Shadow Health Special Populations Focused Exams: Children, Adolescents, Pregnancy and Older Adults

In this guide

What Shadow Health special populations focused exams are
How to adapt your interview and exam for children, adolescents, pregnant patients and older adults
Four practice cases, one for each population, with key findings and reasoning
Communication, cultural and safety considerations
Common mistakes and FAQs

What are special populations focused exams?

Shadow Health includes collections focused on pediatrics, maternal health, gerontology, mental health and community health, as well as graduate primary care collections for pediatrics, women’s reproductive health and adult care (Elsevier, n.d.). In these assignments, the basic focused-exam skills, which are a clear history, a targeted exam and sound clinical reasoning, still apply, but you must adapt them to the patient’s developmental stage, physiology and social situation. Normal findings in one population can be abnormal in another, and serious illness can look very different in a toddler, a pregnant woman or an 85-year-old (Jarvis & Eckhardt, 2024). For the core focused exam method, see our Shadow Health Focused Exams: Complete Guide.

Children

Adapting the interview

Gather history from the caregiver, and include the child at an age-appropriate level.
Ask about prenatal and birth history, growth, developmental milestones, immunizations, feeding and sleep, daycare or school, and household exposures such as smoke.
Ask about intake and output: number of wet diapers or voids, fluids and food.

Adapting the exam

Do the least invasive parts first (observation, heart and lungs while the child is calm) and the ears and throat last.
Use age-specific vital sign ranges; children normally have faster heart and respiratory rates than adults.
Look for signs of respiratory distress: nasal flaring, retractions, grunting, head bobbing.
Look for signs of dehydration: dry mucous membranes, no tears, decreased urine output, sunken fontanel in infants, delayed capillary refill.
Measure growth (weight, length or height, and head circumference in infants) and plot on growth charts.

Practice case: child with ear pain and fever

Original practice cases for learning; not taken from Shadow Health and not answer keys.

Patient: Mia, 3 years old, brought by her mother. “She’s been pulling at her ear and crying all night.”

Subjective (mother): runny nose for four days, then fever to 102°F last night; tugging at right ear; fussy; drinking less but still urinating; attends daycare; immunizations up to date; no previous ear infections; household smoker (father smokes outside).

Objective: T 101.6°F, HR 128, RR 26, SpO2 98%. Irritable but consolable. Right tympanic membrane red and bulging with no visible landmarks; left normal. Clear rhinorrhea. Lungs clear. Mucous membranes moist.

Reasoning: fever, ear pain and a bulging, red tympanic membrane after a cold suggest acute otitis media. Report findings; teach fever and pain management with correct weight-based dosing as prescribed, hydration, completing any prescribed antibiotic, avoiding secondhand smoke, and warning signs such as stiff neck, lethargy or poor fluid intake.

Adolescents

Interview the adolescent alone for part of the visit, after explaining confidentiality and its limits.
Use the HEADSSS psychosocial screen: Home, Education and employment, Activities, Drugs and substances, Sexuality, Suicide and depression, Safety.
Assess puberty, body image, eating patterns, sleep, screen time and mental health.

Patient: Jordan, 16. “I keep getting headaches and I’m tired all the time.”

Subjective (alone): headaches most afternoons for two months; sleeps about five hours on school nights because of late-night phone use; skips breakfast; grades dropping; feels “stressed and down”; vapes nicotine daily; denies suicidal thoughts when asked directly, but says friends have noticed he is withdrawn.

Objective: vital signs normal; neurological exam normal; flat affect.

Reasoning: sleep deprivation, nicotine use, skipped meals and possible depression may all contribute. Report findings; screen formally for depression (for example, with the PHQ-A); teach sleep hygiene and nutrition; offer vaping cessation support; and explain how to reach crisis support, such as the 988 Suicide & Crisis Lifeline, if he ever feels unsafe.

Pregnant patients

Ask about gestational age, prenatal care, previous pregnancies and outcomes, fetal movement, contractions, vaginal bleeding or fluid leakage.
Screen for warning signs of preeclampsia: headache, visual changes, upper abdominal pain, sudden swelling of the face or hands, shortness of breath.
Remember normal changes of pregnancy: increased heart rate, lower blood pressure in the second trimester, heartburn, back pain and dependent edema.
Screen for depression and intimate partner violence, which can begin or worsen during pregnancy.

Patient: Aisha Johnson, 29, 33 weeks pregnant with her first baby. “I have a headache that won’t go away and my rings are tight.”

Subjective: headache for one day not relieved by acetaminophen; seeing “spots”; swelling of hands and face over three days; mild pain under the right ribs; baby moving normally; no bleeding or leaking fluid.

Objective: BP 158/102, repeated 15 minutes later 160/104; HR 92; facial and hand edema; brisk reflexes (3+) bilaterally; fetal heart rate in the expected range on monitoring.

Reasoning: new high blood pressure after 20 weeks of pregnancy with headache, visual disturbance and right upper quadrant pain suggests preeclampsia with severe features, an obstetric emergency (American College of Obstetricians and Gynecologists [ACOG], 2020). Report immediately, keep her on her side, monitor maternal and fetal status, and prepare for urgent evaluation.

Older adults

Expect atypical presentations: infection may cause confusion or falls instead of fever; a heart attack may cause fatigue or shortness of breath instead of chest pain.
Review all medications for polypharmacy and potentially inappropriate medicines.
Assess function (activities of daily living), cognition, mood, falls, continence, nutrition, hearing and vision, and social support.
Screen for delirium when there is a sudden change in attention or thinking, for example with the Confusion Assessment Method (Inouye et al., 1990).
Allow extra time, speak clearly, face the patient and ensure hearing aids and glasses are in place.

