often helps
crystallise the diagnostic thought processes.
The distribution of a dermatosis can be very informative. Is the
eruption symmetrical? If so, it is likely to have a constitutional
basis, and if not, it may well have an extrinsic cause. This
golden rule has occasional exceptions (such as lichen simplex)
but holds true in the majority of instances. Its application will
almost always prevent the common misdiagnosis of ‘bilateral
cellulitis’ (bacterial infection) of the legs, which in actuality is
usually lipodermatosclerosis or varicose eczema; bacteria are
not known for their sense of symmetry!
The pattern of a rash may immediately suggest a diagnosis: for
example, the antecubital and popliteal fossae in atopic eczema
(Fig. 14.3A); the extensor limb surfaces, scalp, nails and umbilicus
in psoriasis (Fig. 14.3B); the flexural aspects of the wrists and
the oral mucous membranes in lichen planus; the scalp, alar
grooves and nasolabial folds in seborrhoeic dermatitis; and the
sparing of covered areas in photosensitive eruptions. Does the
rash follow a dermatome (as with shingles), or Langer’s lines of
skin tension (as with pityriasis rosea), or Blaschko (developmental)
lines (as with certain genetic disorders)? The localisation of an
eruption to fresh scars or tattoos may be a manifestation of
sarcoidosis, and the anatomical location may provide a clue to
diagnosis, such as the tendency of erythema nodosum, pretibial
myxoedema and necrobiosis lipoidica (Fig. 14.4) to involve
The morphology (shape and pattern) of a rash is equally
important. Violaceous, polygonal, flat-topped papules, topped
by a lacy patterning (Wickham striae), are typical of lichen planus
(Fig. 14.5). The Koebner (isomorphic) phenomenon, where a
dermatosis is induced by superficial epidermal injury, results in
linear configurations (Fig. 14.6A), and occurs par excellence in
14.2 Fitzpatrick scale of skin types
• Type 1: always burns, never tans
• Type 2: usually burns, tans minimally
• Type 3: sometimes burns, usually tans
• Type 4: always tans, occasionally burns
• Type 5: tans easily, rarely burns
• Type 6: never burns, permanent deep pigmentation
Fig. 14.3 Distribution of rash. A Atopic eczema localising to the
flexural aspect of the knees. B Psoriasis involving the extensor aspect of
The physical examination • 287
psoriasis, lichen planus, viral warts and molluscum contagiosum.
Linear or angular markings (erythema or scarring) raise the
likelihood of artefactual (self-inflicted) damage to the skin. The
presence of blisters limits the diagnostic possibilities to a relatively
small number of autoimmune (such as dermatitis herpetiformis,
pemphigoid (Fig. 14.6B) and pemphigus), reactive (including
Abscess A collection of pus, often associated with signs
and symptoms of inflammation (includes boils and
Angioedema Deep swelling (oedema) of the dermis and
Atrophy Thinning of one or more layers of the skin
Blister A liquid-filled lesion (vesicles and bullae)
Bulla A large blister (>0.5 cm)
Burrow A track left by a burrowing scabies mite
Callus (callosity) A thickened area of skin that is a response to
Crust (scab) A hard, adherent surface change caused by
leakage and drying of blood, serum or pus
Cyst A fluid-filled papular lesion that fluctuates and
Erosion A superficial loss of skin, involving the epidermis;
scarring is not normally a result
Erythema Redness of the skin that blanches on pressure
Erythroderma Any inflammatory skin disease that affects >80%
Fissure A split, usually extending from the skin surface
through the epidermis to the dermis
Freckle An area of hyperpigmentation that increases in the
summer months and decreases during winter
Haematoma A swelling caused by a collection of blood
Horn A hyperkeratotic projection from the skin surface
Hyperkeratosis Thickening of the stratum corneum
Keratosis A lesion characterised by hyperkeratosis
Lentigo An area of fixed hyperpigmentation
Lichenification Thickening of the epidermis, resulting in
accentuation of skin markings; usually indicative of
Macule A flat (impalpable) colour change
Naevus A localised developmental defect (vascular,
melanocytic, epidermal or connective tissue)
Nodule A large papule (>0.5 cm)
Onycholysis Separation of the nail plate from the nail bed
Papilloma A benign growth projecting from the skin surface
Papule An elevated (palpable) lesion, arbitrarily <0.5 cm
Petechiae Pinhead-sized macular purpura
Pigmentation A change in skin colour
Plaque A papule or nodule that in cross-sectional profile is
Poikiloderma A combination of atrophy, hyperpigmentation and
Purpura Non-blanchable redness (also called petechiae)
Pustule A papular lesion containing turbid purulent material
Scale A flake on the skin surface, composed of stratum
corneum cells (corneocytes), shed together rather
Scar The fibrous tissue resulting from the healing of a
wound, ulcer or certain inflammatory conditions
Telangiectasia Dilated blood vessels
Ulcer A deep loss of skin, extending into the dermis or
deeper; usually results in scarring
Umbilication A depression at the centre of a lesion
Vesicle A small blister (<0.5 cm)
Wheal A transient (<24 hours), itchy, elevated area of
skin resulting from dermal oedema that
Xerosis Mild/moderate dryness of the skin
erythema multiforme, Stevens–Johnson syndrome and toxic
epidermal necrolysis), infective (such as bullous impetigo and
herpes simplex infection) and inherited (for example, epidermolysis
bullosa) disorders. An annular (ring-like) morphology may be seen
in granuloma annulare (Fig. 14.6C), subacute cutaneous lupus
erythematosus, and fungal infections (‘ringworm’).
