• Identifiable bruises, e.g. fingertips, handprints, belt buckle, bites
• Circular (cigarette) burns or submersion burns with no splash marks
• Long-bone fractures or bruises in non-mobile infants
• Subconjunctival or retinal haemorrhage
• Dirty, smelly, unkempt child
Nurse in Charge review. Hourly observations.
Nurse in Charge & Doctor to review patient. Half-hourly observations.
Nurse in Charge & SpR to review patient. Consider informing Consultant.
*nb: BP, GCS and Pain Score values do not contribute to the overall COAST score.
Nurse in Charge & Senior Doctor to see immediately.
If airway compromise, call ITU Registrar immediately.
CHILDREN’S OBSERVATION AND SEVERITY TOOL
SOUTH COAST CHILDREN’S EARLY WARNING SCORE: CHILDREN’S UNIT
treatment unit; SpR, specialist registrar. Courtesy Dr Sandell.
OSCE example case 1: Cyanotic episodes
Please perform a newborn examination, focusing on the cardiovascular system
• Introduce yourself to the parent and clean your hands
• Carry out a general inspection: are there any signs of congenital heart disease?
• Look for signs of respiratory distress (tachypnoea, indrawing, accessory muscle use).
• Check for scars on the chest.
• Look at the colour and perfusion of the patient (cyanosis, pallor, sweatiness).
• Look for signs of dysmorphic features that might indicate an associated chromosomal abnormality.
• Look for signs of poor weight gain.
• Palpate: is the infant warm and well perfused? Are there any palpable cardiac abnormalities?
• Check central capillary refill. Feel the temperature.
• Palpate peripheral pulses (brachial, femoral).
• Assess whether there is palpable hepatomegaly or finger clubbing.
• Auscultate: is there a murmur?
• Auscultate the heart in a systematic fashion.
• Auscultate the back to check whether the murmur radiates.
• Clean your hands and thank the parent.
Finger clubbing is not usually present in young infants.
Pulse oximetry, echocardiogram, electrocardiogram, chest X-ray.
Please perform a chest examination, focusing on the respiratory system
• Introduce yourself to the parent and patient, and clean your hands.
• Carry out a general inspection: are there any signs of acute or chronic respiratory distress?
• Look for chest wall deformity (pectus excavatum, Harrison’s sulcus).
• Look for signs of respiratory distress (tachypnoea, indrawing, accessory muscle use).
• Count the respiratory rate over 1 minute.
• Look at the colour and perfusion of the patient (cyanosis, pallor, sweatiness).
• Look for finger clubbing and poor weight gain.
• Auscultate: warm the stethoscope.
• Heart sounds are normal with no murmur.
• Clean your hands and thank the parent and patient.
This child has tachypnoea and a widespread, loud, polyphonic wheeze on expiration.
skin-prick testing) and, if required, a trial of a stepwise increase in baseline asthma therapy.
Suggest initial investigations
Peak expiratory flow or spirometry, and oxygen saturation.
Integrated examination sequence for the newborn child
• Perform a general examination:
• Skin: note cuts, bruising, naevi (haemangiomas or melanocytic), blisters or bullae.
• Head: check shape, swellings, anterior fontanelle, cranial sutures.
• Eyes: check for jaundice, ocular movements and vestibular function; perform ophthalmoscopy.
• Mouth: check mucosa, tongue, palate, jaw and any teeth.
• Ears: note size, shape and position; check the external auditory meatus.
• Neck: inspect and palpate for asymmetry, sinuses and swellings.
• Examine the cardiovascular system:
• Inspect: pallor, cyanosis and sweating.
• Palpate: apex, check for heave or thrill, count heart rate, femoral pulses, feel for hepatomegaly.
• Auscultate: heart sounds I and II, any additional heart sounds or murmurs.
• Examine the respiratory system:
• Auscultate anteriorly, laterally and posteriorly, comparing sides.
