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
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