Examining Children and Adults
A complete history of the nature, onset, extent, and duration of the chief complaint and associated complaints must be taken. This should include previous diseases, personal and family history, occupational data, and social history. A complete listing of medications is essential. It may be desirable—or necessary—to interview relatives and friends.
Detailed information is particularly important in regard to the following:
Note the duration, time of onset, location, frequency, severity, progression, precipitating circumstances, associated symptoms, and response to medications. A worsening headache, or “the worst headache of my life,” is especially concerning.
Record the character of the individual episode, age at onset, frequency, duration, mental status during and after episodes, associated signs and symptoms, aura, and type and effectiveness of previous treatment.
The frequency, progression or remissions, scotomas, acuity changes, diplopia, field changes, and associated phenomena should be noted.
Has the patient become weak? Has the patient lost coordination? Are distal muscles (eg, those of the hand or foot) affected more than proximal ones (eg, those of the upper arm or leg)? Are there abnormal muscle movements? Have muscles wasted?
Has the patient noticed numbness or tingling? Over which part of the body? What is the location of the sensory loss? Can the patient tell where his or her legs are located? Is there a history of painless burns?
Is there double vision? Note any facial drooping, slurred speech, difficulty swallowing, problems with balance, tinnitus (a ringing or buzzing sound in one or both ears), or impaired hearing.
Include in the assessment the onset, location, progression, frequency, characteristics, effect of physical measures, associated complaints, and type and effectiveness of previous treatment.
It is very important to obtain a clear picture of the time course of the disorder. Was onset of symptoms sudden or gradual? If gradual, over what time scale (hour, days, months)? Are symptoms always present, or are they intermittent? What precipitates symptoms, and what relieves them?
Even before beginning the formal physical examination, important information may be gleaned by observing the patient while the history is given. Is the patient well groomed or unkempt? Is the patient aware of and appropriately concerned about the illness? Does the patient attend equally well to stimuli on the left and right sides; that is, does the patient relate equally well to the physician when asked questions from the left and then the right? The examiner can learn much simply by interacting with the patient and observing closely.
A general physical examination should always be performed. The circulatory, respiratory, genitourinary, gastrointestinal, and skeletal systems should be studied and the temperature, pulse rate, respiratory rate, and blood pressure routinely recorded. Note any deformity or limitation of movement of the head, neck, vertebral column, or joints. If there is any question of disease involving the spinal cord, determine whether there is tenderness or pain on percussion over the spinal column. (Immobilize the neck in any patient in whom acute cervical spinal cord injury is suspected.) Inspect and palpate the scalp and skull for localized thickening of the skull, clusters of abnormal scalp vessels, depressed areas, abnormal contours or asymmetry, and craniotomy and other operative scars. Percussion may disclose local scalp or skull tenderness over diseased areas and, in hydrocephalic children, a tympanic cracked-pot sound. Auscultate the skull and neck for bruits.
The patient’s level of consciousness and degree of alertness should be noted. Is the patient conscious and fully alert, lethargic, stuporous, or comatose? A depressed level of consciousness can be the first clue, for example, in patients harboring subdural hematomas.
Note the patient’s ability to focus attention. Is the patient fully alert or confused (ie, unable to maintain a coherent stream of thought)? Confusional states occur with a variety of focal lesions in the brain and are commonly seen as a result of metabolic and toxic disorders.
Some changes in mental status have important localizing value; that is, they suggest the presence of focal brain lesions in particular areas. Wernicke’s and Broca’s aphasia, for example, are seen with lesions involving Wernicke’s and Broca’s areas in the dominant cerebral hemisphere (see Chapter 21). Spatial disorientation suggests disease involving the dominant parietal lobe. Hemispatial neglect, in which the patient neglects stimuli, usually in the left-hand side of the world, suggests a disorder involving the right hemisphere. With some neurologic disorders (eg, brain tumor, multiple sclerosis), the insidious onset and the course of remissions and exacerbations can result in the misdiagnosis of psychogenic illness. Early neurologic disease may occur without significant physical, laboratory, imaging, or other special diagnostic findings, and changes in mental status as a side effect of medications may further complicate the clinical picture.
As noted previously, the examiner can learn much by observing the patient’s behavior, mode of speech, appearance, grooming, and degree of cooperation. Can the patient give a coherent and accurate history? Is the patient appropriately concerned about the illness? Does the patient interact appropriately with family members who are present in the examining room?