• Inspect: abdomen, umbilicus, anus and groins, noting any swellings.
• Palpate: superficial, then deeper structures. Spleen, then liver.
• Both sexes: check normal anatomy.
canal if the testes are not in the scrotum. Transilluminate scrotal swellings.
• Examine the spine and sacrum:
• Examine the neurological system:
• Inspect: asymmetry in posture and movement, any muscle wasting.
• Pick the baby up to note any stiff or floppy tone.
• Sensation: does the baby withdraw from gentle stimuli?
• In dim light, the eyes should open; in bright light, babies screw up their eyes.
• Check the primitive reflexes:
• Inspect: limbs, counting digits and checking feet are, or can be, normally positioned.
• Check hips for developmental dysplasia/dislocation.
• Weigh the infant to the nearest 5 g.
• Measure: occipitofrontal circumference, crown–heel length (neonatal stadiometer).
The mental state examination 320
Putting it all together: clinical vignettes 325
OSCE example 1: Assessing suicidal risk 327
OSCE example 2: Assessing delirium 328
Integrated examination sequence for the psychiatric assessment 328
320 • The patient with mental disorder
death) or incriminating (illicit drug misuse, other crime, homicidal
ideas). For interviews undertaken in non-clinical settings such as
police stations or prisons, or for the provision of court reports,
the latter is obviously especially pertinent, and it is important to
be clear with the patients about any limits to confidentiality in
Try to develop rapport early in the interview, if possible, and to
consolidate it before raising a sensitive topic, although sometimes
you must cover such material without delay. It is particularly
important to ask about suicidal thoughts.
Adapt your approach to a patient who is mute, agitated, hostile or
otherwise uncooperative during the interview, by relying more on
observation and collateral information. The safety of the patient,
other patients and staff is paramount, so your initial assessment
of an agitated or hostile patient may be only partial.
The mental state examination (MSE) is a systematic evaluation
of the patient’s mental condition at the time of interview. The
aim is to establish signs of mental disorder that, taken with the
history, enable you to make, suggest or exclude a diagnosis.
While making your specific enquiries, you need to observe,
evaluate and draw inferences in the light of the history. This is
daunting, but with good teaching, practice and experience you
The MSE incorporates elements of the history, observation
of the patient, specific questions exploring various mental
phenomena and short tests of cognitive function. Like the history,
its focus is determined by the potential diagnoses. For example,
detailed cognitive assessment in an elderly patient presenting
with confusion is crucial; similarly, you should carefully evaluate
mood and suicidal thoughts when the presenting problem is
Think of this as a written account of a still photograph, prepared
for someone who cannot see it. Observe:
• general elements such as attire and signs of self-neglect
• tattoos and scars (especially any that suggest recent or
• evidence of substance misuse (such as injection tracks
from intravenous drug use; spider naevi and jaundice from
• possibly relevant physical disease (such as exophthalmos
Think of this as a written account of a video, observing such
• cooperation, rapport, eye contact
• social behaviour (such as aggression, disinhibition, fearful
• apparent responses to possible hallucinations or
Mental disorders are very common, frequently coexist with physical
disorders and cause much mortality and morbidity. Psychiatric
assessment is therefore a required skill for all clinicians. It consists
of four elements: the history, mental state examination, selective
physical examination and collateral information. Each element can
be expanded considerably, so the assessment must be adapted
to its purpose. Is it a quick screening of a patient presenting
with other problems, a confirmation of a suspected diagnosis
or a comprehensive review for a second opinion?
The distinction between symptoms and signs is less clear in
psychiatry than in the rest of medicine. The psychiatric interview,
which covers both, has several purposes: to obtain a history of
symptoms, to assess the present mental state for signs, and to
establish rapport that will facilitate further management.
