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 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.

Nails

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 history

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.

Common presenting symptoms

These include:

a rash: scaly, blistering or itchy

a lump or lesion

pruritus (itch)

hair loss or excess hair (hirsutism, hypertrichosis)

nail changes.

Ask:

When did the lesion appear or the rash begin?

Where is the rash/lesion?

Has the rash spread, or the lesion changed, since its

onset?

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

there blisters?

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

exacerbation.

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

eruptions?

Are there any aggravating or relieving factors? For

example, exercise or exposure to heat may precipitate

cholinergic urticaria.

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

inflammatory reactions.

Are there any associated constitutional symptoms,

such as joint pain (psoriasis), muscle pain and

weakness (dermatomyositis), fever, fatigue or

weight loss?

Very importantly, what is the impact of the rash on the

individual’s quality of life?

Past medical and drug history

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.

Distal edge of nail plate

Nail plate

Lateral nail fold

(paronychium)

Lunula

Cuticle

Eponychium

A

Hyponychium

Nail bed

Nail plate

Distal phalanx

Matrix

Proximal nail fold (paronychium)

Cuticle

B

286 • The skin, hair and nails

Family and social history

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

and confirm smoking status.

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

(Box 14.2).

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.

The physical examination

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

syndrome).

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

scale (Box 14.2).

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.

Distribution of a rash

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 shins.

Morphology of a rash

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 elbow.

A

B

The physical examination • 287

14

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

14.3 Descriptive terminology

Term Definition

Abscess A collection of pus, often associated with signs

and symptoms of inflammation (includes boils and

carbuncles)

Angioedema Deep swelling (oedema) of the dermis and

subcutis

Annular Ring-like

Arcuate Curved

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

repeated friction or pressure

Circinate Circular

Comedo A blackhead

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

transilluminates

Discoid Disc-like

Ecchymosis

(bruise)

A deep bleed in the skin

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%

of the body surface

Exanthem A rash

Excoriation A scratch mark

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

Furuncle A boil

Gyrate Wave-like

Haematoma A swelling caused by a collection of blood

Horn A hyperkeratotic projection from the skin surface

Hyperkeratosis Thickening of the stratum corneum

Ichthyosis Very dry skin

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

a chronic eczematous process

Term Definition

Macule A flat (impalpable) colour change

Milium A keratin cyst

Naevus A localised developmental defect (vascular,

melanocytic, epidermal or connective tissue)

Nodule A large papule (>0.5 cm)

Nummular Coin-shaped

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

in diameter

Patch A large macule

Pedunculated Having a stalk

Petechiae Pinhead-sized macular purpura

Pigmentation A change in skin colour

Plaque A papule or nodule that in cross-sectional profile is

plateau-shaped

Poikiloderma A combination of atrophy, hyperpigmentation and

telangiectasia

Purpura Non-blanchable redness (also called petechiae)

Pustule A papular lesion containing turbid purulent material

(pus)

Reticulate Net-like

Scale A flake on the skin surface, composed of stratum

corneum cells (corneocytes), shed together rather

than individually

Scar The fibrous tissue resulting from the healing of a

wound, ulcer or certain inflammatory conditions

Serpiginous Snake-like

Stria(e) A stretch mark

Targetoid Target-like

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

Verrucous Wart-like

Vesicle A small blister (<0.5 cm)

Wheal A transient (<24 hours), itchy, elevated area of

skin resulting from dermal oedema that

characterises urticaria

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

of the dermis.

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

striae on the buccal mucosa.

A

B

C

Fig. 14.6 Rash morphology. A Koebner response. B Pemphigoid.

C Granuloma annulare.

A

B

C

The physical examination • 289

14

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

(Fig. 14.8C).

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.

A B

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.

A B

C

Fig. 14.9 Scabies burrows.

290 • The skin, hair and nails

Fig. 14.10 Lesion morphology. A Malignant

A B melanoma. B Seborrhoeic keratosis.

Fig. 14.11 Basal cell carcinoma. A Viewed with the naked eye. B Dermatoscopy highlights distinctive telangiectasia.

A B

Morphology of lesions

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

(Fig. 14.11).

Hair and nail signs

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

14

Fig. 14.12 Alopecia areata.

Fig. 14.13 Nail appearances in systemic diseases. A The typical linear pattern of dermatomyositis with Gottren’s papules on the dorsum of the hand.