Patient: Mr. Alfred Brown, 84, brought by his daughter. “Dad isn’t himself. He’s confused and fell yesterday.”

Subjective (daughter and patient): sudden confusion over two days, worse at night; fell in the bathroom; urinating more often with new incontinence; drinking less; usually independent and sharp; takes eight medications, including a sleeping pill started last week.

Objective: T 99.0°F, HR 104, BP 108/62 sitting and 94/58 standing. Inattentive, disoriented to date, drifts in and out of the conversation. Dry mucous membranes. Mild suprapubic tenderness. Bruise on right hip; no deformity.

Reasoning: acute, fluctuating confusion with inattention suggests delirium, possibly from a urinary tract infection, dehydration and the new sedative. Report immediately; anticipate urine and blood tests; review medications; ensure fall precautions, hydration, orientation and family presence.

Sample documentation: pregnant patient

Subjective: 29-year-old G1P0 at 33 weeks’ gestation reports persistent headache × 1 day unrelieved by acetaminophen, visual “spots,” swelling of face and hands × 3 days and mild RUQ pain. Reports normal fetal movement. Denies vaginal bleeding, leakage of fluid or contractions.

Objective: BP 158/102, repeat 160/104 after 15 minutes; HR 92; RR 18; SpO2 98%. Facial and bilateral hand edema. DTRs 3+ bilaterally; no clonus. Fetal heart rate within expected range on monitor. Provider notified immediately; patient positioned on left side.

Sample documentation: older adult with acute confusion

Subjective: History from daughter and patient: 84-year-old male with acute onset confusion × 2 days, worse at night; fall in bathroom yesterday; new urinary frequency and incontinence; decreased oral intake. Baseline independent in ADLs and cognitively intact per daughter. Started new sleep medication 1 week ago; takes 8 medications total.

Objective: T 99.0°F, HR 104, BP 108/62 sitting and 94/58 standing, RR 18, SpO2 96%. Inattentive; disoriented to date; fluctuating level of alertness during interview (CAM positive for features 1, 2 and 3). Mucous membranes dry. Mild suprapubic tenderness. 4 cm bruise right lateral hip; no deformity; able to bear weight. Fall precautions initiated; provider notified.

Communication and cultural considerations for all populations

Use professional interpreters, not family members, when there is a language barrier.
Assess health literacy and use plain language and teach-back.
Respect cultural beliefs about illness, pregnancy, aging and family decision-making.
Screen for safety concerns, including abuse and neglect, which nurses may be required to report for children and vulnerable adults.

Common mistakes in special populations exams

Applying adult vital sign norms to children
Talking only to the caregiver and ignoring the child or older adult
Not interviewing adolescents privately
Attributing new confusion in an older adult to “normal aging”
Missing preeclampsia warning signs because headache and swelling are “common in pregnancy”
Forgetting immunizations, growth and developmental history

Developmental and age-related changes to keep in mind

Population	Expected differences	Findings that should not be dismissed
Infants and toddlers	Faster heart and respiratory rates; abdominal breathing; primitive reflexes in infancy	Poor feeding, lethargy, fewer wet diapers, retractions, fever in a young infant
School-age children	Gradual slowing of vital signs; growth spurts	Falling off growth curves, recurrent abdominal pain with weight loss, signs of abuse
Adolescents	Puberty-related changes; risk-taking	Depression, substance use, disordered eating, self-harm
Pregnancy	Higher heart rate, dependent edema, heartburn, back pain	New hypertension, severe headache, visual changes, bleeding, decreased fetal movement
Older adults	Reduced muscle mass, slower reaction time, some hearing and vision decline	New confusion, falls, incontinence, weight loss, functional decline

Special populations exam checklist

Identify the right historian and include the patient whenever possible
Use age- or stage-appropriate vital sign ranges and growth charts
Ask about immunizations, development, pregnancy status or function as appropriate
Screen psychosocial risks: HEADSSS for adolescents, depression and safety in pregnancy, cognition and falls in older adults
Watch for atypical presentations and red flags
Use interpreters, plain language and teach-back
Document who provided the history and any safety concerns

Frequently asked questions

How do I remember normal vital signs for children?

Keep an age-based reference chart from your pediatrics textbook handy. In general, the younger the child, the faster the normal heart and respiratory rates, and blood pressure rises with age.

What is the difference between delirium and dementia?

Delirium develops suddenly over hours or days, fluctuates and affects attention; it is often caused by illness, medications or dehydration and may be reversible. Dementia develops gradually over months or years and mainly affects memory and thinking. A patient with dementia can also develop delirium.

Why is interviewing an adolescent alone important?

Adolescents are more likely to disclose sensitive information about substance use, sexual activity, mood and safety when they can speak privately and understand the limits of confidentiality.

Who gives the history for a young child in Shadow Health?

Usually the caregiver. Document that the history was provided by the caregiver, and include the child’s own words when they can describe symptoms.

Are preeclampsia warning signs part of every prenatal visit?

Yes. Blood pressure, headache, visual changes, upper abdominal pain and swelling should be assessed at prenatal visits after 20 weeks because preeclampsia can develop quickly.

More in the series: Shadow Health Focused Exam: Cough, Shadow Health Focused Exam: Mobility and Shadow Health Documentation.

References

American College of Obstetricians and Gynecologists. (2020). Gestational hypertension and preeclampsia: ACOG Practice Bulletin, Number 222. Obstetrics & Gynecology, 135(6), e237–e260.

Elsevier. (n.d.). Shadow Health: Undergraduate. https://www.elsevier.com/products/shadow-health/undergraduate

Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The Confusion Assessment Method. Annals of Internal Medicine, 113(12), 941–948. https://doi.org/10.7326/0003-4819-113-12-941

Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.

Academic Writer & Editor