288 • The skin, hair and nails
extravasation and entrapment in the collagen and elastic fibres
The tint of the erythema may be helpful: a violaceous hue
distinguishes lichen planus; a beefy-red or salmon-pink colour
often typifies psoriasis; and a heliotrope (pink–purple) colour is
a feature of dermatomyositis, especially on the eyelids.
Macular purpura may be the result of thrombocytopenia or
capillary fragility, but palpable purpura (often painful) usually
indicates vasculitis (Fig. 14.7A) and necessitates exclusion of
vasculitic inflammation in other organs. Purpura elicitable by
pinching the skin (‘pinch purpura’) may be indicative of AL
(light-chain) amyloidosis (Fig. 14.7B).
The vascular contribution to the colour of a rash can be pivotal
in diagnosis since erythematous and purpuric eruptions usually
have very different underlying causes. It is not sufficient to describe
a rash as ‘red’ or ‘pink’; it is essential to demonstrate whether
or not a rash blanches on direct pressure or when the skin
is stretched. Blanchable redness (erythema) indicates that the
red blood cells causing the colour remain within blood vessels;
non-blanchable redness (purpura) is the result of erythrocyte
Fig. 14.4 Necrobiosis lipoidica diabeticorum.
Fig. 14.5 Lichen planus. A Discrete flat-topped papules on the wrist.
B Wickham striae, visible on close inspection. C A white lacy network of
Fig. 14.6 Rash morphology. A Koebner response. B Pemphigoid.
The physical examination • 289
There are also a number of subtle clinical signs that can be of
great diagnostic help in common rashes, such as the distinctive
silver-coloured scale that appears when psoriasis is scratched
with a wooden orange stick (Fig. 14.8AB), the urtication that
develops when the pigmented lesions of urticaria pigmentosa
(a form of cutaneous mastocytosis) are rubbed (Darier’s sign),
the separation of epidermis on applying a shearing force in
pemphigus (Nikolsky’s sign), and the very earliest lesions of
lichen planus glinting in reflected light like stars in the night sky
Scratch marks (excoriations) indicate an itchy rash. In any
pruritic eruption it is prudent to look specifically for the burrows
of scabies (Fig. 14.9) on the hands and feet, as well as testing
for dermographism and examining for lymphadenopathy (p. 33),
as urticaria and lymphoma are also important causes of itch.
Fig. 14.7 Purpura. A Cutaneous vasculitis. B AL (light-chain) amyloidosis.
Fig. 14.8 Clinical signs in the diagnosis of skin disease. A Psoriasis
before rubbing the surface. B After surface rubbing. C Lichen planus
showing light reflection from small early lesions.
290 • The skin, hair and nails
Fig. 14.10 Lesion morphology. A Malignant
A B melanoma. B Seborrhoeic keratosis.
Lesions should be measured and described according to
their anatomical location, colour, symmetry, surface texture,
consistency, demarcation of margin, and whether they are
freely mobile or attached to underlying tissue (p. 32). Remember
to examine the regional lymph nodes. If a pigmented lesion
demonstrates a variable outline and colour variation, the possibility
of malignant melanoma must be considered (Fig. 14.10A). It
is reassuring to see hair growing out of pigmented lesions, as
this usually indicates a benign process such as a melanocytic
naevus. An irregularly roughened, jagged surface texture is
often indicative of sunlight-induced damage (actinic keratosis),
whereas the surface of a seborrhoeic keratosis (Fig. 14.10B) has
a smoother feel. The consistency of a lesion is often of diagnostic
help: for example, the firm, button-like quality of a dermatofibroma
is very characteristic; neurofibromas are rather soft; calcium
deposits are hard; and cysts fluctuate and transilluminate. Basal
cell carcinoma, the most common malignant tumour, is usually
smooth (but may ulcerate); on inspection, it exhibits a milky,
pearlescent colour (which may glint) and irregular telangiectasia
General physical examination should always include the hair
and nails. Is there excess hair, either in a masculine distribution
(hirsutism) or not (hypertrichosis), or hair loss (alopecia)? Hirsutism
may be a marker for hyperandrogenism, and hypertrichosis
may be seen in malnutrition states, malignancy and porphyria
cutanea tarda. Discrete, coin-sized areas of hair loss, with small
‘exclamation mark’ hairs at the periphery, are characteristic of
alopecia areata (Fig. 14.12), an autoimmune disorder that may
coexist with other autoimmune disorders. Diffuse, pronounced
hair shedding (telogen effluvium) may be a physiological response
to severe illness, major surgical operations or childbirth, and
may be accompanied by transverse grooves on the finger nails,
which gradually grow out normally (Beau’s lines; see Fig. 3.7B).
Common abnormalities of the nails associated with underlying
disease are covered on page 24 and in Box 3.4 and Fig. 3.7.
The physical examination • 291
Some rare diseases produce specific nail appearances,
such as the ‘ragged cuticles’ and abnormal capillary nail-bed
loops associated with dermatomyositis (Fig. 14.13AB), and the
progressive thickening and opacification of nails in yellow nail
Supplementary examination techniques
It is often necessary to complement naked-eye observation of the
skin with assisted examination techniques, such as dermatoscopy,
A dermatoscope consists of a powerful light source (polarised or
non-polarised) and a magnifying lens, and enables considerably
more cutaneous anatomical detail to be seen (Fig. 14.14).
