12345678 9 10 11 12345678 9 10 11
Age (completed months and years)
childgrowth/standards/weight_for_age/en/ © World Health Organization 2017. All rights reserved.
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
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
Similarities in examination between
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
• 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
• 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
The appropriate approach varies with the child’s age.
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
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
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.
8 1 9 1 0 12 14 16 18 2 1 13 15 17 19 0
8 1 9 1 0 12 14 16 18 2 1 13 15 17 19 0
Fig. 15.18 Timing of puberty in males and females.
The physical examination • 313
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.
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
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’.
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
15.10 Serious signs requiring urgent attention
• Poor perfusion with reduced capillary refill and cool peripheries
• 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
Head straight, eyes and ears level
Gentle upward traction on mastoid process
Barefoot with feet flat on floor
Fig. 15.20 Stadiometer for measuring height accurately in children.
Healthy tonsils and pharynx look pink; when inflamed, they are
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).
• Sit the child across their knees with the child’s ear
• Place one arm around the child’s shoulder and upper
arm that are facing you (to stop them pushing you
• Place their other hand over the parietal area above
the child’s ear that is facing you (to keep the child’s
• 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
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).
Normal ranges for vital signs vary according to age (Box 15.11).
• 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
• 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
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
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.
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
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).
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.
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).
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.
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
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
• Tonsillitis, pharyngitis, sinusitis
• ‘Glandular fever’ (infectious mononucleosis/cytomegalovirus)
• Tuberculosis (uncommon in developed countries)
• Febrile illness with a generalised rash
• Systemic juvenile chronic arthritis (Still’s disease)
• Mucocutaneous lymph node syndrome (Kawasaki disease)
15.13 Clinical signs associated with severe
• Hypotension (a late sign in shocked children where blood pressure
is initially maintained by tachycardia and increased peripheral
15.14 Signs that may suggest child neglect or abuse
• Identifiable bruises, e.g. fingertips, handprints, belt buckle, bites
• Circular (cigarette) burns or submersion burns with no splash marks
• Long-bone fractures or bruises in non-mobile infants
• Subconjunctival or retinal haemorrhage
• Dirty, smelly, unkempt child
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.
CHILDREN’S OBSERVATION AND SEVERITY TOOL
SOUTH COAST CHILDREN’S EARLY WARNING SCORE: CHILDREN’S UNIT
treatment unit; SpR, specialist registrar. Courtesy Dr Sandell.
OSCE example case 1: Cyanotic episodes
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).
• Assess whether there is palpable hepatomegaly or finger clubbing.
• Auscultate: is there a murmur?
• Auscultate the heart in a systematic fashion.
• Auscultate the back to check whether the murmur radiates.
• Clean your hands and thank the parent.
Finger clubbing is not usually present in young infants.
Pulse oximetry, echocardiogram, electrocardiogram, chest X-ray.
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.
• Auscultate: warm the stethoscope.
• Heart sounds are normal with no murmur.
• Clean your hands and thank the parent and patient.
This child has tachypnoea and a widespread, loud, polyphonic wheeze on expiration.
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.
Integrated examination sequence for the newborn child
• Perform a general examination:
• 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.
• 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:
• Auscultate anteriorly, laterally and posteriorly, comparing sides.
• Inspect: abdomen, umbilicus, anus and groins, noting any swellings.
• Palpate: superficial, then deeper structures. Spleen, then liver.
• Both sexes: check normal anatomy.
canal if the testes are not in the scrotum. Transilluminate scrotal swellings.
• Examine the spine and sacrum:
• 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:
• Inspect: limbs, counting digits and checking feet are, or can be, normally positioned.
• Check hips for developmental dysplasia/dislocation.
• Weigh the infant to the nearest 5 g.
• Measure: occipitofrontal circumference, crown–heel length (neonatal stadiometer).
The mental state examination 320
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
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.
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 (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
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
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
• tattoos and scars (especially any that suggest recent or
• evidence of substance misuse (such as injection tracks
from intravenous drug use; spider naevi and jaundice from
• possibly relevant physical disease (such as exophthalmos
Think of this as a written account of a video, observing such
• cooperation, rapport, eye contact
• social behaviour (such as aggression, disinhibition, fearful
• apparent responses to possible hallucinations or
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 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).
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
• 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)
The mental state examination • 321
any aspect of life, and at interview appear downcast, withdrawn
and tearful, with little brightening even when talking about their
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
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
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,
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)
• volume (whispering, shouting)
• tone and quality (accent, emotionality)
• fluency (staccato, monotonous)
• abnormal language (neologisms, dysphasia, clanging,
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
Agitation A combination of psychic anxiety and excessive,
Compulsion A stereotyped action that the patient cannot
Disinhibition Loss of control over normal social behaviour
Motor retardation Decreased motor activity, usually a combination
Posturing The maintenance of bizarre gait or limb positions
Clang associations Thoughts connected by their similar sound
Echolalia Senseless repetition of the interviewer’s words
Mutism Absence of speech without impaired
Neologism An invented word, or a new meaning for an
Pressure of speech Rapid, excessive, continuous speech (due to
Word salad A meaningless string of words, often with loss
Blunting Loss of normal emotional sensitivity to experiences
An extreme emotional and behavioural over-reaction
Flattening Loss of the range of normal emotional responses
Incongruity A mismatch between the emotional expression and
Lability Superficial, rapidly changing and poorly controlled
16.6 Thought form: definitions
Circumstantiality Trivia and digressions impairing the flow but
Concrete thinking Inability to think abstractly
Flights of ideas Rapid shifts from one idea to another,
Logical sequence of ideas impaired. Subtypes
include knight’s-move thinking, derailment,
thought blocking and, in its extreme form,
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.
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.
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
• of thought interference (broadcasting, insertion and
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
It may help to illustrate your assessment with verbatim examples
from the interview, chosen to illustrate the patient’s manner of
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 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.
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
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
16.7 Thought content: definitions
Hypochondriasis Unjustified belief in suffering from a particular
disease in spite of appropriate examination and
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
Preoccupation Beliefs that are not inherently abnormal but which
have come to dominate the patient’s thinking
Ruminations Repetitive, intrusive, senseless thoughts or
Obsessions Ruminations that persist despite resistance
16.8 Abnormal beliefs: definitions
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
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
An irrational belief that certain actions and outcomes
are linked, often culturally determined by folklore or
custom, e.g. fingers crossed for good luck
Beliefs that are held, valued, expressed and acted
on beyond the norm for the culture to which the
The belief that the patient’s thoughts are heard by
The belief that thoughts are being placed in the
The belief that thoughts are being removed from the
The mental state examination • 323
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?’
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
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:
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.
This is a key aspect of cognitive function, being particularly
Comments
Post a Comment
اكتب تعليق حول الموضوع