In an outpatient consultation, the pulse, blood pressure (figures 1 & 2) and urine should be routinely recorded, together with a patient’s weight (figure 3). The height (figure 4) is usually known, but when growth patterns are being studied, this should be measured, together with span and segments (figure 5a,b). In hospital, examine the ward chart for patient details and dates. These commonly record temperature, pulse, respiration, blood pressure, weight, bowel habit and the results of urine testing. Note all these records carefully, and personally examine all abnormal specimens. The latter include sputum, urine, vomit, faeces, the contents of surgical drainage bottles and any discharges. Discharge may be from ulcers, wounds or other sites, and smaller amounts can be observed on dressings.
In the physical examination, keep the patient comfortable, relaxed and reassured. Talk through what is going to happen, if this is not obvious, and ensure minimal discomfort and inconvenience. A warm environment is essential and your hands must be warm. The privacy of a small room or a curtained area is desirable with optimal, preferably natural, lighting. The patient undresses down to underclothes and puts on a dressing gown. They then lie supine on a couch with an adjustable backrest, to provide head support, and covered with a sheet or blanket. Each area must be adequately exposed as required without embarrassment. A chaperone may be appropriate when examining members of the opposite sex. Relatives are usually best excluded except when examining children.
Thoroughness of examination is important. Efficiency and speed develop with practice. The examination time should not be prolonged in sick or frail patients; in an emergency it may be appropriate to concentrate on diseased areas, completing a routine examination at a later time.
Stand on the right side of the patient. The general impression obtained during the history, is expanded during the examination. Note the patient’s physical and mental status, as well as the severity of their presenting problems, their shape, posture, state of hygiene, and mental and physical activity, and abnormal movements. In the initial stage, examine particularly the exposed parts, i.e. the hands, and the head and neck. This provides information of changes of nutrition and hydration, such as obesity, edema, weight loss, cachexia, loss of skin turgor and skin laxity. Weight loss with an increased appetite is seen in diabetes, thyrotoxicosis and malabsorption. Other potent causes of weight loss are malnutrition (due to lack of food, inability to eat and lack of desire to eat), parasitic disease, particularly of the gut, and progressive malignancy.
In the general examination, the pulse, blood pressure, venous and arterial pulsation in the neck, and the respiratory rate and movements, in the chest and abdomen, are part of the routine. However, they are considered in detail with their respective systems.