292 • The skin, hair and nails
Dermatoscopy is particularly useful in the assessment of
pigmented lesions but is also often of great help in assessing
other skin tumours, hair disorders and certain infections (scabies,
viral warts and molluscum contagiosum).
The pressure of a glass slide on the skin will compress the
cutaneous blood vessels and blanch the area of contact. If blood
is still visible through the glass, it is because red blood cells have
extravasated (purpura). When granulomatous disorders (such as
sarcoidosis or granuloma annulare) are diascoped, they typically
manifest a green–brown (‘apple jelly’) colour.
Examination of the skin using an ultraviolet light (Wood’s lamp) is
useful in two clinical situations: it enhances the contrast between
normal skin and under- or overpigmented epidermis (making
conditions such as vitiligo and melasma easier to see); and it can
identify certain infections by inducing the causative organisms
to fluoresce (such as erythrasma, pityriasis versicolor and some
After clinical examination, specific investigative techniques may
be necessary in some cases to enable a precise diagnosis.
This involves a sample of skin being removed, under local
anaesthesia, and subjected to histological or immunohistochemical
examination in the laboratory. However, clinicopathological
correlation is usually necessary.
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
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.
Mr Thomson, 45 years old, presents with a 4-month history of intense
• 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.
• 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
Full blood count, renal, liver and thyroid function tests, ferritin level and
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.
• 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.
• 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
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
• Arrange for a chaperone, if necessary.
• 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:
• Distribution: symmetry, pattern.
• Specific features, e.g. scale, signs of infection/infestation.
• Carry out a specific examination of a lesion:
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16 The patient with mental disorder 319
17 The frail elderly patient 329
18 The deteriorating patient 339
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Presenting problems and definitions 298
The physical examination of newborns 299
Timing and efficacy of the routine neonatal examination 299
Cardiovascular examination 301
The physical examination of infants beyond the newborn period 307
Obtaining a history from children compared with adults 307
Common presenting symptoms 308
Normal growth and development 310
Physical examination techniques in children 312
Cardiovascular examination 315
OSCE example case 1: Cyanotic episodes 317
Integrated examination sequence for the newborn child 318
15.1 Classification of newborn infants
• Extremely preterm: <28 weeks
• Preterm: <37 weeks (<259th day)
• Post-term: >42 weeks (>294th day)
Heart rate Absent <100 bpm >100 bpm
Muscle tone Flaccid Some flexion of
Colour Blue, pale Pink body, blue
Add scores for each line; maximum score is 10.
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
Ask the mother and look in the maternal notes for relevant
• Is there a family history of significant illness (e.g. diabetes,
• What were the outcomes of any previous pregnancies?
• Did the mother take medications or other drugs?
• What did antenatal screening tests show?
• What was the birthweight, gestation at birth and mode of
• Was there prolonged rupture of the fetal membranes or
• 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?
• Has the infant passed meconium and urine since
• In later infancy, what are the specific signs and systems
and developmental progress, depending on the presenting
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.
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 is tachypnoea (respiratory rate) >60 breaths
per minute with intercostal and subcostal indrawing, sternal
recession, nasal flaring and the use of accessory muscles.
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 is a bluish-purple discoloration of the hands and feet
and is a normal finding, provided the newborn is centrally pink.
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
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.
• Observe whether the baby looks well and is well grown.
• plethora (suggesting polycythaemia).
• Note any dysmorphic features.
• Auscultate the heart and palpate the abdomen if the baby
• If the baby cries, does the cry sound normal?
The skin may look normal, dry, wrinkled or vernix-covered in
healthy babies. There may be meconium staining of the skin
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
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 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.
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 (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
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
The physical examination of newborns
Timing and efficacy of the routine
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.
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.
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.
• Inspect the eyebrows, lashes, lids and eyeballs.
• Gently retract the lower eyelid and check the sclera for
• 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
• 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.
Harmless yellow crusting without inflammation is common after
birth in infants with narrow lacrimal ducts.
Term infants usually fix visually.
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
• 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.
• Note the baby’s head shape (Box 15.3) and any swellings.
• Feel the anterior fontanelle (Fig. 15.3). Is it sunken, flat or
• Palpate the cranial sutures.
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
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
Fig. 15.2 Mongolian blue spot.
Microcephalic (small-headed) Small cranial vault
Megalencephalic (large-headed) Large cranial vault
Hydrocephalic (water-headed) Large cranial vault due to
Brachycephalic (short-headed) Flat head around the occiput
Dolichocephalic (long-headed) Head that looks long relative to
Plagiocephalic (oblique-headed) Asymmetrical skull
Fig. 15.3 The fetal skull from above.
The physical examination of newborns • 301
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
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
Teeth usually begin to erupt at around 6 months but can be
• 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.
The helix can be temporarily folded due to local pressure in utero.
Preauricular skin tags do not require investigation.
Abnormal ear shape and position is a feature of some syndromes.
• Inspect the neck for asymmetry, sinuses and swellings.
• Palpate any masses. Use ‘SPACESPIT’ (see Box 3.8) to
• Transilluminate swellings. Cystic swellings glow, as the
light is transmitted through clear liquid. Solid or blood-filled
One-third of normal neonates have palpable cervical, inguinal
or axillary lymph nodes. Neck asymmetry is often due to fetal
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.
• Observe the baby for pallor, cyanosis and sweating.
• 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.
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.
An absent red reflex suggests cataract; refer to an ophthalmologist.
• Exclude obstructed nostrils (choanal atresia) by blocking
each nostril in turn with your finger to check that the infant
breathes easily through the other.
• 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
• Palpate the palate using your fingertip.