B Nail-fold telangiectasia in dermatomyositis, viewed through the dermatoscope. C Yellow nail syndrome in a patient with lymphoedema and pleural

effusions.

A

B

C

Fig. 14.14 Dermatoscope.

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

syndrome (Fig. 14.13C).

Supplementary examination techniques

It is often necessary to complement naked-eye observation of the

skin with assisted examination techniques, such as dermatoscopy,

diascopy and Wood’s lamp.

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

Fig. 14.15 Patch testing.

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).

Diascopy

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.

Wood’s lamp

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

ringworm infections).

Investigations

After clinical examination, specific investigative techniques may

be necessary in some cases to enable a precise diagnosis.

Skin biopsy

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.

Mycology

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

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

samples of nail or plucking hair, and undertaking microscopic

examination and culture.

Patch testing

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

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

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

patches undisturbed for 2 days, removing them and then reading

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

inflammatory reaction at the site of the patch.

OSCE example 1: Pruritus

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

itch disturbing his sleep.

Please examine his skin

• Introduce yourself to the patient and clean your hands.

• Ask him to undress to underwear.

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

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

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

• Palpate the pulse for tachycardia and atrial fibrillation.

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

thyroid acropachy and koilonychia.

• Examine the abdomen for an enlarged liver or spleen.

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

• Test for dermographism.

• Examine for lymphadenopathy.

• Thank the patient and clean your hands.

Suggest a differential diagnosis

Intense pruritus may be caused by dermatoses such as scabies and

dermatitis herpetiformis, but also by systemic disorders such as

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

hypothyroidism, and lymphoma.

Suggest investigations

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

chest X-ray.

Investigations • 293

14

OSCE example 2: Pigmented lesion

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

changing pigmented lesion on her right calf.

Please examine her skin

• Introduce yourself to the patient and clean your hands.

• Ask her to undress to underwear.

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

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

lesions that might require close assessment.

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

margins, variation of pigmentation and ulceration.

• Palpate the lesion.

• Examine for enlargement of regional lymph nodes.

• Examine the abdomen for an enlarged liver.

• Undertake a similar examination of any other suspicious lesions.

• Thank the patient and clean your hands.

Suggest a differential diagnosis

Any changing lesion should raise suspicion of malignant melanoma,

although melanocytic naevi, seborrhoeic keratoses, dermatofibromas,

haemangiomas and pigmented basal cell carcinomas can cause

diagnostic confusion.

Suggested investigations

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

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

Integrated examination sequence for the skin

• Prepare the patient:

• Arrange for privacy.

• Arrange for a chaperone, if necessary.

• Remove sufficient clothing.

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

• Carry out a general examination of the skin:

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

suspicious lesions, for example.

• Carry out a specific examination of a rash:

• Extent.

• Distribution: symmetry, pattern.

• Morphology.

• Colour.

• Erythema/purpura.

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

• Mouth, hair and nails.

• Regional lymph nodes.

• Carry out a specific examination of a lesion:

• Site, size, colour.

• Symmetry.

• Surface texture.

• Consistency.

• Mobility.

• Pattern of vasculature.

• Regional lymph nodes.

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Section 3

Applying history

and examination skills

in specific situations

15 Babies and children 297

16 The patient with mental disorder 319

17 The frail elderly patient 329

18 The deteriorating patient 339

19 The dying patient 347

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15

Babies and children

Ben Stenson

Steve Cunningham

Babies 298

The history 298

Maternal history 298

Pregnancy history 298

Birth history 298

Infant’s progress 298

Presenting problems and definitions 298

The physical examination of newborns 299

Timing and efficacy of the routine neonatal examination 299

General examination 299

Cardiovascular examination 301

Respiratory examination 302

Abdominal examination 303

Neurological examination 304

Limbs 305

Weighing and measuring 306

Final inspection 307

The physical examination of infants beyond the newborn period 307

Older children 307

The history 307

Obtaining a history from children compared with adults 307

Common presenting symptoms 308

Past medical history 310

Birth history 310

Vaccination history 310

Developmental history 310

Drug history 310

Family and social history 310

Systematic enquiry 310

The physical examination 310

Normal growth and development 310

Physical examination techniques in children 312

The acutely unwell child 313

General examination 313

Ears, nose and throat 314

Cardiovascular examination 315

Respiratory examination 315

Abdominal examination 315

Neurological examination 315

Spotting the sick child 315

Child protection 315

OSCE example case 1: Cyanotic episodes 317

OSCE example 2: Asthma 317

Integrated examination sequence for the newborn child 318

298 • Babies and children

BABIES

15.1 Classification of newborn infants

Birthweight

• Extremely low: <1000 g

• Very low: <1500 g

• Low: <2500 g

• Normal: ≥2500 g

Gestational age

• Extremely preterm: <28 weeks

• Preterm: <37 weeks (<259th day)

