¾ The correct use of the formula to compute the INR.

¾ Uniform understanding of the INR system by clinicians

as well as laboratorians.

Patient Variables in PT/INR Testing

There are many factors that can influence the results of the

PT/INR tests so that they do not reflect the patient’s usual

coagulation state. Coagulation tests are susceptible to

errors introduced by suboptimal specimen quality because

of a number of factors such as blood collection technique,

labile state of several coagulation proteins, and laboratory

transportation factors. In order to get acceptable accuracy

it is important to understand and control these factors as

much as possible.

Factors that Influence Coagulation Test Results

Age and Gender

Age specific reference ranges are critical for correct

interpretation of coagulation data. Bleeding time declines

with age and many coagulation factors increase with age

as do markers of coagulation activation. Age and gender

can also influence platelet function. Females tend to have

longer bleeding times than males.

Blood Type

Type O individuals have significantly lower von

Willebrand factor and factor VIII activity than subjects

with type A, B, or AB. This causes increased bleeding and

dotting times.

Within Day Variation

Incidences of platelet activation are highest in the

mornings, resulting in increased coagulation activation.

Seasonal Variation

Increased coagulation activity has been described in cold

weather.

Intraindividual Variability

Many coagulation analytes are less precise than other

analytes and thus can give variable results within the same

individual.

Diet, Alcohol and Smoking

Cardiac risk factors can increase coagulation factor level/

activation. Smoking elevates plasma fibrinogen. Von

Willebrand factor, thrombin generation and platelet

activation may all have an effect causing variability.

Moderate ethanol intake inhibits platelet reactivity and

increases fibrinolysis and INR.

Medications

A number of other medications, including hormone

replacement therapy, selective estrogen receptor,

modifiers and oral contraceptives can alter coagulation

and raise the INR. In addition, non-steroidal antiinflammatory drugs, antibiotics and fluoroquinolones

can also alter the INR.

Menstrual Cycle, Pregnancy

Significant hormonally determined changes in coagulation

factors, inhibitors, fibrinolysis and activation markers

must be considered as interpretation of the results.

Diseases

States, which lead to anemia, polycythemia or hemolysis

or uremia, can also interfere with coagulation tests.

Physical and Emotional Stress

These are commonly associated with increased coagulation

and platelet activation.

Clinical Hematology: Bleeding Disorders 293

Posture

Values can change from supine to upright positions

due to the shift of water and subsequent reduction in

plasma volume. Hence, standardization of posture is

recommended.

Venous Occlusion

Traumatic or prolonged phlebotomy accentuates the

hemostatic activation, producing artificially altered

coagulation times.

Vitamin K

Certain fat substitutes in some snackitems contain

unspecified amount of vitamin K. Green, leafy vegetables

and green tea also contain high levels of vitamin K. This

can have an impact on serum vitamin K levels and the INR

can drop as a result. Alternative medicines: According to

the AANA (American Association of Nurse Anesthetists)

some sources, certain herbal drugs can cause interference

in coagulation cycles, falsely elevating the INR.

Anticoagulant Therapy

It is of utmost importance to bear in mind that patients on

heparin will show inaccurate INR results.

While certain pre-analytical factors are not entirely

controllable, every effort must be made to ensure that most

conditions have been stable for a period of time. Patient

preparation and blood collection should be standardized

according to the guidelines.

Prothrombin Determination (Two-stage Method)

Principle

Prothrombin in the presence of optimal procoagulants

and calcium will form thrombin. The amount of thrombin

formed can be calculated by determining the dilution of

plasma that will clot a standard fibrinogen reagent in a

specific period of time. The amount of thrombin formed

is a measure of the amount of prothrombin present in the

starting sample.

The test consists of two stages. In the first stage,

prothrombin is incubated with a standard mixture

containing thromboplastin, calcium, a buffer and a source

of procoagulants. In the second stage, samples of the

incubating mixture are added to a standard fibrinogen

solution and the clotting time is determined.

Results

1. The object of the procedure is to determine the dilution

of plasma from which will evolve one unit of thrombin

under optimal conditions. A unit of thrombin is defined

as that amount which will form a clot of 1 mL of fibrinogen in 15 seconds under standard conditions.

