1. Environment, general appearance
2. Hydration
3. Posture, weight, body shape
4. Vital signs
5. Nails, hands
6. Head
7. Examination tips

Environment

General appearance

• Pre-exam checklist: WIPE:
  • Wash your hands
  • Introduce yourself to pt
  • Position pt
  • Expose the area
• Always examine from the R side of the pt.
• Ask pt. if tenderness anywhere, before start touching them.
• Skin colors. See Skin Colors Reference.

Posture, weight, body shape

• If pt. enters, examine gait. See Gait.
• Posture, stature, height..
• Obesity [BMI = kg/m^2. Normal <25].
• Limb amputations, deformities.
• Physique expected for age.

Hydration

• Sunken orbits.
• Mucus membrane dryness.
• Axillae.
• Skin turgor [pinch skin: normal returns immediately].
• Postural hypotension [less BP when sit, stand].
• Peripheral perfusion [press nose, time capillary return].
• Examine weight loss over hours.

Vital signs

• Often logged on ward chart.
• See Taking Vital Signs Reference.

Nails

• Clubbing.
• Nail signs.
• Nail fold.
• See Nails Reference.

Hands

• Palms:
  • Palmar erythema (cirrhosis, polycythaemia, pregnancy).
  • Pigmentation of crease (Addison's, but normal in asians, blacks).
  • Pallor of palmar crease. Better results if hyperextend fingers, or stretch skin on either side of crease (anemia).
  • Dupuytren's contracture [fibrosis, contracture of palm's fascia] (liver dz, epilepsy, trauma, elderly).
• Joints:
  • Herberdens, Bouchards (OA).
  • Swollen PIP, distal PIP spared (RA).

Head

• Hair: deficiency, excess.
• Facial hallmarks (Down's, Grave's, acromegaly, Cushing's, etc).
• Teeth: nicotine stains.

Examination tips

• Initial examination is from the foot of the bed.
• Always ask if any part tender, before touching pt.
• Watch pt's head as palpate, to look for pain flinches.
• Percussion is R middle finger hitting middle of middle phalynx of L middle finger.
• To measure circumference of limbs, choose the bony landmark on each, measure down the correct distance, then take the circumference at that point.