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Complete History Taking in General Medicine with Systemic Examination

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STRUCTURE OF CLINICAL HISTORY TAKING

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1. BIOGRAPHICAL / IDENTIFICATION DATA

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2. CHIEF COMPLAINT (CC)

• State the main presenting symptom(s) in the patient's own words
• Record duration alongside each complaint
• List in chronological order if multiple complaints
• Avoid using diagnostic labels - use the symptom itself (e.g., "chest pain for 2 days", not "angina")

Example: "Fever, cough, and breathlessness for 5 days"

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3. HISTORY OF PRESENT ILLNESS (HPI)

SOCRATES Framework for Each Symptom

Additional HPI Details

• Sequence of events - how the illness evolved from first symptom to present
• Prior episodes - any similar illness in the past?
• Treatment sought - any medications or interventions already tried, and response
• Functional impact - effect on work, sleep, appetite, activities of daily living

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4. PAST MEDICAL HISTORY (PMH)

Medical Illnesses

• Previous diagnoses: hypertension, diabetes mellitus, asthma, TB, rheumatic fever, epilepsy, jaundice/hepatitis, peptic ulcer, renal disease, thyroid disease
• Previous hospitalisations (when, where, reason, outcome)
• Known allergies (drug, food, environmental) - always document

Surgical History

• Operations with dates, type of procedure, and any complications (including anaesthetic reactions)

Obstetric/Gynaecological History (in females)

• LMP (last menstrual period)
• Menstrual cycle: regularity, duration, flow, dysmenorrhoea
• Number of pregnancies (G), deliveries (P), abortions (A)
• Complications of pregnancy (pre-eclampsia, gestational diabetes)
• Menopausal status

Immunisation History

• Childhood vaccinations
• Adult vaccines (influenza, hepatitis B, COVID-19, pneumococcal)

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5. DRUG HISTORY

• Current medications: name, dose, frequency, duration, route (include over-the-counter drugs, herbal remedies, supplements, oral contraceptives)
• Compliance: is the patient taking medications as prescribed?
• Drug allergies and adverse reactions: nature of reaction (rash, anaphylaxis, GI upset), not just "allergy" label
• Recent changes to medications

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6. FAMILY HISTORY

• Health status of parents, siblings, children (alive/dead - cause of death if deceased)
• Hereditary / familial conditions: ischaemic heart disease, hypertension, diabetes mellitus, cancers, epilepsy, mental illness, haemophilia, sickle cell disease, thyroid disease, autoimmune conditions
• Consanguinity (especially relevant in populations where this is common)
• Pedigree chart if needed for complex family patterns

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7. PERSONAL / SOCIAL HISTORY

Lifestyle

• Smoking: current/ex/never - type (cigarettes, bidi, pipe, chewing tobacco), pack-years (packs/day × years)
• Alcohol: units per week, pattern (binge vs. regular), duration, type
• Recreational drugs: type, route of use, duration
• Diet: vegetarian/non-vegetarian, special dietary restrictions, caloric intake if relevant
• Exercise: level of physical activity

Social Context

• Occupation: current and past, workplace exposures (dust, chemicals, radiation, asbestos, noise)
• Living conditions: housing (cramped, overcrowded), sanitation, water supply
• Marital status and domestic relationships
• Recent travel (international or to endemic areas - malaria, TB, typhoid, parasites)
• Sexual history: relevant when evaluating STIs, HIV, hepatitis B/C (asked sensitively)
• Financial / insurance status: affects treatment compliance
• Education and literacy: affects communication strategy

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8. REVIEW OF SYSTEMS (ROS) / SYSTEMIC ENQUIRY

General / Constitutional

• Fever, chills, night sweats
• Weight loss or weight gain (quantify: how many kg over what period)
• Fatigue, malaise, lethargy
• Appetite change (anorexia)
• Sleep disturbance