• Term: 37–42 weeks

• Post-term: >42 weeks (>294th day)

15.2 Apgar score

Clinical score 0 1 2

Heart rate Absent <100 bpm >100 bpm

Respiratory

effort

Absent Slow and

irregular

Good: strong

Muscle tone Flaccid Some flexion of

arms and legs

Active movement

Reflex

irritability

No

responses

Grimace Vigorous crying,

sneeze or cough

Colour Blue, pale Pink body, blue

extremities

Pink all over

Add scores for each line; maximum score is 10.

bpm, beats per minute.

Reproduced with permission of International Anesthesia Research Society from

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

conveyed through Copyright Clearance Center, Inc.

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

year. Neonates are classified by gestational age or birthweight

(Box 15.1).

The history

Ask the mother and look in the maternal notes for relevant

history:

Maternal history

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

hereditary illnesses)?

What were the outcomes of any previous pregnancies?

Pregnancy history

How was maternal health?

Did the mother take medications or other drugs?

What did antenatal screening tests show?

Birth history

What was the birthweight, gestation at birth and mode of

delivery?

Was there prolonged rupture of the fetal membranes or

maternal pyrexia?

Was there a non-reassuring fetal status during delivery or

meconium staining of the amniotic fluid?

Was resuscitation required after birth?

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

umbilical cord blood gas tests?

Infant’s progress

Has the infant passed meconium and urine since

birth?

In later infancy, what are the specific signs and systems

and developmental progress, depending on the presenting

problem?

Presenting problems and definitions

Infants cannot report symptoms, so you must recognise the

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

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

Pallor

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

poor perfusion. Newborn infants have higher haemoglobin levels

than older children and are not normally pale. Haemoglobin levels

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

infants look red because they lack subcutaneous fat.

Respiratory distress

Respiratory distress is tachypnoea (respiratory rate) >60 breaths

per minute with intercostal and subcostal indrawing, sternal

recession, nasal flaring and the use of accessory muscles.

Cyanosis

Bluish discoloration of the lips and mucous membranes due

to hypoxia is difficult to see in newborn infants unless oxygen

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

congenital heart disease and respiratory disease, and cyanosis

always needs investigation (p. 28).

Acrocyanosis

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

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

Jaundice

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

yellow sclerae in newborns with coloured skin or you may miss

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

jaundice cannot be distinguished clinically from jaundice from

a pathological cause. Do not use clinical estimates instead of

measurements to evaluate jaundice.

The physical examination of newborns • 299

15

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

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

may disturb the baby later in the examination.

Examination sequence

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

• Look for:

• cyanosis

respiratory distress

pallor

plethora (suggesting polycythaemia).

Note posture and behaviour.

Note any dysmorphic features.

Auscultate the heart and palpate the abdomen if the baby

is quiet.

If the baby cries, does the cry sound normal?

Skin

Normal findings

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

healthy babies. There may be meconium staining of the skin

and nails.

Prominent capillaries commonly cause pink areas called ‘stork’s

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

15.1). Facial marks fade spontaneously over months; those

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

neonatorum (larger cream-coloured spots) are collected glandular

secretions and disappear within 2–4 weeks. Erythema toxicum

is a common fleeting, blanching, idiopathic maculopapular rash

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

first few days after birth.

Abnormal findings

Document any trauma such as scalp cuts or bruising.

Dense capillary haemangiomas (port wine stains) will not

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

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

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

underlying brain lesion, associated with risk of later seizures,

cerebral calcification and reduced cognitive function). Melanocytic

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

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

bluish discoloration over the buttocks, back and thighs. Easily

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

Jitteriness

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

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

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

excessive, exclude hypoglycaemia, polycythaemia and neonatal

abstinence syndrome (drug withdrawal). Infrequent jerks in light

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

Dysmorphism

Identifying abnormal body structure (dysmorphism) is subjective

because of human variability. Individual features may be minor and

isolated, or may signify a major problem requiring investigation

and management. A recognisable pattern of several dysmorphic

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

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

possible dysmorphism with parents of a newborn child.

