• 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
No comments:
Post a Comment
اكتب تعليق حول الموضوع