Cardiovascular System

• Chest pain / discomfort (character, radiation, relationship to exertion)
• Palpitations (onset, duration, regularity, associated symptoms)
• Breathlessness / dyspnoea (at rest vs. on exertion, how many flights of stairs)
• Orthopnoea (number of pillows used)
• Paroxysmal nocturnal dyspnoea (PND)
• Ankle / leg oedema (bilateral vs. unilateral, pitting, time of day)
• Syncope / pre-syncope
• Claudication (leg pain on walking, distance)

Respiratory System

• Cough (dry vs. productive, duration)
• Sputum (colour, amount, consistency, blood-stained)
• Haemoptysis (amount, frequency)
• Dyspnoea (grading: MRC scale 1-5)
• Wheeze
• Chest pain (pleuritic - worse with breathing)
• Snoring / sleep apnoea

Gastrointestinal System

• Dysphagia (to solids, liquids, or both; progressive?)
• Heartburn / regurgitation / waterbrash
• Nausea and vomiting (content - blood / bile / faeculent)
• Haematemesis
• Abdominal pain (site, character, radiation, relation to meals, bowel habit)
• Change in bowel habit (constipation, diarrhoea, alternating)
• Stool character: colour (melaena, fresh blood, pale/steatorrhoea), consistency
• Flatulence, bloating
• Jaundice (skin/eyes/urine/stool changes)
• Pruritus (with or without jaundice)

Genitourinary System

• Dysuria, frequency, urgency
• Nocturia (how many times)
• Haematuria (frank vs. microscopic, at beginning / end / throughout stream)
• Incontinence
• Hesitancy, poor stream, terminal dribbling (males - prostatic symptoms)
• Loin pain
• Frothy urine (proteinuria), dark urine
• Urethral / vaginal discharge

Nervous System

• Headache (location, character, timing, associated nausea/photophobia/phonophobia)
• Dizziness / vertigo (true rotatory vs. light-headedness)
• Syncope / transient loss of consciousness
• Seizures / fits (type, frequency, post-ictal state, aura)
• Memory problems / confusion
• Weakness (focal vs. generalised, upper vs. lower limb)
• Sensory disturbance: numbness, tingling, paraesthesiae
• Visual disturbance (diplopia, blurring, visual field loss, amaurosis fugax)
• Speech disturbance (dysarthria, dysphasia)
• Tremor, coordination problems
• Gait disturbance
• Hearing loss, tinnitus

Musculoskeletal System

• Joint pain (which joints, bilateral/unilateral, migratory/fixed, morning stiffness duration)
• Joint swelling, warmth, redness
• Back pain (site, radiation to leg, relationship to posture)
• Muscle pain / cramps / weakness
• Bone pain

Endocrine System

• Heat/cold intolerance
• Excessive sweating
• Polydipsia, polyuria (diabetes)
• Skin/hair/nail changes
• Changes in libido or sexual function
• Growth abnormalities

Haematological System

• Easy bruising or bleeding
• Petechiae / purpura
• Prolonged bleeding from cuts
• Recurrent infections
• Lymph node enlargement (painless vs. painful, duration)
• Pallor, fatigue (anaemia symptoms)

Psychiatric / Mental Health

• Mood (depression, elation)
• Anxiety
• Hallucinations, delusions
• Sleep patterns
• Memory and cognition

Skin

• Rashes (site, character, spread, relationship to sun)
• Itching
• Changes in moles
• Hair loss, nail changes

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PHYSICAL EXAMINATION

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9. GENERAL PHYSICAL EXAMINATION (GPE)

General Appearance

• Level of consciousness: AVPU or GCS
• Apparent age vs. stated age
• Built: thin, average, obese; well-nourished vs. malnourished
• Well / ill / toxic / distressed
• Comfortable at rest vs. in obvious distress
• Posture and gait (if ambulant)

Vital Signs (MUST document all)