2. If varying amounts of thrombin are added to standard

amounts of fibrinogen the clotting time of the mixture

is an index of the thrombin concentration within a

specific range. When thrombin concentrations are

plotted against clotting times, the results describe

a hyperbolic curve. With thrombin concentrations

between 0.80 and 1.34 units, there is good correlation

between thrombin concentration and clotting time.

With greater amounts of thrombin, there is little

change in the speed of clotting, with relatively large

changes in thrombin concentration. With lesser

amounts of thrombin, small changes in thrombin

concentration result in large changes in the speed of

clotting.

APTT/PTTK CEPHALOPLASTIN REAGENT FOR

PARTIAL THROMBOPLASTIN TIME (APTT)

DETERMINATION USING ELLAGIC ACID AS

ACTIVATOR LIQUICELIN-E®

(Courtesy: Tulip Group of Companies)

Summary

The arrest of bleeding depends upon primary platelet plug

formed along with the formation of a stable fibrin clot.

Formation of this clot involves the sequential interaction of

a series of plasma proteins in a highly ordered and complex

manner and also the interaction of these complexes with

blood platelets and materials released from the tissues.

Activated partial thromboplastin time is prolonged by a

deficiency of coagulation factors of the intrinsic pathway of

the human coagulation mechanism such as factor XII, XI,

IX, VIII, X, V, II and fibrinogen. Determination of APTT helps

in estimating abnormality in most of the clotting factors of

the intrinsic pathway including congenital deficiency of

factor VIII, IX, XI and XII and is also a sensitive procedure

for generating heparin response curves for monitoring

heparin therapy.

 

Sources of third-party information will usually include family and

other carers, as well as past and present general practitioners

and other health professionals. Previous psychiatric assessments

are particularly valuable when a diagnosis of personality disorder

is being considered, as this depends more on information about

behaviour patterns over time than the details of the current

presentation (Box 16.10).

16.10 Personality disorder: definition

Patterns of experience and behaviour that are:

• pathological (i.e. outside social norms)

• problematic (for the patient and/or others)

• pervasive (affecting most or all areas of a patient’s life)

• persistent (adolescent onset, enduring throughout adult life and

resistant to treatment)

From Hodkinson HM. Evaluation of a mental test score for assessment of mental

impairment in the elderly. Age and Ageing 1972; 1(4):233–238, by permission

of Oxford University Press.

16.11 The Abbreviated Mental Test

• Age

• Date of birth

• Time (to the nearest hour)

• Year

• Hospital name

• Recognition of two people, e.g. doctor, nurse

• Recall address

• Dates of First World War (or other significant event)

• Name of the monarch (or prime minister/president as appropriate)

• Count backwards 20–1

Each question scores 1 mark; a score of 8/10 or less indicates

confusion.

16.12 The CAGE questionnaire

• Cut down: Have you ever felt you should cut down on your drinking?

• Annoyed: Have people annoyed you by criticising your drinking?

• Guilty: Have you ever felt bad or guilty about your drinking?

• Ever: Do you ever have a drink first thing in the morning to steady

you or help a hangover (an ‘eye opener’)?

Positive answers to two or more questions suggest problem

drinking; confirm this by asking about the maximum taken.

326 • The patient with mental disorder

16.14 Clinical vignette: overdose

A 19-year-old woman attends the accident and emergency

department, having taken a medically minor overdose. She has

presented in this way three times in the last 2 years. She needs no

specific medical treatment.

Your assessment should concentrate first on the circumstances of

the overdose and her intentions at the time. Collateral information

should include assessments after previous presentations and any

continuing psychiatric follow-up. Mental state examination should

screen for any new signs of mental disorder emerging since her last

assessment, and in particular any mood problems or new psychotic

symptoms. She will clearly have undergone a detailed physical

assessment, but even if the overdose appears medically trivial, you

need to undertake a risk assessment to judge the chances of further

self-harm or completed suicide in the near future. She probably does

not need a detailed cognitive assessment or psychiatric rating scales.

