General Examination

Introduction
 The general examination is usually done in either sitting or lying position. Observation begins as soon as you see the patient (as they enter the room, or as they are lying in bed).
 Move from general observation to specific inspection of different parts of their body
Mental and emotional state
 What is their mental state? (confused, delirious, agitated, somnolent)
 What is their emotional state? (anxious, depressed, apathetic)
Physique
 Is appearance consistent with their age? (younger or older than stated age?)
 What is their body habitus? (tall, short, fat, thin, muscular, asthenic, wasted)
 Are there obvious deformities or scars? (kyphosis, scoliosis, pectus excavatum/carinatum)
Face
 Is there any asymmetry?
 Do they have any swelling? (general puffiness, parotid swelling)
 What is their color? (pale, red, bluish, facial plethora)
 Do they have any rashes? (telangiectasias, naevi, malar rash)
 Are their eyes or eyelids irregular?
Skin
 What is its color? (pallor, jaundice, central cyanosis, peripheral cyanosis)
 What is its temperature? (cool, pyrexia)
 What is its appearance? (dry, pitting edema, scratch marks, bruising, spider naevi)
 If there is edema, what is its distribution? How far up the leg does it go? How severe is it?
Hands/Feet
 What is the appearance of the fingers/joints? (redness, swelling, deformity, Dupuytren’s contracture)
 What is the appearance of the nails? (clubbing, splinter haemorrhage, koilonychia)
 What is the appearance of the palms/pads? (Osler’s nodes, laneway lesions, palmar erythema)
 Any abnormal movements? (hepatic flap, tremor)
o Checking for hepatic flap: When the hands are arms are fully extended and the wrists extended with palms facing forward perpendicular to the ground, the patient will be unable to sustain the hands in extension and will periodically flap his hands.
 What is the appearance of their shins and feet? (hair loss, ulcers)
Neck
 Is there lymphatic swelling?
 Is there thyroid gland swelling?
 Are there abnormal pulsations of the neck vessels? (elevated jugular venous pressure, pulsus paradoxus)
 Checking for jugular venous pressure: have the patient lie at a forty five degree angle. Inspect the neck for the pulsations of the internal jugular vein. Measure its height from the level of the sternal angle. It should normally be less than 3 cm above the sternal angle.
 Checking for pulsus paradoxus: The systolic blood pressure normally decreases slightly during inspiration. Pulsus paradoxus is an abnormally large decrease in this normal variation. To check this, inflate a blood pressure cough as you normally would until you hear no sounds. Slowly deflate the cuff until you hear the first Korotkoff sound only during expiration and note the blood pressure. Continue to decrease the blood pressure until you hear the first Korotkoff sound during both inspiration and expiration. Subtract this from the first pressure. If it is greater than 10 mm Hg difference, then the patient has pulsus paradoxus.

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