Hypotonia

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

infant. Term infants’ muscle tone normally produces a flexed

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

lack this flexion. Hypotonia can occur with hypoxia, hypoglycaemia

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

problem. Preterm infants have lower tone than term infants and

are less flexed.

Apgar score

This first clinical assessment of a neonate is made immediately

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

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

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

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

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

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

minutes predict death or later disability. Neonates with scores

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

is clear they are healthy.

The physical examination of newborns

Timing and efficacy of the routine

neonatal examination

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

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

disease may be missed because signs have not developed. If

it is delayed, some babies will present before the examination

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

of neonates have an identifiable congenital abnormality but most

are not serious. Always record your examination comprehensively

to avoid problems if illness or physical abnormality is identified

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

or congenital cataract are detected by newborn examination.

General examination

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

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

300 • Babies and children

Separated cranial sutures with an obvious gap indicate raised

intracranial pressure. Rarely, the cranial sutures are prematurely

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

is usually abnormal. Abnormal head size requires detailed

investigation, including neuroimaging.

Eyes

Examination sequence

Inspect the eyebrows, lashes, lids and eyeballs.

• Gently retract the lower eyelid and check the sclera for

jaundice.

Test ocular movements and vestibular function:

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

eyes move in the opposite direction. These are called

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

Fig. 8.15).

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

horizontal arc. The infant should look in the direction of

movement and have optokinetic nystagmus. This

response becomes damped by 3 months.

Normal findings

Harmless yellow crusting without inflammation is common after

birth in infants with narrow lacrimal ducts.

Term infants usually fix visually.

Abnormal findings

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

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

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

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

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

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

when palpated through the lids suggest congenital glaucoma

(buphthalmos).

Ophthalmoscopy

Examination sequence

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

side so that the baby will open their eyes.

Subcutaneous fat necrosis causes palpable firm plaques, often

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

associated hypercalcaemia that may require treatment. Blisters

or bullae are usually pathological.

Head

Examination sequence

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

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

bulging?

Palpate the cranial sutures.

Normal findings

Transient elongation of the head is common from moulding

during birth. Caput succedaneum is soft-tissue swelling over

the vertex due to pressure in labour. Overriding cranial sutures

have a palpable step.

Abnormal findings

Cephalhaematoma is a firm, immobile, usually parietal swelling

caused by a localised haemorrhage under the cranial periosteum.

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

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

with the boggy, mobile, poorly localised swelling of subgaleal

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

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

if unrecognised.

Fig. 15.2 Mongolian blue spot.

15.3 Neonatal head shapes

Head shape Description

Microcephalic (small-headed) Small cranial vault

Megalencephalic (large-headed) Large cranial vault

Hydrocephalic (water-headed) Large cranial vault due to

enlarged ventricles

Brachycephalic (short-headed) Flat head around the occiput

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

its width

Plagiocephalic (oblique-headed) Asymmetrical skull

Anterior fontanelle

Posterior fontanelle

Sagittal suture

Frontal bone

Frontal suture

Sinciput

Occiput

Parietal bone

and eminence

Lambdoid suture

Fig. 15.3 The fetal skull from above.

The physical examination of newborns • 301

15

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

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

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

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

multidisciplinary team. Micrognathia (a small jaw) is sometimes

associated with cleft palate in the Pierre Robin syndrome,

with posterior displacement of the tongue and upper airway

obstruction.

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

is related to the sublingual or submandibular salivary ducts.

Congenital ranulas may resolve spontaneously but sometimes

require surgery.

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

present at birth.

Ears

Examination sequence

Note the size, shape and position.

The helix should attach above an imaginary line through

the inner corners of the eyes.

Check that the external auditory meatus looks normal.

Normal findings

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

Preauricular skin tags do not require investigation.

Abnormal findings

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

Neck

Examination sequence

Inspect the neck for asymmetry, sinuses and swellings.

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

interpret your findings.

Transilluminate swellings. Cystic swellings glow, as the

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

swellings do not.

Normal findings

One-third of normal neonates have palpable cervical, inguinal

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

posture and usually resolves.

Abnormal findings

A lump in the sternocleidomastoid muscle (sternomastoid

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

muscle shortening. This may produce torticollis, with the head

turned in the contralateral direction.

Cardiovascular examination

Examination sequence

Observe the baby for pallor, cyanosis and sweating.

Count the respiratory rate.