Anthropometric Measures

• Waist circumference (metabolic syndrome)
• Waist-to-hip ratio

Skin and Nails

• Pallor (conjunctival, palmar, mucosal)
• Jaundice / icterus (scleral first)
• Cyanosis: central (tongue, lips) vs. peripheral (fingertips)
• Clubbing (grades I-IV: Schamroth's sign, loss of angle, drum-stick appearance)
• Koilonychia (iron deficiency)
• Leuconychia (hypoalbuminaemia)
• Pigmentation: hyperpigmentation (Addison's, haemochromatosis), depigmentation (vitiligo)
• Spider naevi (>5 significant, upper body distribution)
• Palmar erythema
• Xanthomata / xanthelasma
• Purpura, petechiae, ecchymoses
• Oedema (pitting vs. non-pitting, bilateral vs. unilateral, sacral)

Head and Face

• Facial puffiness (myxoedema, nephrotic syndrome, superior vena cava obstruction)
• Malar flush (mitral stenosis, SLE)
• Facial asymmetry
• Periorbital oedema

Eyes

• Conjunctival pallor (anaemia)
• Scleral icterus
• Xanthelasma
• Exophthalmos / proptosis (thyroid)
• Corneal arcus (dyslipidaemia, especially if < 50 years)
• Kayser-Fleischer rings (Wilson's disease)

Oral Cavity

• Lips: pallor, central cyanosis, angular stomatitis (B12/iron deficiency)
• Tongue: glossitis (B12/folate/iron), geographical tongue, macroglossia
• Teeth and gums: dental hygiene, gum hypertrophy
• Tonsils
• Palate: high-arched (Marfan's)
• Breath (uraemic fetor, hepatic fetor/foetor hepaticus, ketotic)

Neck and Lymph Nodes

• Lymphadenopathy: cervical (anterior/posterior), submandibular, submental, supraclavicular (Virchow's node - left side), axillary, inguinal
  • Size, consistency, tenderness, mobility, matting
• Thyroid: goitre (size, consistency, nodularity, bruit, tracheal deviation)
• JVP (jugular venous pressure): height from sternal angle, waveform (a, c, v waves), hepatojugular reflux
• Carotid pulse: character

Hands

• Temperature, moisture (hyperthyroidism = warm moist; hypothyroidism = dry)
• Tremor: fine (thyrotoxicosis), coarse (liver flap / asterixis)
• Thenar/hypothenar wasting
• Dupuytren's contracture
• Peripheral cyanosis

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10. SYSTEMIC EXAMINATION

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A. CARDIOVASCULAR SYSTEM (CVS)

• Precordial bulge (childhood cardiac enlargement)
• Apex beat visible?
• Visible pulsations (aortic, carotid)
• Surgical scars (median sternotomy, lateral thoracotomy, pacemaker site)

• Apex beat: location (normally 5th ICS, midclavicular line), character (heaving, thrusting, tapping, diffuse), double impulse
• Parasternal heave (right ventricular hypertrophy)
• Thrills (systolic / diastolic; grade ≥4 murmur)
• Palpable P2 (pulmonary hypertension)

• Cardiac dullness (rarely done in modern practice; can detect massive cardiomegaly or pericardial effusion)

• Heart sounds: S1, S2 (intensity, splitting), S3 (volume overload, heart failure), S4 (stiff ventricle)
• Murmurs: timing (systolic / diastolic / continuous), grade (I-VI), character, location, radiation, behaviour with manoeuvres (Valsalva, standing, squatting)
• Pericardial friction rub
• Additional: carotid artery auscultation (bruits), aorta and renal arteries

• Peripheral pulses: radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis
• Radio-femoral delay (coarctation of aorta)
• Ankle-brachial index if peripheral vascular disease suspected
• Fundoscopy for hypertensive / diabetic retinopathy

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B. RESPIRATORY SYSTEM

• Shape of chest: barrel chest (COPD), pigeon chest (pectus carinatum), funnel chest (pectus excavatum), kyphoscoliosis
• Respiratory rate and rhythm (Cheyne-Stokes, Kussmaul, Biot's)
• Depth and symmetry of chest movement
• Use of accessory muscles (scalene, sternocleidomastoid)
• Intercostal / subcostal / suprasternal recession (in children)
• Tracheal position (central vs. deviated)
• Scars (thoracotomy, drain sites)

