General examination outline
Vital Signs:
Temperature (35.8°C – 37.2°C)
Pulse Rate (60 bpm - 100 bpm)
Respiratory Rate (25 breaths/min - 10 breaths/min)
Blood Pressure (140/90 mmHg - 90/60 mmHg)
General examination
General looking of patient (Gerneral Building):
She/He is looking uncomfortable
is looking tired
is in a good general state
is debilitated patient
is cachectic patient (patient is weak or in a chronic stage or serious condition)
Cachectic: Having cachexia, physical wasting with loss of weight and muscle mass
due to disease. Patients with advanced cancer, AIDS, severe heart failure and some
other major chronic progressive diseases may appear cachectic. (loss of frontalis
muscle, checks, prominent of zygomatic bone & hand muscles).
Speech and Communication disorders (During talking with patient you notice) :
dysarthria: impaired speech caused by muscle
weakness;.
dysphasia or aphasia: impaired or absent
ability to speak caused by a neurological
abnormality.
dysgraphia or agraphia: impaired or absent
ability to write;.
dyspraxia or apraxia: impaired or absent ability
to perform purposeful movements in the
absence of paralysis.
Eye
Anemia
whiting in lower eye lid conjectiva (Pale)
jaundice
Must done in day light
yellowish in upper part of sclera
exophthalmos
State of Mouth:
cyanosis (central or peripheral)
pale ness (bellow the tongue)
state of hydration (well hydrated or dehydration(postoperative may due to renal failure))
oral hygiene good or bad(smokers)?
State of lymph node:
check lymph node for lymph adenopathy?
Hand:
pale or not? (by his color compared with your hand may be due to anemia, jaundice or
malignancy cases )
musle wasting
temperature (febrile or not)
Moist or Dry?
Palmar erythema
Radial Pulse rate (for 1 minute) and if its regular or irregular
Nail: Koilonychia(spoon shaped nail in can be a sign of hypochromic anemia, especially
iron-deficiency anemia )
Nail clubbing (when Schamroth's window is hidden during test)
Any other abnormality
Special characters: (if there is speicial problems we should look to these features)
thyroid problems:
tremor (Hyperthyroidism)
exophthalmos
liver problems or jaundice:
Palmar erythema
tremor
Leg oedema
bilateral or unilateral?
pitting oedema or not?
Cyanosis
central or peripheral or not?
Note: You should examine the patient in lying position and his both hands in the beside and you
must stand on the right side of patient.
Note: Positive clinical signs must be mentioned at first.
Note: if there is a canulla we must mention it also.
Note: in GIT cases you must examine left supraclavicular lymph node (Virchow's node) may be
involved by metastatic malignancies, including those of abdominal or pelvic origin (Because It
takes its supply from lymph vessels in the abdominal cavity)
By Mohammed Musa