16.15 Clinical vignette: confusion, agitation and hostility

An 85-year-old man in a medical ward, where he is undergoing

intravenous antibiotic treatment for a chest infection, now appears

confused, agitated and hostile, in a way not previously evident to his

family.

You need to approach him carefully to establish rapport and to

interview him as much as he will allow, while anticipating that you may

have to rely heavily on collateral information, and a mental state

examination limited to observation of appearance and behaviour. It will

be crucial to talk to his family to establish his normal level of cognition

and independence, and to the nursing staff to establish the diurnal

pattern of his problems. If there is any history of previous episodes,

acquire the results of previous assessments. He will need a

neurological examination and assessment of his cognition via a

standard scale. Risk assessment should focus on the indirect risks to

his health if he tries to leave hospital against advice, generating a view

about his detainability under mental health legislation. A capacity

assessment of his ability to consent to continuing antibiotic treatment

is required, and may result in the issue of an incapacity certificate.

16.13 The fast alcohol screening test (FAST) questionnaire

For the following questions please circle the answer that best applies

1 drink = 1

2 pint of beer or 1 glass of wine or 1 single measure of spirits

1. Men: How often do you have eight or more drinks on one occasion?

Women: How often do you have six or more drinks on one occasion?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

3. How often during the last year have you failed to do what was normally expected of you because of drinking?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

4. In the last year, has a relative or friend, or a doctor or other health worker, been concerned about your drinking or suggested you cut down?

• Never (0)

• Yes, on one occasion (2)

• Yes, on more than one occasion (4)

Scoring FAST

First stage

• If the answer to question 1 is ‘Never’, then the patient is probably not misusing alcohol

• If the answer is ‘Weekly’ or ‘Daily or almost daily’, then the patient is a hazardous, harmful or dependent drinker

• 50% of people are classified using this one question

Second stage

• Only use questions 2–4 if the answer to question 1 is ‘Less than monthly’ or ‘Monthly’:

• Score questions 1–3: 0, 1, 2, 3, 4

• Score question 4: 0, 2, 4

• Minimum score is 0

• Maximum score is 16

• Score for hazardous drinking is 3 or more

Putting it all together: clinical vignettes • 327

16

16.16 Clinical vignette: fatigue

A 35-year-old woman attends her general practitioner, presenting with

fatigue.

Assessment of possible physical causes is required, via history,

examination and appropriate blood tests, but as these proceed, the

interview should also cover possible symptoms of depression, previous

episodes, family history and recent stressors. Mental state examination

should concentrate on objective evidence of lowered mood. Formal

assessment of cognition is probably not necessary, but a standard

rating scale for mood disorder may help establish a diagnosis and a

baseline against which to measure change. Risk assessment is not a

prominent requirement, unless a depressive illness is suspected and

she reports thoughts of self-harm, or is responsible for young children,

in which case the chance of direct or indirect harm to them needs to

be considered.

16.17 Clinical vignette: paranoid thoughts

A 42-year-old man attends a psychiatric outpatient clinic for the first

time, having been referred by his general practitioner for longstanding

paranoid thoughts.

It will be particularly important to establish rapport with a patient

who is likely to be very wary. The interview needs to cover the

psychiatric history in some detail, considering substance misuse, family

history of mental illness and a full personal history in particular. Mental

state examination should explore the paranoid thoughts in detail, to

establish whether they are preoccupations or overvalued ideas

(suggesting a personality disorder), or delusions (suggesting a

psychotic illness). Risk assessment should concentrate on the risk to

others about whom the patient has paranoid fears. Neither detailed

cognitive assessment nor a specific rating scale is likely to add much

to the initial assessment.

OSCE example 1: Assessing suicidal risk

Miss Gardiner, 27 years old, presented to the accident and emergency department the previous day after taking an overdose of paracetamol while

intoxicated with alcohol. She has undergone treatment with acetylcysteine overnight and is now medically fit for discharge.

Please assess her risk of self-harm and suicide

• Introduce yourself and clean your hands.

• Explain the purpose of your assessment; try to gain rapport.

