In general, examination of a patient is not a good screening test. Use the history to guide you to areas where you think you will find an abnormality
In any sick adult, examine the relevant system first followed by all of the other systems
(cardiovascular, respiratory, nervous and gastrointestinal)
In an adult who is not sick, examine the relevant system first and proceed to further examination
as guided by the history and your findings
Basic Observations
All patients should have basic observations taken. These include pulse rate, blood pressure, respiratory rate, temperature and (often) oxygen saturation
General Appearance
Look at the patient. Are they well or sick?
Look at the conjunctiva and the nail beds. Are they pale?
Look at the lips, tongue and fingers. Are they blue?
Is the patient well nourished?
Assessment of Hydration
Eyes – normal or sunken? Tears absent or present?
Mouth and tongue – wet or dry?
Skin turgor – pinch a loose piece of skin. Does it return to normal immediately or stay saggy?
Any recent weight loss?
Assessment of Skin
Always check the whole body
Is there any jaundice, rashes, bruising, unexplained or unusual marks?
Are there any signs of infection such as redness, swelling or tenderness?
Are there any palpable lymph nodes in the neck, axillae or groins? Are they tender?
Assessment of the Cardiovascular System
Assessment of perfusion
Skin colour – pink, white or grey. Is there mottling? Compare the trunk with the limbs
Skin temperature – does it feel hot, warm, cool or cold? Compare the trunk with the limbs
Central perfusion – blanch the skin over the sternum with your thumb. Time how long it
takes for the mark to disappear
Peripheral perfusion – blanch the skin on a finger or toe. Time how long it takes for the mark
to disappear
Any evidence of oedema? – particularly hands, feet and face
Assessment of the Respiratory System
Most information is gained from looking
Can they talk continuously - or only in words or sentences – or unable to talk at all?
Measure the respiratory rate over one minute
Listen for extra noises – cough, wheeze, stridor
Listen with a stethoscope – listen for air entry into both lung fields. Is it good, moderate or poor?
Are there any wheezes or crackles? Do they occur on inspiration or expiration?
Can they lie flat without breathlessness
Measure SaO2
Assessment of Gastrointestinal System
Look – are there any scars or evidence of abdominal distension? Look for hernias
Listen for bowel sounds – they are either present or absent
Feel – is the abdomen soft or firm?
Are there any obvious masses?
Is the abdomen tender to touch? – be able to describe the exact area
Is there any guarding or rigidity? Even when the person is relaxed?
Is there any rebound tenderness? Press down and take your hand away quickly – is pain
greater when you do this?
Tap on the abdomen – is the pain worse when you do this?
In men check the testes. Any redness, swelling or tenderness?
Assessment of the Nervous System
A detailed assessment of the nervous system is both technically difficult and time consuming.
A brief assessment may be all that is needed
Assess conscious level (See GLASGOW COMA SCALE or APVU)
Assess orientation in time, place and person. Ask the patient their name, date of birth, location.
Ask them to tell you the time, date and year
Look for inequality between one side of the body and the other – compare the tone and power of
muscles of each side of the face and limbs
Test touch and pain sensation using cotton wool and the sharp end of the plexor
Test finger nose coordination and if possible observe the patient walking
Assessment of Ears, Nose and Throat
Ears
Look at the pinna – any redness or swelling?
Is there any obvious swelling or redness of the ear canal? If there is, looking with an otoscope will
be painful
Look inside with an otoscope – look at the ear canal first, then the eardrum. Is the eardrum
normal or is there any redness, dullness, bulging or retraction, fluid or air bubbles, perforations or
discharge?
Nose
Is there any discharge or obvious foreign body?
Throat
Is there any swelling, redness, enlargement of the tonsils or pus?
Assessment of the Eyes
Always test the visual acuity of each eye, use a Snellen chart at 6 metres in good light
Look at the eyes and surrounding structures – is there any redness, discharge or swelling?
Look at the pupils – are they equal in size and regular in shape? Check pupillary reflex to light
Check eye movements
For more detail see ASSESSMENT OF THE EYE
Assessment of the Urine
Examine the urine of all sick patients, all patients with abdominal pain or urinary symptoms and all
patients with a history of diabetes
Look at the colour – is it normal, dark or blood stained?
Does it smell normal?
Perform urinalysis
Perform BHCG in all females with abdominal pain
Blood Sugar Level
Perform a finger-prick BGL on all sick patients, and those with a history of diabetes
| In addition see: - the appropriate HMP/Clinical Care Guidelines: IMMUNISATION PROGRAM, ASSESSMENT OF MENTAL HEALTH PROBLEMS, ASSESSMENT OF THE SICK CHILD, WELL WOMEN’S HEALTH CHECK |
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