Palpate for the apex beat with your palm in the

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

Note if the heart beat moves your hand up and down

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

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

Look at each pupil from about 20 cm through the

ophthalmoscope. You should see the red reflex of

reflected light from the retina.

Normal findings

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

If this happens, always examine again later because failure to

detect and treat a cataract will cause permanent amblyopia.

Abnormal findings

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

Nose

Examination sequence

Exclude obstructed nostrils (choanal atresia) by blocking

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

breathes easily through the other.

Mouth

Examination sequence

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

open their mouth. Do not use a wooden tongue

depressor, as this may cause trauma or infection.

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

palate.

Palpate the palate using your fingertip.

Normal findings

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

that disappear spontaneously.

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

swab is usually curdled milk.

Abnormal findings

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

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

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

syndrome (glossoptosis).

Fig. 15.4 Coloboma.

302 • Babies and children

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

elbow to the shoulder tip.

Palpate the abdomen for hepatomegaly (see later).

Normal findings

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%

or higher.

Heart rates between 80 and 160 beats per minute (bpm)

can be normal in the newborn, depending on the arousal state

(Box 15.4).

Abnormal findings

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

effusion.

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

later in childhood.

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.

Respiratory examination

Examination sequence

Note chest shape and symmetry of chest movement.

Count the respiratory rate (for 15 seconds and multiply

by 4).

• Listen for additional noises with breathing.

Look for signs of respiratory distress: tachypnoea;

suprasternal, intercostal and subcostal recession; flaring of

the nostrils.

Remember that percussion of the newborn’s chest is not

helpful.

Use the diaphragm to auscultate anteriorly, laterally and

posteriorly, comparing the sides. Breath sounds in the

healthy newborn have a bronchial quality compared with

older individuals (p. 88).

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.

8

5 3

9

4

1

6 2

7

10

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

rate in the newborn

Sign Preterm neonate Term neonate

Heart rate (beats per minute) 120–160 100–140

Respiratory rate (breaths per

minute)

40–60 30–50

Feel the femoral pulses by placing your thumbs or

fingertips over the mid-inguinal points while abducting the

hips (Fig. 15.5).

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

murmurs (Fig. 15.6).

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

murmur.

The physical examination of newborns • 303

15

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

of the umbilicus.

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

a rectovaginal fistula.

Perineum

Examination sequence

Female

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

Normal findings

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.

Abnormal findings

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.

Abdominal examination

Examination sequence

Remove the nappy.

Inspect the abdomen, including the umbilicus and groins,

noting any swellings.

From the infant’s right side, gently palpate with the flat of

your warm right hand. Palpate superficially before feeling

for deeper structures.

Palpate for splenomegaly. In the neonate the spleen

enlarges down the left flank, not towards the right iliac

fossa.

Palpate for hepatomegaly:

Place your right hand flat across the abdomen beneath

the right costal margin.

Feel the liver edge against the side of your index

finger.

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

positioned.

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

interphalangeal joint.

Normal findings

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

intestinal obstruction.

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

is common in the neonate.

The liver edge is often palpable in healthy infants.

In the neonate the kidneys are often palpable, especially if

ballotted (see Fig. 12.12).

Abnormal findings

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

urgent treatment.

Fig. 15.7 Small exomphalos with loops of bowel in the umbilicus.

From Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd edn.

Edinburgh: Mosby; 2001.

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.

304 • Babies and children

Spine and sacrum

Examination sequence

Turn the baby over.

Inspect and palpate the entire vertebral column from neck

to sacrum for neural tube defects.

Normal findings

Sacral dimples are common and unimportant, provided the dimple

base has normal skin and they are single, <5 mm in diameter

and <2.5 cm from the anus.

Abnormal findings

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

investigation.

Neurological examination

This includes tone, posture, movement and primitive reflexes.

General neurological assessment

Examination sequence

Look for asymmetry in posture and movement, and for

muscle wasting.

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.

Male

Do not attempt to retract the foreskin. It is normal for it to

be adherent in babies.

Check that the urethral meatus is at the tip of the penis.

Note the shape of the penis.

Palpate the testes.

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.

Normal findings

The testes are smooth and soft, and measure 0.7×1 cm across.

The right testis usually descends later than the left and sits

higher in the scrotum.

Abnormal findings

A hydrocoele is a collection of fluid beneath the tunica vaginalis

of the testis and/or the spermatic cord (p. 234). Most resolve

spontaneously in infancy.