• Enquire how she is feeling physically (specifically asking about nausea, vomiting and abdominal pain).

• Tactfully introduce the subject of the overdose.

• Establish the number and type of tablets taken.

• Establish how much alcohol she drank, whether this was with the tablets (to ‘wash them down’) or whether she was already intoxicated at the time

of the overdose.

• Clarify the circumstances. Who else was present or expected? Did she write a note or otherwise communicate what she had done or was planning

to do?

• Clarify how she was found and either came or was brought to hospital.

• Explore recent or chronic stressors.

• Establish her intent at the time of the overdose. Did she expect to die? Is that what she wanted?

• Confirm her view now. Does she still wish to die? Does she have any thoughts about another overdose or other form of self-harm?

• Establish relevant past history. Are there any previous overdoses? Any previous or continuing psychiatric follow-up?

• Confirm whether she has parental or caring responsibilities for young children. Tactfully enquire about any thoughts of harming them.

• Establish who will be with her when she leaves hospital.

• Thank the patient and clean your hands.

Summarise your findings

The risk assessment should concentrate most on the short-term risk of suicide.

Advanced level comments

More advanced students would be expected to tabulate short- and long-term risk of both suicide and further self-harm, and to quote the risk of

completed suicide in the first year after an act of self-harm (1–2%).

328 • The patient with mental disorder

OSCE example 2: Assessing delirium

Mr Duncan, 82 years old, is admitted to an orthopaedic ward after falling and breaking his hip. Forty-eight hours after surgery he became restless and

agitated overnight, pulling out his intravenous line. He is now settled and cooperative.

Please assess the likely cause of this episode

• Introduce yourself and clean your hands.

• Explain the purpose of your assessment; try to establish rapport.

• Enquire how he is feeling physically (specifically asking about pain, fever, constipation, and urinary and respiratory symptoms).

• Establish his awareness of where he is, why he is there and how long he has been in hospital.

• Ask how much he remembers of the night’s events and enquire specifically about any recollection of hallucinations or persecutory fears.

• Enquire about any continuing hallucinations or fears.

• Ask about any previous similar episodes.

• Clarify how active he was before his fall, and whether there is any awareness of memory impairment leading up to it.

• Ask about alcohol intake.

• Administer simple tests of cognitive function, especially of attention and memory (advanced performers should know the Abbreviated Mental Test

questions).

• Undertake a basic physical examination, assessing for tremor, ophthalmoplegia and nystagmus.

• Gain the patient’s permission to speak to his next of kin, general practitioner and others.

• Thank the patient and clean your hands.

Summarise your findings

The diagnosis is delirium, with further enquiries needed to establish the likely cause (which may be alcohol withdrawal, given the timing), as well as

the possibility of pre-existing cognitive impairment as a vulnerability factor.

Integrated examination sequence for the psychiatric assessment

• Review the relevant information to clarify the reason for referral or mode of self-presentation.

• Establish rapport to reduce distress and assist assessment.

• Cover the key headings for the history (presenting symptoms, systematic review, past medical and psychiatric history, current medication, substance

misuse, family history, personal history).

• Cover the headings for the personal history (childhood development, losses and experiences, education, occupation, financial circumstances,

relationships, partner(s) and children, housing, leisure activities, hobbies and interests, forensic history).

• Make the extent, order and content of the assessment appropriate to the presentation and setting.

• Observe closely to gain objective evidence of mental state, especially non-verbal information.

• Cover the headings for the mental state examination systematically (appearance and behaviour, speech, mood, thought form and content,

perceptions, cognition and insight).

• Use brief formal tests to assess cognitive function (Abbreviated Mental Test, Mini-Mental State Examination, Montreal Cognitive Assessment).

• Consider your own emotional response to your patient.

• Consider standardised rating scales as a screening tool (and sometimes to monitor progress).

• Undertake physical examination as appropriate to the setting and the presentation.

• Gather further background information from other sources to the degree necessary (with permission).

• As well as a diagnosis and management plan, be sure to consider:

• assessment of risk to self or others

• capacity to take decisions

• need to use mental health or incapacity legislation.