Epstein’s pearls are small, white mucosal cysts on the palate
White coating on the tongue that is easily scraped off with a
Ankyloglossia (tongue tie) is when the lingual frenulum joining the
underside of the tongue to the floor of the mouth is abnormally
short, which may interfere with feeding. A white coating on the
tongue, which is not easily removed and may bleed when scraped,
is caused by Candida albicans (thrush). Macroglossia (a large
protruding tongue) occurs in Beckwith–Wiedemann syndrome. A
normal-sized tongue protrudes through a small mouth in Down’s
• Do not measure the blood pressure of healthy babies. In ill
babies, cuff measurements overestimate the values when
compared with invasive measurements. The cuff width
should be at least two-thirds of the distance from the
• Palpate the abdomen for hepatomegaly (see later).
In the early newborn period the femoral pulses may feel normal
in an infant who later presents with coarctation because an
open ductus arteriosus can maintain flow to the descending
aorta. Routine measurement of postductal oxygen saturation
is increasingly popular as an additional newborn screening test
for congenital heart disease. Lower limb SpO2 should be 95%
Heart rates between 80 and 160 beats per minute (bpm)
can be normal in the newborn, depending on the arousal state
Infants with heart failure typically look pale and sweaty, and have
respiratory distress (p. 298).
If the apex beat is displaced laterally, there may be cardiomegaly,
or mediastinal shift due to contralateral pneumothorax or pleural
Weak or absent femoral pulses suggest coarctation of the
aorta. Radiofemoral delay is not identifiable in the newborn.
Patent ductus arteriosus may cause a short systolic murmur in
the early days of life because the pulmonary and systemic blood
pressures are similar, which limits shunting through the duct.
The murmur progressively lengthens over subsequent weeks or
months to become the continuous ‘machinery’ murmur recognised
Transient murmurs are heard in up to 2% of neonates but only
a minority have a structural heart problem. An echocardiogram
is needed to make a structural diagnosis.
• Note chest shape and symmetry of chest movement.
• Count the respiratory rate (for 15 seconds and multiply
• Listen for additional noises with breathing.
• Look for signs of respiratory distress: tachypnoea;
suprasternal, intercostal and subcostal recession; flaring of
• Remember that percussion of the newborn’s chest is not
• Use the diaphragm to auscultate anteriorly, laterally and
posteriorly, comparing the sides. Breath sounds in the
healthy newborn have a bronchial quality compared with
Fig. 15.5 Palpating the femoral pulses. The pulse can be difficult to
feel at first. Use a point halfway between the pubic tubercle and the
anterior superior iliac spine as a guide.
Fig. 15.6 Auscultation positions in infants and children.
Recommended order of auscultation: 1, apex; 2, left lower sternal edge;
3, left upper sternal edge; 4, left infraclavicular; 5, right upper sternal
edge; 6, right lower sternal edge; 7, right mid-axillary line; 8, right side of
neck; 9, left side of neck; 10, posteriorly.
15.4 Normal ranges for heart and respiratory
Sign Preterm neonate Term neonate
Heart rate (beats per minute) 120–160 100–140
• Feel the femoral pulses by placing your thumbs or
fingertips over the mid-inguinal points while abducting the
• Auscultate the heart. Start at the apex using the
stethoscope bell (best for low-pitched sounds). Then use
the diaphragm in all positions for high-pitched sounds and
• Describe the heart sounds S1 and S2, any additional heart
sounds and the presence of murmurs. The fast heart rate
of a newborn makes it difficult to time additional sounds.
Take time to tune into the different rate of the harsh breath
sounds of a newborn, as they are easily confused with a
The physical examination of newborns • 303
Umbilical hernias are common; they are easily reduced, have a
very low risk of complications and close spontaneously in infancy.
An omphalocoele, or exomphalos (Fig. 15.7), is a herniation
through the umbilicus containing intestines and other viscera,
covered by a membrane that includes the umbilical cord. It
may be associated with other malformations or chromosomal
abnormality. Gastroschisis is a defect in the anterior abdominal
wall with intestines herniated through it, without a covering
membrane. The most common site is above and to the right
Inguinal hernias are common in the newborn, especially in
boys and preterm infants (Fig. 15.8).
Meconium in the nappy does not guarantee that the baby
has a patent anus because meconium can be passed through
• Abduct the legs and gently separate the labia.
• In preterm infants the labia minora appear prominent,
giving a masculinised appearance that resolves
spontaneously over a few weeks. Milky vaginal secretions
Male and female newborn infants at term have small buds of
palpable breast tissue. Small amounts of fluid are sometimes
discharged from the nipple in the early days after birth.
Stridor indicates large airway obstruction and is predominantly
inspiratory (p. 79). Stridor and indrawing beginning on days 2–3
of life in an otherwise well baby may be due to laryngomalacia
(softness of the larynx). Causes of respiratory distress include
retained lung fluid, infection, immaturity, aspiration, congenital
anomaly, pneumothorax, heart failure and metabolic acidosis.
• Inspect the abdomen, including the umbilicus and groins,
• From the infant’s right side, gently palpate with the flat of
your warm right hand. Palpate superficially before feeling
• Palpate for splenomegaly. In the neonate the spleen
enlarges down the left flank, not towards the right iliac
• Place your right hand flat across the abdomen beneath
• Feel the liver edge against the side of your index
• If you feel more than the liver edge, measure the
distance in the mid-clavicular line from the costal
margin to the liver edge. Describe it in fingerbreadths
or measure it with a tape in centimetres.