A comprehensive history covers a range of areas (Box 16.1), but
the nature of the presenting problem and/or the referral question,
and the setting in which the history is being taken, will determine
the degree of detail needed for each. When seeing someone in
the accident and emergency department with a first episode of
psychosis, the focus is on symptoms, recent changes of function,
family history and drug use; when interviewing someone in an
outpatient clinic with a possible personality disorder, assessment
concentrates instead on their personal history, which is essentially
a systematised biography (Box 16.2).
Some subjects require particular skill. The common theme is
reluctance to disclose, which can arise because the information
is private, and disclosure is potentially embarrassing (such as
sexual dysfunction, gender identity), distressing (major traumatic
experiences, such as rape, childhood sexual abuse, witnessing a
16.1 Content of a psychiatric history
• History of presenting symptom(s)
• Systematic enquiry into other relevant problems and symptoms
• Past medical/psychiatric history
• Prescribed and non-prescribed medication
• Substance use: illegal drugs, alcohol, tobacco, caffeine
• Family history (including psychiatric disorders)
The mental state examination • 321
any aspect of life, and at interview appear downcast, withdrawn
and tearful, with little brightening even when talking about their
Pervasive disturbance of mood is the most important
feature of depression, mania and anxiety, but mood changes
commonly occur in other mental disorders such as schizophrenia
and dementia. You might ask patients ‘How has your mood
been lately?’, ‘Have you noticed any change in your emotions
recently?’ and ‘Do you still enjoy things that normally give you
pleasure?’ Abnormalities of mood include a problematic pervasive
mood, an abnormal range of affect, abnormal reactivity and
inappropriateness or incongruity. Some terms relating to mood
Some patients prompt affective responses in the interviewer,
via the process of countertransference. The elated gaiety of some
hypomanic patients can be infectious, as can the hopeless gloom
of some people with depression. Recognising these responses in
yourself can be helpful in understanding how the patient relates
As with speech, this is a not an assessment of what the patient
is thinking about, but how they think about it. Assess it by
observing how thoughts appear to be linked together, and the
speed and directness with which the train of thought moves,
considering rate, flow, sequencing and abstraction. Some terms
relating to thought form are defined in Box 16.6.
Thinking may appear speeded up, as in hypomania, or
slowed down, as in profound depression. The flow of subjects
• over-activity (agitation, pacing, compulsive hand washing)
• under-activity (stupor, motor retardation)
• abnormal activity (posturing, involuntary movements,
This is not a description of what the patient says (that is, content),
but of how they say it (form). Assess:
• articulation (such as stammering, dysarthria)
• quantity (mutism, garrulousness)
• volume (whispering, shouting)
• tone and quality (accent, emotionality)
• fluency (staccato, monotonous)
• abnormal language (neologisms, dysphasia, clanging,
Mood is the patient’s pervasive emotional state, while affect is the
observable expression of their emotions, which is more variable
over time. Think of mood as the emotional climate and affect
as the weather. Both have elements of subjective experience
(that is, how the patient feels, according to their own report and
your specific questions) and how the patient appears to feel,
according to your own objective observation. So a depressed
patient might describe feeling sad, hopeless and unable to enjoy
Agitation A combination of psychic anxiety and excessive,
Compulsion A stereotyped action that the patient cannot
Disinhibition Loss of control over normal social behaviour
Motor retardation Decreased motor activity, usually a combination
Posturing The maintenance of bizarre gait or limb positions
Clang associations Thoughts connected by their similar sound
Echolalia Senseless repetition of the interviewer’s words
Mutism Absence of speech without impaired
Neologism An invented word, or a new meaning for an
Pressure of speech Rapid, excessive, continuous speech (due to
Word salad A meaningless string of words, often with loss
Blunting Loss of normal emotional sensitivity to experiences
An extreme emotional and behavioural over-reaction
Flattening Loss of the range of normal emotional responses
Incongruity A mismatch between the emotional expression and
Lability Superficial, rapidly changing and poorly controlled
16.6 Thought form: definitions
Circumstantiality Trivia and digressions impairing the flow but
Concrete thinking Inability to think abstractly
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