17

The frail elderly patient

Andrew Elder

Elizabeth MacDonald

Assessment of the frail elderly patient 330

Factors influencing presentation and history 330

The history 331

The presenting symptoms 331

Common presenting symptoms 331

Past medical history 331

Drug history 331

Family history 332

Social and functional history 332

Systematic enquiry 332

The physical examination 333

General examination 333

Systems examination 334

Functional assessment 335

Interpretation of the findings 337

OSCE example 1: History in a frail elderly patient with falls 337

OSCE example 2: Examination of an acutely confused frail

elderly patient 337

Integrated clinical examination for the frail elderly patient 338

330 • The frail elderly patient

Factors influencing presentation

and history

Classical patterns of symptoms and signs still occur in the frail

elderly, but modified or non-specific presentations are common

due to comorbidity, drug treatment and ageing itself. As the

combination of these factors is unique for each individual, their

presentations will be different. The first sign of new illness may

be a change in functional status: typically, reduced mobility,

altered cognition or impairment of balance leading to falls.

Common precipitants are infections, changes in medication and

metabolic derangements but almost any acute medical insult can

produce these non-specific presentations (Fig. 17.1). Each of

these presentations should be explored through careful history

taking, physical examination and functional assessment.

Disorders of cognition, communication and mood are so

common that they should always be considered at the start of

the assessment of a frail older adult.

Communication difficulties,

cognition and mood

Communication can be challenging (Box 17.2). The history

can be incomplete, difficult to interpret or misleading, and the

whole assessment, including physical examination, may be

time-consuming.

Whenever possible, assess the patient somewhere quiet with

few distractions. Make your patient comfortable and ensure they

understand the purpose of your contact. Provide any glasses,

hearing aids or dentures that they need and help them to switch

Assessment of the frail elderly patient

Comprehensive geriatric assessment is an evidence-based

process that improves outcomes. It involves taking the history

from the patient and, with the patient’s consent, from a carer

or relative, followed by a systematic assessment of:

• cognitive function and mood

• nutrition and hydration

• skin

• pain

• continence

• hearing and vision

• functional status.

The extent and focus of the assessment depend on the clinical

presentation. In non-acute settings such as the general practice

or outpatient clinic or day hospital, focus on establishing what

diseases are present, and also which functional impairments

and problems most affect the patient’s life.

In acute settings such as following acute hospital referral,

focus on what has changed or is new. Seek any new symptoms

or signs of illness and any changes from baseline physical or

cognitive function.

The complexity of the problems presented, and the need for

comprehensive and systematic analysis, mean that assessment

is divided into components undertaken at different times, by

different members of the multiprofessional team (Box 17.1).

There is no specific age at which a patient becomes

‘elderly’; although age over 65 years is commonly used as the

definition, this has no biological basis, and many patients who

are chronologically ‘elderly’ appear biologically and functionally

younger, and vice versa.

Frailty becomes more common with advancing age and is

likely to be a response to chronic disease and ageing itself. A frail

elderly person typically suffers multimorbidity (multiple illnesses)

and has associated polypharmacy (multiple medications). They

often have cognitive impairment, visual and hearing loss, low

bodyweight and poor mobility due to muscular weakness, unstable

balance and poor exercise tolerance. Their general functional

reserve and the capacity of individual organs and physiological

systems are impaired, making the individual vulnerable to the

effects of minor illness.

17.1 The multiprofessional team

Professional Key roles in assessment of

Physician Physical state, including diagnosis

and therapeutic intervention

Psychiatrist Cognition, mood and capacity

Physiotherapist Mobility, balance, gait and falls risk

Occupational therapist Practical functional activities

(self-care and domestic)

Nurse Skin health, nutrition and continence

Dietician Nutrition

Speech and language therapist Speech and swallowing

Social worker Social care needs

,QIHFWLRQ 0HWDEROLF

SUREOHPV

'UXJV 2WKHU

SUHFLSLWDQWV

)XQFWLRQDOGHFRPSHQVDWLRQRIWKHIUDLOHOGHUO\DGXOW

,PPRELOLW\ 'HOLULXP )DOOV

Fig. 17.1 Functional decompensation in frail elderly people.

