General Examination
General Examination
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)
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- 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)
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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