TRIPASS XR تري باس

 

• Wheeze is auscultated in all lung regions. No crepitations are heard. Air entry is reduced to all lung regions. The respiratory rate is raised at 40

breaths per minute.

• Heart sounds are normal with no murmur.

• Clean your hands and thank the parent and patient.

Summarise your findings

This child has tachypnoea and a widespread, loud, polyphonic wheeze on expiration.

Suggest a diagnosis

Acute asthma attack on the background of unstable asthma is the likely diagnosis with these symptoms and signs. This requires treatment of the acute

episode with bronchodilator and oral glucocorticoids, and consideration of how to improve background control. Stabilising background control includes

an assessment of adherence and technique for current therapies, consideration of new triggers and how exposure may be reduced (by history and/or

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.

318 • Babies and children

Integrated examination sequence for the newborn child

• Perform a general examination:

• Looks well and is well grown? Dysmorphic features? Posture and behaviour? Does the cry sound normal?

• 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.

• Nose: check patency.

• 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:

• Inspect: chest shape, symmetry of movement, respiratory rate, respiratory distress: tachypnoea, suprasternal, intercostal and subcostal recession,

flaring of nostrils.

• Auscultate anteriorly, laterally and posteriorly, comparing sides.

• Examine the abdomen:

• Inspect: abdomen, umbilicus, anus and groins, noting any swellings.

• Palpate: superficial, then deeper structures. Spleen, then liver.

• Examine the perineum:

• Both sexes: check normal anatomy.

• Male: assess the penis, noting shape; check the urethral meatus is at the tip. Do not retract the foreskin. Palpate the testes, and the inguinal

canal if the testes are not in the scrotum. Transilluminate scrotal swellings.

• Examine the spine and sacrum:

• With the infant in the prone position, inspect and palpate the entire spine for neural tube defects.

• 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:

• Check grasp responses, ventral suspension/pelvic response to back stimulation, place-and-step reflexes, Moro reflex, root-and-suck responses.

• Inspect the limbs:

• Inspect: limbs, counting digits and checking feet are, or can be, normally positioned.

• Check hips for developmental dysplasia/dislocation.

• Weigh and measure:

• Weigh the infant to the nearest 5 g.

• Measure: occipitofrontal circumference, crown–heel length (neonatal stadiometer).

• Record on a centile chart.

16

The patient with

mental disorder

Stephen Potts

The history 320

General approach 320

Sensitive topics 320

The uncooperative patient 320

The mental state examination 320

Appearance 320

Behaviour 320

Speech 321

Mood 321

Thought form 321

Thought content 322

Perceptions 323

Cognition 323

Insight 324

Risk assessment 324

Capacity 324

The physical examination 325

Collateral history 325

Psychiatric rating scales 325

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

your interview.

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.

The uncooperative patient

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

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

will learn the skills.

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

depression.

Appearance

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

• facial expression

• tattoos and scars (especially any that suggest recent or

previous self-harm)

• evidence of substance misuse (such as injection tracks

from intravenous drug use; spider naevi and jaundice from

alcoholic liver disease)

• possibly relevant physical disease (such as exophthalmos

from thyrotoxicosis).

Behaviour

Think of this as a written account of a video, observing such

features as:

• cooperation, rapport, eye contact

• social behaviour (such as aggression, disinhibition, fearful

withdrawal)

• apparent responses to possible hallucinations or

unobserved stimuli

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.