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General Examination

This document outlines the 24 steps for conducting a general examination of a patient in a clinical skills lab. It includes assessing vital signs, general appearance, posture, examining all body systems like head, eyes, nose, ears, mouth, throat, hands, lower extremities, skin, lymph nodes, joints, and breasts. The final steps are to document the results in the patient's notes, cover the patient, explain the findings, and thank the patient.

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98 views3 pages

General Examination

This document outlines the 24 steps for conducting a general examination of a patient in a clinical skills lab. It includes assessing vital signs, general appearance, posture, examining all body systems like head, eyes, nose, ears, mouth, throat, hands, lower extremities, skin, lymph nodes, joints, and breasts. The final steps are to document the results in the patient's notes, cover the patient, explain the findings, and thank the patient.

Uploaded by

manal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Libyan International Medical University

Clinical Skills Lab

Student name: ……………………


Student number: …………………

General Examination
Items
1- Explain the procedure to the patient
2- Take a permission from a patient
3- Wash your hand
4- Worm your hands
5- Stand on the patient right side of the patient
6- Examine the patient in a good light & warm surrounding
:Assess the routine data & vital signs -7
- Height
- Weight
- Temperature
- Respiratory rate
- Pulse
- Blood pressure
8- Assess the general appearance:
- Physical built
- Nutrition (obesity or emaciation)
- Deformities
- Abnormal movements
9- Assess posture:
- In bed (decubitus)
- On standing or walking (gait)
10- Examine head for:
- Size
- Shape
- Local abnormalities
- Tenderness
- Hair distribution
11- Examine face for:
- Facial appearance (expression)
- Complexion, color (pallor, cyanosis, jaundice)
- Asymmetry
- Swelling or oedema
12- Examine eyes for:
- Eye lids (oedema, ptosis, retraction)
- Conjunctiva (redness)
- Sclera (jaundice)

1
- Cornea (opacities)
- Pupils
- Eyeballs (exophthalamos, sunken eyes)
- Abnormal movement of the eyeballs (nystagmus)
13- Examine nose for:
- Shape
- Working ala nasi
- Nasal discharge
14- Examine ears for:
- Shape
- Ear discharge
15- Examine parotid glands for swelling
16- Examine mouth & throat for:
- Breath (abnormal odor)
- Lips (cyanosis, pallor, cracking)
- Teeth (caries, loosening, discoloration)
- Gums (Pigmentation, bleeding, hypertrophy)
- Tongue (color, papillary atrophy, tremors)
- Buccal mucosa (pigmentation, inflammation)
- Palate (deformities, vesicles)
- Salivation (excessive salivation)
- Tonsils (inflammation)
17- Examine hands for:
- Shape (presence of deformities)
- Skin changes (ulceration, hyperkeratosis)
- Temperature (cold, warm)
- Color (palmar erythema)
- Excessive sweeting
- Muscle wasting
- Tremors
- Nails (clubbing, koilonychias, dystrophies)

18- Examine lower extremities for:


- Shape (presence of deformities)
- Skin changes
- Muscle wasting
- Oedema
19- Examine skin for:
- Pigmentation
- Texture (dry or excessive sweating)
- Elasticity (tense, excessive elasticity)
- Atrophy
- Eruption
- Hair (distribution, hirsutism)
20- Examine lymph nodes (cervical, axillary, epitrochlear, inguinal & popliteal) for:

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- Size (enlargements)
- Consistency
- Tenderness
- Mobility
21- Examine joints for:
- Swelling
- Redness
- Deformity
- Tenderness
- Range of movements
- Crepitus
22- Examine breasts for:
- Size
- Consistency
- Tenderness
- Masses
Document the results in the patient’s notes -23
Cover the patient, explain your findings to the patient and thank him -24

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