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.

Normal urethral meatus

Most common types

Increased incidence

of other genitourinary

abnormalities

Glandular

Coronal

Mid-shaft

Penoscrotal

Types of

hypospadias

Fig. 15.10 Varieties of hypospadias.

A B

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.

Edinburgh: Mosby; 2001.

The physical examination of newborns • 305

15

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

young infants

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.

Examination sequence

Grasp responses

Gently stimulate the palm or sole with your finger to

produce a palmar or plantar grasp.

Ventral suspension/pelvic response

to back stimulation

Hold the baby prone and look for neck extension. Stroke

the skin over the vertebral column to produce an extensor

response with pelvic elevation.

Place-and-step reflexes

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

(Fig. 15.13A).

Lower the upright baby towards the table surface.

When the feet touch the surface, a walking movement

occurs.

Moro reflex

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).

Root-and-suck responses

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.

Asymmetric tonic neck reflex

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).

Limbs

Examination sequence

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,

refer to a specialist.

Examine the hips to check for developmental dysplasia of

the hip (DDH):

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

movements and grasp.

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

pin or needle.

• 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.

Normal findings

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

clonus.

The plantar reflex is normally extensor in the newborn.

Abnormal findings

Hypotonic infants may have a ‘frog-like’ posture with abducted

hips and extended elbows. Causes include Down’s syndrome,

meningitis and sepsis.

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

edn. Edinburgh: Mosby; 2001.

306 • Babies and children

Normal findings

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

in the newborn.

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’.

Abnormal findings

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.

Weighing and measuring

Examination sequence

Weigh the infant fully undressed using electronic scales

accurate to 5 g.

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

aspect of the thigh.

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

is dislocatable.

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

(Ortolani manœuvre).

The history • 307

15

is fully extended (the least reproducible of the three

measurements).

Record the results on a centile chart appropriate to the

infant’s ethnic background.

Final inspection

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

beyond the newborn period

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).

Occipital Frontal

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

pull to sit

Keeps back straight when

held in sitting position

Supports weight

on hands when

laid prone

Rolls front to back

Sits unsupported

Pulls to stand

Walks without

support

Runs

Bounces on

trampoline

Pedals a

tricycle

Fine motor Opens hands

Holds objects placed in

hand

Transfers objects

from hand to hand

and to mouth

Uses pincer grip

bilaterally without

hand preference

Holds a crayon

and scribbles

Can draw a circle Can draw a

cross, square,

face/person

Personal

social

Shows interest in toys

Laughs, vocalises

Has a variety of

speech noises

Plays peep-bo

Starts to understand

some words

Claps hands

Has 10–20

recognisable

words

Can communicate

verbally

Has 500–1500

words

Is dry by day

*Development is extremely variable and failure to attain only one milestone is of little significance whereas failure to attain several milestones is cause for concern.

OLDER CHILDREN

Individuals between 12 months and 16 years are known

by non-specific terms, including toddlers, preschoolers,

schoolchildren, adolescents, teenagers or young adults.

The history

Obtaining a history from children

compared with adults

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

asking specific questions.

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

308 • Babies and children

Common presenting symptoms

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

0 1 2

Face No particular expression or

smile

Occasional grimace or frown, withdrawn,

uninterested

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,

moves easily

Squirming, shifting back and forth, tense Arched, rigid or jerking

Cry No cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints

Consolability Content, relaxed Reassured by occasional touching,

hugging or being talked to, distractible

Difficult to console or comfort

Each category is scored on a 0–2 scale to give a total score of 0–10: 0 = no pain; 1–3 = mild pain; 4–7 = moderate pain; 8–10 = severe pain.

15.7 Respiratory system

Symptoma,b Frequency

Diagnostic

significance

Significance heightened

if associated with Differential diagnosis

Acute

Short of breath at

rest (SOBar)

*** High (indicates loss of

all respiratory reserve)

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

Chest pain * High Exercise

Fever

Musculoskeletal pain, empyema, reflux oesophagitis,

cardiac ischaemia

Stridor *** High URTI, high fever, choking Croup, foreign body, epiglottitis (if not immunised)

Chronic

Short of breath on

exercise (SOBoe)

** Low Cough, wheeze, failure to

thrive

Lack of fitness, respiratory pathology, cardiac pathology,

neurological weakness

Cough *** Low Wheeze, SOBoe, failure

to thrive

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,

very rarely cardiac ischaemia

a

Respiratory sounds: clarify what noise the parent or child is describing. The history sometimes reveals the source, e.g. nose (stertor), throat (stridor) or chest (rattle or

wheeze). A constant respiratory sound is more likely to be stertor, stridor or rattle (a sound associated with vibration of the chest). A very loud sound, such as one heard in

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.