• Tracheal position (fingers in suprasternal notch)
• Chest expansion: upper, middle, lower zones bilaterally (normal >5 cm)
• Tactile vocal fremitus (TVF): increased (consolidation), decreased (pleural effusion, pneumothorax)
• Apex beat position

• Systematically front and back: resonant (normal), dull (consolidation, effusion, collapse), stony dull (effusion), hyper-resonant (pneumothorax, emphysema)
• Liver and cardiac dullness on right side as reference points

• Breath sounds: vesicular (normal), bronchial (consolidation, upper lobe collapse), diminished / absent
• Adventitious sounds:
  • Crackles (fine = pulmonary oedema / fibrosis; coarse = bronchiectasis / pneumonia)
  • Wheeze (expiratory = asthma, COPD; inspiratory = stridor = upper airway)
  • Pleural friction rub (pleuritis, PE, pneumonia)
• Vocal resonance / whispering pectoriloquy / aegophony

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C. GASTROINTESTINAL SYSTEM (ABDOMEN)

• Contour: flat, scaphoid (hollow), distended (generalised or localised)
• Visible peristalsis
• Pulsations (epigastric - aortic aneurysm)
• Dilated veins: caput medusae (periumbilical, portal hypertension), inferior/superior vena caval obstruction pattern
• Herniae: umbilical, inguinal, incisional, epigastric
• Scars (previous surgery)
• Stria (stretch marks - pregnancy, ascites, Cushing's)
• Skin discolouration: Grey-Turner's sign (flank bruising - haemorrhagic pancreatitis), Cullen's sign (periumbilical - intraperitoneal haemorrhage)
• Visible masses

• Systematic 9-region or 4-quadrant approach
• Tenderness: site, severity, guarding (voluntary / involuntary), rigidity
• Rebound tenderness (peritoneal irritation)
• Organomegaly:
  • Liver: lower edge in mid-clavicular line; size (cm below costal margin), consistency (soft / firm / hard / nodular), surface (smooth / irregular), tenderness, pulsatility
  • Spleen: enlarges towards right iliac fossa; Traube's space dullness; spleen notch palpable
  • Kidneys: bimanual palpation; ballottement; palpable in thin patients normally
  • Bladder: suprapubic dullness when full
  • Aorta: epigastric pulsation, expansile vs. transmitted
• Murphy's sign (cholecystitis)
• Masses: site, size, shape, surface, edges, consistency, mobility, pulsatility

• Liver size (upper and lower borders by dullness)
• Splenic dullness in Traube's space
• Ascites: shifting dullness, fluid thrill (for large ascites)
• Tympany over gas-filled bowel

• Bowel sounds: normal, increased (obstruction, gastroenteritis), decreased / absent (ileus, peritonitis)
• Arterial bruits (renal artery, aortic)
• Friction rubs (liver / spleen)

• Perianal inspection: haemorrhoids, fissures, fistulae
• Digital rectal exam: sphincter tone, rectal mucosa, prostate (males), masses, blood on glove

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D. NERVOUS SYSTEM

• Level of consciousness (GCS: E+V+M)
• Orientation: time, place, person
• Attention and concentration
• Memory: immediate recall, short-term, long-term
• Language: fluency, comprehension, repetition, naming (dysphasia types)
• Praxis, visuospatial function, executive function
• Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) if cognitive impairment suspected

• Inspection: muscle bulk, wasting, fasciculations, involuntary movements
• Tone: normal / hypotonia / spasticity (clasp-knife) / rigidity (lead-pipe / cogwheel)
• Power: MRC grade 0-5 for each muscle group (proximal and distal, upper and lower limbs)
• Reflexes:
  • Deep tendon reflexes: biceps (C5/6), brachioradialis (C5/6), triceps (C7), knee (L3/4), ankle (S1/2)
  • Grade: 0 (absent), 1+ (diminished), 2+ (normal), 3+ (brisk), 4+ (clonus)
  • Plantar response (Babinski): flexor (normal) vs. extensor (UMN lesion)
  • Abdominal reflexes, cremasteric reflex