• Check that the anus is present, patent and normally
• Digital rectal examination is usually unnecessary and could
cause an anal fissure. Indications include suspected rectal
atresia or stenosis and delayed passage of meconium. Put
on gloves and lubricate your little finger. Gently press your
fingertip against the anus until you feel the muscle
resistance relax and insert your finger up to your distal
Abdominal distension from a feed or swallowed air is common.
You may see the contour of individual bowel loops through
the thin anterior abdominal wall in the newborn, particularly with
The umbilical cord stump usually separates after 4–5 days. A
granuloma may appear later as a moist, pink lump in the base
of the umbilicus. A small amount of bleeding from the umbilicus
The liver edge is often palpable in healthy infants.
In the neonate the kidneys are often palpable, especially if
In excessive umbilical bleeding, check that the infant received
vitamin K and consider factor XIII deficiency. Spreading erythema
around the umbilicus suggests infective omphalitis and requires
Fig. 15.7 Small exomphalos with loops of bowel in the umbilicus.
From Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd edn.
Fig. 15.8 Bilateral inguinal hernias in a preterm infant. An inguinal
hernia is primarily a groin swelling; only when it is large does it extend into
the scrotum. From Lissauer T, Clayden G. Illustrated Textbook of
Paediatrics. 2nd edn. Edinburgh: Mosby; 2001.
• Inspect and palpate the entire vertebral column from neck
to sacrum for neural tube defects.
Sacral dimples are common and unimportant, provided the dimple
base has normal skin and they are single, <5 mm in diameter
Pigmented patches may indicate spina bifida occulta. Dimples
above the natal cleft, away from the midline, or hairy or pigmented
patches with a base that cannot be visualised require further
This includes tone, posture, movement and primitive reflexes.
General neurological assessment
• Look for asymmetry in posture and movement, and for
• To assess tone, pick the baby up and note if they are stiff
or floppy. Note any difference between each side.
are normal. Later in the first week, there is sometimes
slight vaginal bleeding (pseudomenses) as the infant uterus
‘withdraws’ from maternal hormones. Vaginal skin tags are
common and do not require treatment.
• Do not attempt to retract the foreskin. It is normal for it to
• Check that the urethral meatus is at the tip of the penis.
• Note the shape of the penis.
• If you cannot feel the testes in the scrotum, assess for
undescended, ectopic or retractile testes. Palpate the
abdomen for smooth lumps, moving your fingers down
over the inguinal canal to the scrotum and perineum.
• A retractile testis just below the inguinal canal may be
gently milked into the scrotum. Re-examine at 6 weeks if
there is any doubt about the position of the testes.
• Transilluminate any large scrotal swellings using a torch to
see if the light is transmitted through the swelling. This
suggests a hydrocoele but can be misleading, because a
hernia of thin-walled bowel may transilluminate (Fig. 15.9).
• An inguinal hernia usually produces a groin swelling but, if
large, this may extend into the scrotum. Try to reduce it
by gently pushing the contents upwards from the scrotum
through the inguinal canal into the abdomen.
The testes are smooth and soft, and measure 0.7×1 cm across.
The right testis usually descends later than the left and sits
A hydrocoele is a collection of fluid beneath the tunica vaginalis
of the testis and/or the spermatic cord (p. 234). Most resolve
In hypospadias the meatal opening is on the ventral aspect
of the glans, the ventral shaft of the penis, the scrotum or
more posteriorly on the perineum (Figs 15.10 and 15.11A). In
epispadias, which is rare, it is on the dorsum of the penis.
Chordee is curvature of the penis and is commonly associated
with hypospadias and tethering of the foreskin (Fig. 15.11B).
Fig. 15.9 How to transilluminate a scrotal swelling.
Fig. 15.10 Varieties of hypospadias.
Fig. 15.11 Hypospadias and chordee. A Penile shaft hypospadias.
B Lateral view showing the ventral curvature of the penis (chordee). From
Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd edn.
The physical examination of newborns • 305
Facial nerve palsy causes reduced movement of the cheek
muscles, and the side of the mouth does not turn down when
the baby cries. Most cases are transient.
Primitive reflexes in newborn and
The primitive reflexes are lower motor neurone responses that are
present at birth but that become suppressed by higher centres
by 4–6 months. They may be absent in infants with neurological
depression or asymmetrical in infants with nerve injuries.
Persistence into later infancy may indicate neurodevelopmental
abnormality (p. 141). There are many examples and there is no
need to elicit them all because their individual value is limited.
• Gently stimulate the palm or sole with your finger to
produce a palmar or plantar grasp.
Ventral suspension/pelvic response
• Hold the baby prone and look for neck extension. Stroke
the skin over the vertebral column to produce an extensor
response with pelvic elevation.
• Hold the baby upright and touch the dorsum of their
foot against the edge of a table. The baby will flex
the knee and hip, placing their foot on the table
• Lower the upright baby towards the table surface.
When the feet touch the surface, a walking movement
• Support the supine baby’s trunk and head in a
semi-upright position. Let their head fall backwards
slightly. The baby will quickly throw out both arms and
spread their fingers (Fig. 15.13B).
• Gently stroke the baby’s cheek. The baby turns to that
side and their mouth opens, as though looking for a
nipple. This is ‘rooting’. If you place your finger in a healthy
infant’s mouth, they will suck it vigorously.
• Turn the supine infant’s head to the side. The arm and leg
on the same side will extend and the arm and leg on the
opposite side will flex. This reflex is present at term and
maximal at 1 month (Fig. 15.13C).