17.2 Communication difficulties: the seven Ds

Problem Comment/causes

Deafness Nerve or conductive

Dysphasia Most commonly due to stroke disease but sometimes

a feature of dementia

Dysarthria Cerebrovascular disease, motor neurone disease,

Parkinson’s disease

Dysphonia Parkinson’s disease

Dementia Global impairment of cognitive function

Delirium Impaired attention, disturbance of arousal and

perceptual disturbances

Depression May mimic dementia or delirium

 

Pubic hair stage

12mL

4mL

IV

III

II

IV

III

II

Fig. 15.18 Timing of puberty in males and females.

The physical examination • 313

15

signs, they should ideally be reassessed in 1–2 hours if there

is a high level of parental or clinical anxiety that the signs are

out of keeping with a simple viral illness in a child of that age.

General examination

Height

Use a stadiometer (Fig. 15.20).

and turning round; if so, comment warmly on this cooperation

and provide positive feedback on helpful behaviour. Children’s

social skills regress when they are unwell and some are very

apprehensive of strangers.

5+ years

The child may comply with a full adult-style examination. Although

children under 11 years are often not able to express themselves

well, those over 5 years are able to understand and comply with

requests such as finger-to-nose pointing, heel-to-toe walking, and

being asked to ‘sit forward’ and ‘take a deep breath in and hold it’.

The acutely unwell child

There are many non-specific signs that are common to a range

of conditions from a simple cold to meningitis. These include

a runny nose, fever, lethargy, vomiting, blanching rash and

irritability. However, some signs are serious, requiring immediate

investigation and management (Box 15.10).

Children become ill quickly. If a child has been unwell for less

than 24 hours and initial examination reveals only non-specific Male genital development Pubic hair MALE FEMALEBreast development

BI

Prepubertal

BII

Breast bud

BIII

Juvenile smooth

contour

BIV

Areola and papilla

project above breast

BV

Adult

PHI

Pre-adolescent

No sexual hair

PHIII

Dark, coarser, curlier

PHIV

Filling out towards

adult distribution

PHV

Adult in quantity and type

with spread to medial thighs

in male

GI

Pre-adolescent

GII

Lengthening

of penis

GIII

Further growth in length

and circumference

GIV

Development of glans penis,

darkening of scrotal skin

GV

Adult genitalia

PHII

Sparse, pigmented, long,

straight, mainly along

labia and at base of penis

Fig. 15.19 Stages of puberty in males and females. Pubertal changes according to the Tanner stages of puberty.

15.10 Serious signs requiring urgent attention

• Poor perfusion with reduced capillary refill and cool peripheries

(indicating shock)

• Listless, poorly responsive, whimpering child (suggesting sepsis)

• Petechial rash over the trunk (suggesting meningococcal sepsis)

• Headache with photophobia or neck stiffness (suggesting meningitis)

• Respiratory distress at rest (rapid rate and increased respiratory

effort, indicating loss of respiratory reserve due to pneumonia or

asthma)

Calibration checked

Head straight, eyes and ears level

Gentle upward traction on mastoid process

Knees straight

Heels touching back of board

Barefoot with feet flat on floor

Fig. 15.20 Stadiometer for measuring height accurately in children.

314 • Babies and children

Abnormal findings

Healthy tonsils and pharynx look pink; when inflamed, they are

crimson–red.

Inspecting the throat reveals the presence, but not the cause, of

the infection; pus on the tonsils and pharynx does not differentiate

a bacterial from a viral infection (p. 185).

Ears

Examination sequence

• Ask the parent to:

• Sit the child across their knees with the child’s ear

facing you.

• Place one arm around the child’s shoulder and upper

arm that are facing you (to stop them pushing you

away, Fig. 15.22).

• Place their other hand over the parietal area above

the child’s ear that is facing you (to keep the child’s

head still).

• Use an otoscope with the largest speculum that will

comfortably fit the child’s external auditory meatus.

• To straighten the ear canal and visualise the canal and

tympanic membrane, hold the pinna gently and pull it out

and down in a baby or toddler with no mastoid

development, or up and back in a child whose mastoid

process has formed.