• Light touch (cotton wool)
• Pain (pinprick - use neurological pin)
• Temperature (cold/warm tubes)
• Vibration sense (128 Hz tuning fork at bony prominences - great toe, malleolus, knee, ASIS, sternum)
• Proprioception / joint position sense (fingers and toes)
• Cortical sensations: two-point discrimination, stereognosis, graphaesthesia

• Dysdiadochokinesia (rapid alternating movements)
• Ataxia (gait - tandem walking, broad-based)
• Nystagmus (horizontal - fast phase to side of lesion)
• Intention tremor (finger-nose test, heel-shin test)
• Scanning speech (dysarthria)
• Hypotonia

• Normal gait
• Hemiplegic (circumduction)
• Spastic scissor gait
• Parkinsonian (shuffling, festinant, reduced arm swing)
• Cerebellar (wide-based, ataxic, staggering)
• Steppage gait (foot drop)
• Antalgic gait (pain avoidance)
• Waddling gait (proximal myopathy)

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E. MUSCULOSKELETAL SYSTEM

• Gait (as above)
• Posture and spinal alignment (scoliosis, kyphosis, lordosis)

• Swelling (bony vs. soft tissue), deformity, muscle wasting, skin changes (redness, rash, tophi)

• Temperature (warm = inflammation)
• Tenderness: joint line vs. periarticular
• Crepitus on movement
• Effusion tests (e.g., patellar tap, bulge sign for knee effusion)

• Active range of motion (patient moves)
• Passive range of motion (examiner moves)
• Resisted movement (tests muscle/tendon strength)

• Shoulder: Hawkins, Neer, empty can (rotator cuff)
• Elbow: golfer's / tennis elbow tests
• Wrist/Hand: Tinel's, Phalen's (carpal tunnel)
• Hip: FABER/FADIR, Thomas test (flexion contracture), Trendelenburg sign
• Knee: Lachman, anterior drawer (ACL), McMurray (meniscus), valgus/varus stress
• Ankle/Foot: anterior drawer, Thompson test (Achilles)

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F. ENDOCRINE SYSTEM (Targeted)

• Goitre: size, consistency, surface, mobility with swallowing, bruit
• Features of hyper/hypothyroidism: pulse, skin, hair, eyes, reflexes, weight

• Cushing's: moon face, buffalo hump, central obesity, purple striae, skin fragility, hypertension
• Addison's: hyperpigmentation (buccal mucosa, skin creases, scars), postural hypotension

• Acromegaly: enlarged jaw, hands, feet, frontal bossing, macroglossia, widely spaced teeth
• Hypopituitarism: pale, fine wrinkled skin, loss of secondary sexual characteristics

• Signs of complications: peripheral neuropathy, retinopathy, foot changes, lipodystrophy at injection sites

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G. RENAL SYSTEM

• Ballottement of kidneys
• Renal angle (costovertebral angle) tenderness
• Bladder palpation and percussion
• Blood pressure (hypertension in renal disease)
• Oedema (periorbital in nephrotic syndrome, peripheral)
• Signs of uraemia: asterixis, encephalopathy, pericardial rub, pallor, sallow complexion, scratch marks

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11. CLINICAL SUMMARY AND FORMULATION

1. Working diagnosis / differential diagnosis (in order of likelihood)
2. Relevant positive and negative findings that support or refute each diagnosis
3. Investigations required: bloods, imaging, special tests
4. Initial management plan

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QUICK REFERENCE: ORDER OF HISTORY TAKING