• Inspect the limbs and count the digits.
• If the foot is abnormally positioned, gently try to place it in
a normal position. If the abnormal position is at all fixed,
• Examine the hips to check for developmental dysplasia of
• Lay the baby supine on a firm surface.
• Inspect the skin creases of the thighs for symmetry.
• Power is difficult to assess and depends on the state of
arousal. Look for strong symmetrical limb and trunk
• Tendon reflexes are of value only in assessing infants with
neurological or muscular abnormalities.
• Check sensation by seeing whether the baby withdraws
from gentle stimuli. Do not inflict painful stimuli or use a
• Check eyesight by carrying the alert baby to a dark
corner. This normally causes the eyes to open wide. In a
bright area the baby will screw up their eyes.
Ideally, electronic audiological screening should also be
performed in the newborn period.
Movements should be equal on both sides.
Tone varies and may be floppy after a feed.
Reflexes are brisk in term infants, often with a few beats of
The plantar reflex is normally extensor in the newborn.
Hypotonic infants may have a ‘frog-like’ posture with abducted
hips and extended elbows. Causes include Down’s syndrome,
Increased tone may cause back and neck arching and limb
extension; the baby feels stiff when picked up. Causes include
meningitis, asphyxia and intracranial haemorrhage.
Brachial plexus injuries include Erb’s palsy, which affects
brachial plexus roots C5 and C6, producing reduced movement
of the arm at the shoulder and elbow, medial rotation of the
forearm and failure to extend the wrist (Fig. 15.12). Klumpke’s
palsy may be seen after breech delivery due to damage to roots
C8 and T1, with weakness of the forearm and hand. These
injuries can be associated with ipsilateral Horner’s syndrome
and/or diaphragmatic weakness in severe cases. Most perinatal
brachial plexus injuries recover over subsequent weeks.
Fig. 15.12 Erb’s palsy. The right arm is medially rotated and the wrist is
flexed. From Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd
A small percentage of normal babies have single palmar creases
but this is also associated with Down’s syndrome (see Fig. 3.31B)
and other chromosomal abnormalities. Tibial bowing is common
It is common to hear or feel minor ligamentous clicks during
hip examination. These are of no consequence and feel quite
different to the dislocation and relocation of DDH. If in any doubt,
obtain an expert opinion. Never use the term ‘clicky hips’.
Oligodactyly (too few digits), polydactyly (too many) or syndactyly
(joined digits) may occur. In talipes equinovarus the foot is
plantar-flexed and rotated, with the sole facing medially. In
talipes calcaneovalgus the foot is dorsiflexed so that the heel is
prominent and the sole faces laterally.
Many cases of DDH have associated risk factors, including
a family history, breech delivery, positional talipes (especially
calcaneovalgus) or oligohydramnios.
Some centres offer hip ultrasound screening.
• Weigh the infant fully undressed using electronic scales
• Use a paper tape to measure the maximal occipitofrontal
circumference round the forehead and occiput (Fig.
15.15). Repeat the measurement three times, noting the
largest measurement to the nearest millimetre.
• Measure the crown–heel length using a neonatal
stadiometer (Fig. 15.16). Ask a parent or assistant to hold
the baby’s head still and stretch out the legs until the baby
• Examine each hip separately. Hold the thigh with the
knee and hip flexed and your thumb on the medial
• Move the proximal end of the thigh laterally and then
push down towards the examining table (Barlow
manœuvre, Fig. 15.14A); a clunk indicates that the hip
• Now abduct the thigh; if you feel a clunk, this is the
head of the femur returning into the acetabulum
(Ortolani manœuvre, Fig. 15.14B). If the femoral head
feels lax and you feel a clunk with an Ortolani
manœuvre without first performing the Barlow
manœuvre, then the hip was already dislocated.
Fig. 15.13 Primitive reflexes. A Placing
reflex. B The Moro reflex. C Tonic neck reflex.
Fig. 15.14 Examination for developmental dysplasia of the hip.
A The hip is dislocated posteriorly out of the acetabulum (Barlow
manœuvre). B The dislocated hip is relocated back into the acetabulum
is fully extended (the least reproducible of the three
• Record the results on a centile chart appropriate to the
Perform a final top-to-toe inspection to avoid missing anything
and to allow the parents a further opportunity to ask questions.
The physical examination of infants
Examination of young infants beyond the newborn period is
similar to the newborn examination. Transient neonatal findings
will no longer be present. Older infants are usually happier when
examined on their parent’s lap than on an examination table.
The examination of the ears should include otoscopy (p. 314).
You should check the hips whenever you examine an infant
until they are walking normally. After the first few months the
Ortolani and Barlow manœuvres cannot be performed and
the most important signs are limitation of abduction in the hip,
and thigh skin crease asymmetry. Neurological history and
examination should take account of the developmental stage
of the child. The primitive reflexes disappear by 4–6 months.
In later infancy, ask additional questions to obtain information
about neurodevelopmental progress (Box 15.5).
Fig. 15.15 Measurement of head circumference.
Fig. 15.16 Measuring length accurately in infants.
15.5 Developmental attainment of preschool children at different ages*
Skills 4 months 6 months 10 months 1–2 years 2–3 years 3–5 years
Gross motor Has good head control on
Individuals between 12 months and 16 years are known
by non-specific terms, including toddlers, preschoolers,
schoolchildren, adolescents, teenagers or young adults.
