What are the steps involved in a general examination of a patient?

Steps for a General Examination of a Patient

A comprehensive general examination of a patient should follow a systematic approach that includes history taking, physical examination, and appropriate diagnostic testing to ensure accurate diagnosis and effective management of health conditions.

Step 1: Initial Clinical Evaluation

• Begin with a general clinical evaluation focusing on assessing symptoms and signs, differentiating causes of complaints, and ruling out acute conditions 1
• Document demographic data including name, date of birth, gender, and ethnicity 2
• Record vital signs including blood pressure, heart rate, respiratory rate, temperature, height, weight, and waist circumference 1, 2
• Perform a 12-lead resting electrocardiogram (ECG) as part of the initial evaluation when indicated 1
• Order basic blood tests appropriate to the clinical situation 1

Step 2: Comprehensive History Taking

• Document the patient's primary concern and detailed history of present illness 2
• Obtain past medical history including previous conditions, surgeries, hospitalizations 2
• Record current medications, allergies, and adverse reactions 2
• Document family history of relevant diseases, especially those with genetic predisposition 2
• Take a social history including occupation, tobacco use, alcohol consumption, illicit drug use, family and living situation, and sexual history 2
• Assess for symptoms related to all major body systems to identify issues not mentioned in the chief complaint 2

Step 3: Physical Examination

• Perform a systematic examination of all body systems 2:
  • General appearance (mental status, distress level, posture) 2
  • Skin examination (color, lesions, integrity) 2
  • Head and neck examination (lymph nodes, thyroid, carotid arteries) 2
  • Eye examination (visual acuity, pupillary response, fundoscopy when indicated) 1, 2
  • Ear, nose, and throat examination 2
  • Respiratory system (breathing pattern, chest expansion, auscultation) 2
  • Cardiovascular system (heart sounds, murmurs, peripheral pulses) 2
  • Abdominal examination (inspection, auscultation, palpation, percussion) 2
  • Musculoskeletal examination (joint range of motion, muscle strength) 2
  • Neurological examination (mental status, cranial nerves, motor/sensory function, reflexes, coordination) 1, 2
  • Peripheral vascular assessment (pulses, edema) 1, 2

Step 4: Special Assessments Based on Patient Characteristics

• For diabetic patients, include comprehensive foot examination with inspection of skin integrity, assessment of foot deformities, neurological assessment (10-g monofilament testing with pinprick, temperature, or vibration testing), and vascular assessment 1
• For elderly patients, assess functional and cognitive performance, frailty, fall risk, and need for assistive devices 2
• For patients with suspected kidney disease, perform nutritional assessment including unintentional weight loss, physical performance, body composition, muscle mass, and strength 1
• For patients with suspected neurological disorders, include timed gait, motor movements, reflexes, and Babinski signs 1

Step 5: Diagnostic Testing and Management Planning

• Order appropriate laboratory and diagnostic tests based on history, examination findings, and clinical suspicion 2
• Consider age-appropriate screening tests according to current guidelines 2
• Develop a management plan that includes lifestyle modifications, risk factor management, and disease-specific interventions 1
• Ensure effective communication with the patient's primary care physician about findings and recommendations 1

Important Considerations

• Adapt the sequence, technique, and focus of history taking and clinical examination to the individual situation and condition of the patient 3
• Use active listening, empathetic communication, and cultural sensitivity during the examination process 4
• Recognize that a thorough history and physical examination remain fundamental diagnostic tools despite technological advances 5
• Document all findings systematically to facilitate diagnosis, treatment planning, and continuity of care 6