Patient Bedside Assessment — Systematic Approach for the Junior Doctor

1. Before You Enter the Room

• Review available notes, vitals, observations, and drug chart
• Note isolation precautions (contact/droplet/airborne)
• Introduce yourself, confirm patient identity (name + DOB)
• Obtain consent and ensure privacy (curtains, gown/cover-up)
• Wash hands / don PPE as needed

"An examination should never be done by placing the stethoscope under a shirt or blouse, and full inspection of the chest and extremities is always necessary." — Fuster & Hurst's The Heart, 15th Ed.

2. History

In most patients, the physical examination confirms thoughts formulated during history-taking — "time of onset, symptom progression, associated complaints, and exacerbating factors are often the key to patient evaluation." — Tintinalli's Emergency Medicine

3. Physical Examination — Systematic Framework

Step 1: General Inspection (Start at the Foot of the Bed)

• Appearance vs. stated age — Does the patient look older/sicker than expected?
• Level of distress — At rest, with movement, or in obvious pain?
• Nutritional status — Cachectic, obese, edematous?
• Posture and mobility — Guarding, splinting, unable to lie flat?
• Skin — Jaundice, pallor, cyanosis, diaphoresis, rashes
• Frailty markers — Grip strength, gait speed, get-up-and-go test (quick functional screen)
• Stigmata of systemic disease — e.g., jaundice (liver disease), exophthalmos (Graves'), buffalo hump/striae (Cushing's), cogwheel rigidity (Parkinson's)

"Several diseases may have stigmata... often patients' appearance is compared with the stated age." — Campbell Walsh Wein Urology

Step 2: Vital Signs

Step 3: Systematic Organ Examination

3A. Hands → Arms

• Nails: Clubbing, cyanosis, leukonychia, koilonychia, splinter haemorrhages
• Palms: Pallor, palmar erythema, Dupuytren's
• Pulse: Rate, rhythm; palpate both radials simultaneously for symmetry
• Tremor, asterixis (flap)
• Peripheral perfusion: Cap refill, temperature gradient

3B. Head & Neck

• Eyes: Conjunctival pallor, scleral icterus, exophthalmos, corneal arcus, Kayser-Fleischer rings
• Mouth: Mucous membranes (hydration), dentition, central cyanosis, angular stomatitis
• Neck: JVP (estimate central venous pressure at 45°), lymph nodes, thyroid, tracheal position, carotid bruits

"Examining the venous pulsations in the sitting position will provide an initial clue as to whether there is elevation of venous pressure." — Fuster & Hurst's The Heart

3C. Cardiovascular (Sitting → Supine → Left Lateral Decubitus)

3D. Respiratory

• Inspect: Chest shape, respiratory rate, use of accessory muscles, intercostal recession, tracheal deviation
• Palpate: Chest expansion (symmetry), tactile fremitus
• Percuss: Resonance vs. dullness vs. hyper-resonance (compare sides)
• Auscultate: Air entry, breath sounds, added sounds (wheeze, crackles, rub)

3E. Abdomen

• Begin with general inspection (contour, scars, distension, visible peristalsis)
• Auscultate before palpation (bowel sounds)
• Palpate: Light then deep, all 9 regions; begin away from pain; identify tenderness, guarding, rigidity, rebound
• Organomegaly: Liver (span, texture, pulsatility), spleen (dullness to percussion), kidneys (ballottement)
• Ascites: Shifting dullness, fluid thrill
• Hernial orifices, genitalia/groins as indicated
• Digital rectal exam (DRE) when indicated: stool, mass, prostate, sphincter tone

3F. Neurological

• Mental status / cognition: Orientation, MoCA or bedside cognitive screen
• Cranial nerves: Targeted or full CN I–XII
• Motor: Tone, power (MRC 0–5), reflexes (biceps, triceps, supinator, knee, ankle, plantars)
• Sensation: Light touch, pin-prick, vibration, proprioception
• Coordination: Finger-nose, heel-shin, rapid alternating movements
• Gait: Romberg test; observe walking

3G. Musculoskeletal / Extremities

• Oedema: Pitting (sacral + ankles), grade 1–4
• Peripheral pulses: All (radial, brachial, femoral, popliteal, dorsalis pedis, posterior tibial)
• Joints: Swelling, warmth, tenderness, range of motion
• Skin: Pressure areas, wounds, bruising

4. Synthesis at the Bedside

1. Primary diagnosis or working differential — combine history + exam + vitals
2. Active issues — unstable parameters, abnormal signs requiring action
3. Investigations needed — bloods, imaging, ECG, cultures
4. Management plan — immediate, short-term, escalation threshold
5. Safety netting — who to call, when, with what findings

5. Documentation

"History → Examination findings → Impression → Plan" (SOAP or problem-based format)

• Date, time, designation
• All vital signs with exact values
• Positive AND relevant negative findings
• Differential diagnosis ranked by probability
• Management decisions and rationale
• Escalation criteria

Quick Reference: Red Flags Requiring Urgent Action

• Fuster & Hurst's The Heart, 15th Ed. — Cardiovascular examination stepwise approach
• Tintinalli's Emergency Medicine — General examination principles
• Campbell Walsh Wein Urology — General inspection framework
• Harrison's Principles of Internal Medicine, 22nd Ed. — History & physical in diagnosis