Obtaining a history from children
There are many similarities in taking a history from a child and
from an adult. Introduce yourself to the child and accompanying
adult, and begin to observe the child. Establish who the adult
is – a parent, grandparent or foster carer, for example – and
consider to what extent the child will be able to contribute to
the history. Let the child become accustomed to you before
Start with open-ended questions. Most often a parent will
wish to explain their perspective on their child’s problem and it is
important to enable them to do so. Some teenagers may welcome
this but most often they do not. Once the presenting symptoms
have been outlined, the history should focus on questions that
aim to elucidate the differential diagnosis; children are often good
at helping with these more specific questions. Respect age ability
to recall events and adopt a balanced perspective on whether
Diagnosis is built on patterns of symptoms; rarely will any one
symptom or sign lead to a ‘spot diagnosis’. The initial history
suggests a differential diagnosis and prompts additional questions
to assess the probability of particular diagnoses. As with adults,
presenting symptoms should be described in terms of onset,
frequency, severity, duration, aggravating and relieving factors,
associated features and impact on function. Pain and the need
for analgesia can be particularly difficult to assess in young
children; objective scoring systems may help (Box 15.6).
The most common presenting problems in the child affect
the respiratory, gastrointestinal and nervous systems (covered
in Boxes 15.7–15.9), and the skin.
answers from parents are more likely to be accurate than those
from the child. Children under 6 years often provide little history,
those aged 6–11 years can do so if they are sufficiently confident,
and those aged 12 years and above should be able to provide
a valuable history in the correct environment and with the use
of questions that are framed in appropriate terminology. As you
would for adult history taking, include reflective summing up: for
example, ‘So what you are saying is that …’.
A paediatric history includes elements that are not part of the
adult history (obstetric, developmental, immunisation histories),
systematic enquiry has different components from those in
adults (see later), and the differential diagnosis may include
conditions seen only in children such as abdominal migraine,
toddler diarrhoea, croup, viral wheeze and febrile convulsion.
Most other diagnoses also occur in adults.
15.6 Pain assessment tool: FLACC scale
Face No particular expression or
Occasional grimace or frown, withdrawn,
Frequently or constantly quivering chin, clenched jaw
Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, normal position,
Squirming, shifting back and forth, tense Arched, rigid or jerking
Consolability Content, relaxed Reassured by occasional touching,
hugging or being talked to, distractible
Difficult to console or comfort
if associated with Differential diagnosis
LRTI, asthma, acute episodic wheeze, inhaled foreign
body. Rarely, supraventricular tachycardia, congenital
heart disease, heart failure or muscular weakness
Cough *** Low SOBar, fever LRTI, asthma, acute episodic wheeze, foreign body
Wheeze *** Moderate SOBar, fever LRTI, asthma, acute episodic wheeze, foreign body
Musculoskeletal pain, empyema, reflux oesophagitis,
Stridor *** High URTI, high fever, choking Croup, foreign body, epiglottitis (if not immunised)
** Low Cough, wheeze, failure to
Lack of fitness, respiratory pathology, cardiac pathology,
Cough *** Low Wheeze, SOBoe, failure
Isolated cough with sputum suggests infection,
commonly bronchitis, rarely bronchiectasis, cystic
fibrosis, inhaled foreign body. If also wheezy, consider
asthma or viral-induced wheeze
Wheeze *** Moderate SOBoe, failure to thrive Isolated, persistent ‘wheeze’ usually arises from the
nose (stertor, e.g. adenoidal hypertrophy) or the largest
airways (stridor, e.g. laryngomalacia). Episodic wheeze
with cough suggests asthma or viral-induced wheeze
Chest pain * High Exercise Non-specific chest pain, musculoskeletal chest pain,
the next room, is not genuine wheeze. b
Coexistent failure to thrive or weight loss always increases the significance of any symptom.
LRTI/URTI, lower/upper respiratory tract infection.
not blanch with pressure are of most concern. These may be viral
in origin but importantly can be an early sign of meningococcal
disease (particularly if the child is febrile). A differential diagnosis
of a purpuric rash is idiopathic thrombocytopenic purpura.
Chronic skin excoriation, most commonly in the flexures,
suggests eczema, while plaques on the elbows/knees may
Hair loss is distressing to a child. If associated with itch, it
is often due to tinea capitis; with a history of preceding illness,
Skin symptoms can be acute or chronic. Acute-onset rash
is common in children and can be described using the same
terminology as for adults (p. 286). Most rashes are viral and
Rash with blisters is often itchy. It may be urticaria (with an
environmental, viral, food or medicine trigger) or an insect bite.
Blisters with associated yellow crusting may be infected bullous
impetigo (most commonly caused by Staphylococcus aureus).
Red, circular lesions with a pink centre are most often erythema
multiforme (target lesions). Petechial or purpuric rashes that do
associated with Differential diagnosis
Vomiting *** Low: a very non-specific
Acute gastritis/gastroenteritis, any infection (otitis media,
pneumonia, urinary tract infection, meningitis), head injury,
Diarrhoea *** Moderate Fever, dehydrationa Acute gastroenteritis/colitis, appendicitis
** Moderate Fever, bloody stools Acute gastroenteritis/colitis, acute surgical causes, e.g.
Vomiting *** Moderate Failure to thrivec
Gastro-oesophageal reflux (rare in older children compared
with infants), raised intracranial pressure, food allergy
Diarrhoea *** Moderate Failure to thrivec Commonly toddler’s diarrhoea, also lactose intolerance. If
failure to thrive, consider coeliac disease, inflammatory
*** Low Pain that is not periumbilical
If isolated and periumbilical, non-specific abdominal pain
is common and other diagnoses include abdominal
migraine, renal colic. If associated with other symptoms
and/or failure to thrive, consider coeliac disease,
inflammatory bowel disease, constipation
Symptoms of dehydration include dry mouth, foul-smelling breath, anuria and lethargy. b
Abdominal pain can be difficult to identify in young children who are not able to
Coexisting failure to thrive or weight loss always increases the significance of any symptom.