Lymphadenopathy

Normal findings

Palpable neck and groin nodes are extremely common in children

under 5 years old. They are typically bilateral, less than 1 cm in

diameter, hard and mobile with no overlying redness, and can

persist for many weeks. In the absence of systemic symptoms

such as weight loss, fevers or night sweats, these are typically

a normal, healthy immune response to infection. Only rarely are

they due to malignancy (Box 15.12).

Vital signs

Normal ranges for vital signs vary according to age (Box 15.11).

Ears, nose and throat

The preschool child

Throat

Examination sequence

• Ask the parent to:

• Sit the child on their knees, both facing you.

• Give an older child the opportunity to open their mouth

spontaneously (‘Roar like a lion!’). If this is not

successful, proceed as described here.

• Place one arm over the child’s upper arms and chest

(to stop the child pushing you away, Fig. 15.21).

• Hold the child’s forehead with their other hand (to stop

the child pulling their chin down to their chest).

• Hold the torch in your non-dominant hand to illuminate the

child’s throat.

• Slide a tongue depressor inside the child’s cheek with

your dominant hand. The child should open their clenched

teeth (perhaps with a shout), showing their tonsils and

pharynx.

Fig. 15.21 How to hold a child to examine the mouth and throat.

Fig. 15.22 How to hold a child to examine the ear.

15.11 Physiological measurements in

children of different ages

Age (years) Pulse (bpm)

Respiratory

rate (breaths

per minute)

Systolic blood

pressure (mmHg)

0–1 110–160 30–60 70–90

2–5 60–140 25–40 80–100

6–12 60–120 20–25 90–110

13–18 60–100 15–20 100–120

Child protection • 315

15

want to move, and if they are forced to do so, the neck remains

aligned with the trunk. With a young child, move a toy to catch

their attention and see if they move their head.

Spotting the sick child

It can be difficult to identify a child with severe illness. With

experience you will learn to identify whether a child is just miserable

or really ill. Early-warning scores (such as PEWS or COAST, Fig.

15.23) can help. Certain features correlate with severe illness

(Box 15.13).

Child protection

Children who experience neglect or physical and/or emotional

abuse are at increased risk of health problems. At-risk children

are often already known to other agencies but this information

may not be available to you in the acute setting. Injuries from

physical abuse can be detected visually. Consider non-accidental

injury if the history is not consistent with the injury, or the injury

is present in unusual places such as over the back. It may be

difficult to detect neglect during a brief encounter but consider

it if the child appears dirty or is wearing dirty or torn clothes

that are too small or large. The parent–child relationship gives

insight into neglect; the child is apparently scared of the parent

(‘frozen watchfulness’) or the parent is apparently oblivious to

the child’s attention (Box 15.14).

Cardiovascular examination

Feel the brachial pulse in the antecubital fossa in children below

2–3 years. Do not palpate the carotid or radial pulses in young

children. Measure blood pressure using a cuff sized two-thirds

the distance from elbow to shoulder tip. Repeat with a larger

cuff if the reading is elevated. If in doubt, use a larger cuff, as

smaller cuffs yield falsely high values.

Respiratory examination

Abnormal findings

The child under 3 years has a soft chest wall and relatively

small, stiff lungs. When the lungs are made stiffer (by infection

or fluid), the diaphragm must contract vigorously to draw air into

the lungs. This produces recession (ribs ‘sucking in’ – tracheal,

intercostal and subcostal) and paradoxical outward movement

of the abdomen (wrongly called ‘abdominal breathing’). These

important signs of increased work of breathing are often

noticed by parents. Older children may be able to articulate

the accompanying symptom of dyspnoea.

Children’s small, thin chests transmit noises readily, and

their smaller airways are more prone to turbulence and added

sounds. Auscultation may reveal a variety of sounds, including

expiratory polyphonic wheeze (occasionally inspiratory too), fine

end-expiratory crackles, coarse louder crackles transmitted from

the larger airways, and other sounds described as pops and

squeaks (typically in the chest of recovering patients with asthma).