The history • 309

15

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

indicate psoriasis.

Hair loss is distressing to a child. If associated with itch, it

is often due to tinea capitis; with a history of preceding illness,

alopecia is a likely cause.

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

resolve spontaneously.

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

15.8 Gastrointestinal system

Symptom Frequency

Diagnostic

significance

Significance heightened if

associated with Differential diagnosis

Acute

Vomiting *** Low: a very non-specific

symptom in children

Fever, drowsiness,

dehydrationa

Acute gastritis/gastroenteritis, any infection (otitis media,

pneumonia, urinary tract infection, meningitis), head injury,

encephalitis

Diarrhoea *** Moderate Fever, dehydrationa Acute gastroenteritis/colitis, appendicitis

Abdominal

painb

** Moderate Fever, bloody stools Acute gastroenteritis/colitis, acute surgical causes, e.g.

appendicitis, intussusception

Chronic

Vomiting *** Moderate Failure to thrivec

Headache

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

bowel disease

Abdominal

painb

*** Low Pain that is not periumbilical

Headaches

Diarrhoea and vomiting

Failure to thrivec

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

a

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

express themselves. c

Coexisting failure to thrive or weight loss always increases the significance of any symptom.

Symptom Frequency

Diagnostic

significance

Significance heightened if

associated with Differential diagnosis

Acute

Headache ** Low

Vomiting, fever, neck stiffness,

photophobia

Acute (simple) headache, migraine, meningitis/

encephalitis

Unsteady gait * High Varicella encephalomeningitis, vestibular neuronitis

Seizurea * High Febrile seizure, meningitis/encephalitis

Epilepsy, metabolic disorder

Disturbed level of

consciousness

* High Encephalitis, intoxication/drug ingestion

(accidental/ deliberate)

Chronic

Headacheb ** Low Vomiting

Abdominal pain

Brain tumour, migraine, chronic non-specific

headache

Failure to pass

developmental

milestones

* Moderate Widening gap between age and

age when ‘normal’ milestone

should have been passed

Cerebral palsy, neglect

Developmental

regression

* High Muscular dystrophy, inborn error of metabolism,

neurodegenerative conditions

Seizure * High Epilepsy; rarely, long QT syndrome or inborn error

of metabolism

}

15.9 Nervous system

a

An acute seizure can be confused with a rigor in a febrile child. A seizure involves slow (1 beat per second), coarse, jerking that cannot be stopped, loss of consciousness

and postictal drowsiness. A rigor is characterised by rapid (5 beats per second), fine jerking that can be stopped by a cuddle with no loss of consciousness. b

Chronic

headache can also arise from the mouth (e.g. dental abscess) or face.

310 • Babies and children

Past medical history

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?

Birth history

The impact of preterm birth goes beyond early childhood and

so it is helpful to ask:

Was the child born at term or preterm (if so, at what

gestation)?

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

pregnancy?

Vaccination history

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.

Developmental history

This is particularly important for children under 3 years of age

or those with possible neurodevelopmental delay (see p. 307

and Box 15.5).

Drug history

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.

Family and social history

Ask:

Who lives in the family home and who cares for the child?

Does anyone smoke at home?

Are there any pets? Are any symptoms associated with

pet contact?

Are there any similar symptoms in the child’s first- or

second-degree relatives?

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

several caregivers.

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

symptoms is used.

Systematic enquiry

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

sleep apnoea).

Gastrointestinal system: ask whether growth is as

expected and whether there is pain or difficulty in opening

the bowels (constipation).

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.

The physical examination

Normal growth and development

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

normally, however.

Growth

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

on the 99.6th centile.

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).

Neurological development

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

15

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

and social activity.

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).

Birth to 2 years (z-scores)

17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

17 3

2

0

-2

-3

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

1 2 345 6 7 8 9 10 11 1 2 345 6 7 8 9 10 11

Birth 1 year

Age (completed months and years)

2 years

Months Weight (kg)

Weight-for-age BOYS

Birth to 2 years (z-scores)

17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

3 17

2

0

-2

-3

16

15

14

13

12

11

10

9

8

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