associated with Differential diagnosis
Vomiting, fever, neck stiffness,
Acute (simple) headache, migraine, meningitis/
Unsteady gait * High Varicella encephalomeningitis, vestibular neuronitis
Seizurea * High Febrile seizure, meningitis/encephalitis
* High Encephalitis, intoxication/drug ingestion
Brain tumour, migraine, chronic non-specific
* Moderate Widening gap between age and
* High Muscular dystrophy, inborn error of metabolism,
Seizure * High Epilepsy; rarely, long QT syndrome or inborn error
headache can also arise from the mouth (e.g. dental abscess) or face.
Has the child regularly seen a healthcare professional (current or
past) or are they currently taking any regular medication? Have
they been in hospital before, and if so, why?
The impact of preterm birth goes beyond early childhood and
• Was the child born at term or preterm (if so, at what
• Was the neonatal period normal? For example, did the
child need to go to a special care baby unit?
• If the child is under 3 years of age: what was the
birthweight and were there any complications during
Are the child’s immunisations up to date according to
country-specific schedules? If not, explore why and consider
how best to encourage catch-up.
This is particularly important for children under 3 years of age
or those with possible neurodevelopmental delay (see p. 307
Prescribing errors often arise from poor reconciliation of medication
lists between different healthcare professionals. It is a doctor’s
duty to ensure that medicines are accurately reconciled within
documentation. Transcribe the medication, dose and frequency
direct from the medication package or referral letter if possible.
Enquire about any difficulties in taking medication to establish
adherence. Clarify any adverse or allergic reactions to medications.
• Who lives in the family home and who cares for the child?
• Are there any pets? Are any symptoms associated with
• Are there any similar symptoms in the child’s first- or
Sketch a family tree, noting any step-parents, step-siblings
or shared care arrangements Consider parental consanguinity,
which is not uncommon in some ethnic groups. Children at risk
of neglect may have complex domestic arrangements such as
Occasionally, chronic symptoms are associated with anxiety
or potential ‘secondary’ gain for the child; these include
chronic cough, abdominal pain and headache in a well-looking
8–12-year-old in whom examination is normal. Look carefully
at the child’s facial expression, eye contact and body language
when asking questions. Ask specifically about school (avoidance
and bullying), social interactions (does the child have many
friends?) and out-of-school activities. School avoidance should
be addressed if it is related to anxiety or if the pretext of medical
This screens for illnesses or symptoms that may be not recognised
as important or relevant by the child or parents. For children aged
over 12 years, the questions used for adults are appropriate. In
younger children, ask age-related questions. Specific areas include:
• Ear, nose and throat: ask the parents about their
perception of a child’s hearing ability (reduced in chronic
otitis media) or the presence of regular snoring with
periods of struggling to breathe (symptomatic obstructive
• Gastrointestinal system: ask whether growth is as
expected and whether there is pain or difficulty in opening
• Respiratory system: ask whether the child has regularly
coughed when otherwise well or had wheeze on a
recurrent basis (consider asthma).
• Urinary system: 15% of children at 5 years of age will
continue to have primary nocturnal enuresis.
An understanding of child development is vital to identifying
whether symptoms and signs are consistent with age.
Infants born prematurely should have their age adjusted to
their expected date of delivery instead of their date of birth
for the first 2 years of life when growth and development are
assessed. Failure to make this correction would otherwise create
a false impression of poor growth and developmental delay.
Prematurely born infants are at increased risk of impaired growth
and development, and merit increased surveillance; most develop
Growth after infancy is extremely variable. Use gender- and
ethnic-specific growth charts (such as those shown in Fig. 15.17).
These compare the individual with the general population and
with their own previous measurements. Each child should grow
along a centile line for height and weight throughout childhood.
Failure to thrive is failure to attain the expected growth trajectory.
A child on the 0.4th centile for height may be thriving if this has
always been their growth trajectory, while a child on the 50th
centile for height may be failing to thrive if previously they were
A child’s height is related to the average of their parents’
height centile ± 2 standard deviations. Parents whose average
height lies on the 50th centile will have children whose height will
normally lie between the 2nd and 98th centiles (approximately
10 cm above and below the 50th centile).
Normal development is heterogeneous within the population, which
makes identifying abnormalities difficult. Important determinants
are the child’s environment and genetic potential. Developmental
The physical examination • 311
The school-age child (5+ years)
By this age, developmental problems are usually known to parents
and relevant agencies, such as educational ones, may already be
engaged. However, more subtle developmental problems such as
dyslexia (learning disability affecting fluency and comprehension
in reading) may be unrecognised and can be a major handicap.
Ask general questions such as, ‘How is your child getting on at
school?’ and follow up by enquiring specifically about academic
assessment requires patience, familiarity with children and an
understanding of the range of normality for a given age.
The preschool child (1–5 years)
At the younger end of this range, questions relating to gross
motor skills are most sensitive; as the child becomes older,
questions relating to fine motor and personal social skills are
more meaningful. Delayed speech with normal attainment of
motor milestones is not uncommon, particularly in boys, but
should prompt hearing assessment (see Box 15.5).
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