Look for anxiety, depression, apathy, fear, suspicion, or irritability.
Listen to the patient’s spontaneous language and to the response to your verbal questions. Is the patient’s speech fluent, nonfluent, or effortful? Is word choice appropriate? Can the patient name simple objects (pen, pencil, eraser, button), colors (point to various objects), and body parts? Is the patient able to repeat simple words (“dog”) or phrases of varying complexity (“President Kennedy”; “no ifs, ands, or buts”; “if he were here, then I would go home with him”)? Check comprehension of spoken language. This can be accomplished even in the patient who cannot speak by asking the patient to “make a fist”; “show me two fingers”; “point to the ceiling”; “point to the place where I entered the room”; or by asking the patient to nod “yes” or “no” in response to questions such as “is school meant for children?” and “Do helicopters eat their young?”
Check the patient’s ability to read and write. (Make sure the patient is wearing reading glasses, if necessary, or use a large-print newspaper.)
Check for orientation with respect to person, place, time, and situation.
Ask about details and dates of recent and remote events, including such items as birth date, marriage date, names and ages of children, and specific details of the past few days and from more remote times. It is best to ask about objective facts (“What happened in sports last week?”, “Who won the World Series?”, “Who is the president?”, “Who was president before that?”).
These questions should be adapted to the patient’s background and education. Examples are the names of prominent political and world figures, the capitals of countries and states, and current events in politics, sports, and performing arts.
Have the patient compare wood and coal; president and king; dwarf and child; human and plant; lie and mistake.
The patient should count backward from 100 by 7s; that is, subtract 7s from 100 (eg, 100 − 7 = 93; 93 − 7 = 86; 86 − 7 = 79). Add, multiply, or divide single numbers (eg, 3 × 5, 4 × 3, 16 × 3) and double-digit numbers (11 × 17 = 187). Calculate interest at 6% for 18 months. The examiner should make the calculations easier or more difficult depending on the patient’s educational background.
Ask the patient to repeat digits in natural or reverse order. (Normally, an adult can retain seven digits forward and five backward.) After instruction, ask the patient to repeat a list of three cities and three two-digit numbers after a pause of 3 minutes.
The patient’s ability to distinguish right from left and to recognize fingers can be tested with the request “Touch your left ear with your right thumb.” Defective right–left orientation and inability to recognize fingers are seen (together with impaired ability to calculate and difficulty writing) in Gerstmann’s syndrome as a result of lesions in the left angular gyrus.
Ask the patient for the symbolic or specific meaning of simple proverbs such as the following: “A stitch in time saves nine,” “A rolling stone gathers no moss,” “People who live in glass houses should not throw stones.”
The content of a simple story from a newspaper or magazine can be read and the patient’s retention, comprehension, and formulation observed. Alternatively, the examiner tells a story, which is then retold in the patient’s own words. The patient is also asked to explain the meaning of the story. The following stories can be used.
A cowboy went to San Francisco with his dog, which he left at a friend’s house while he went to buy a new suit of clothes. Dressed in his brand-new clothing, he came back to the dog, whistled to it, called it by name, and patted it. But the dog would have nothing to do with him in his new coat and hat. Coaxing was to no avail, so the cowboy went away and put on his old suit, and the dog immediately showed its wild joy in seeing its master as it thought he ought to be.
At the coronation of one of the popes, about 300 years ago, a little boy was chosen to play the part of an angel. So that his appearance might be as magnificent as possible, he was covered from head to foot with a coating of gold foil. The little boy fell ill, and although everything possible was done for his recovery except the removal of the fatal golden covering, he died within a few hours.
Thought content may include obsessions, phobias, delusions, compulsions, recurrent dreams or nightmares, depersonalization, or hallucinations.
Olfaction should be assessed in cases in which head trauma has occurred, when disease at the base of the skull is suspected, and in patients with abnormal mental status. (Subfrontal meningiomas and frontal lobe gliomas can compress the underlying olfactory nerve.) Use familiar odors, such as peppermint, coffee, or vanilla, and avoid irritants, such as ammonia and vinegar. The patient must identify the substance with eyes shut and one nostril held closed. Anosmia is considered to be significant in the absence of intranasal disorders and can suggest, for example, compression of the olfactory tract by a tumor.