1. Biographical Data
2. Chief Complaints (with duration)
3. History of Present Illness (SOCRATES + sequence)
4. Past Medical/Surgical History
5. Drug History + Allergies
6. Family History
7. Personal and Social History
8. Review of Systems (Systemic Enquiry)
----------- PHYSICAL EXAMINATION -----------
9. General Physical Examination (Vitals + General signs)
10. CVS Examination
11. Respiratory Examination
12. Abdominal / GI Examination
13. Neurological Examination
14. Musculoskeletal Examination
15. Endocrine / Other Targeted Examination

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ECG CHANGES IN DIFFERENT HEART CONDITIONS

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STEMI EVOLUTION - Timeline

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MASTER REFERENCE CHART

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1. ACUTE CORONARY SYNDROMES (ACS)

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2. STEMI LOCALISATION BY LEAD TERRITORY

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3. PERICARDITIS

Key differentiator from STEMI: PR depression + diffuse concave ST elevation not localised to one territory.

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4. MYOCARDITIS

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5. LEFT VENTRICULAR HYPERTROPHY (LVH)

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6. RIGHT VENTRICULAR HYPERTROPHY (RVH)

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7. ATRIAL FIBRILLATION (AF)

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8. ATRIAL FLUTTER

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9. AV BLOCK

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10. BUNDLE BRANCH BLOCKS

Left Bundle Branch Block (LBBB)

Right Bundle Branch Block (RBBB)

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11. WOLFF-PARKINSON-WHITE (WPW) SYNDROME

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12. BRUGADA SYNDROME

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13. PULMONARY EMBOLISM (PE)

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14. HYPERKALAEMIA

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15. HYPOKALAEMIA

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16. HYPERCALCAEMIA vs HYPOCALCAEMIA

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17. HYPOTHERMIA

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18. LONG QT SYNDROME

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19. HYPERTROPHIC CARDIOMYOPATHY (HCM)

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20. DILATED CARDIOMYOPATHY (DCM)

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21. DIGOXIN EFFECT vs TOXICITY

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22. ACUTE COR PULMONALE / CHRONIC PULMONARY DISEASE

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QUICK-REFERENCE SUMMARY TABLE

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General Physical Examination (GPE) - Step-by-Step How-To Guide

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BEFORE YOU START

• Position: Patient lying comfortably in bed at 45°, adequately exposed but with dignity maintained
• Lighting: Good natural or bright overhead light
• Equipment ready: Thermometer, sphygmomanometer (correct cuff size), stethoscope, pen torch, tongue depressor
• Order: Always examine from the right side of the patient
• First impression: Stand at the foot of the bed and observe before touching - this is the "end-of-bed diagnosis"

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STEP 1 - GENERAL APPEARANCE (End-of-Bed Assessment)

"The most important vital sign is what the patient looks like." - Goldman-Cecil Medicine

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STEP 2 - VITAL SIGNS

A. Temperature

• Method: Oral electric thermometer preferred; axillary is 0.5°C lower; rectal 0.5°C higher
• Technique: Oral - place under tongue, lips closed, for 1 minute
• Normal: 36.5-37.5°C (oral)
• Interpret:
  • Fever (>37.5°C): infection, inflammation, malignancy
  • Hypothermia (<35°C): exposure, sepsis, hypothyroidism, alcohol/barbiturate OD

B. Pulse

• Site: Right radial artery (thumb side of wrist, between flexor carpi radialis and radial styloid)
• Technique: Use index + middle + ring fingers gently over artery; count for full 60 seconds if irregular, 30 seconds if regular
• Assess systematically:

• Also feel: Both radials simultaneously (radioulnar delay); then radial vs femoral (radio-femoral delay = coarctation of aorta)

C. Blood Pressure

• Cuff selection: Bladder should encircle 80% of arm; too small = falsely high; too large = falsely low
• Technique:
  1. Patient seated or lying, arm at heart level, relaxed for 5 minutes
  2. Palpate radial artery; inflate cuff until radial pulse disappears + 30 mmHg more
  3. Place stethoscope over brachial artery in antecubital fossa
  4. Deflate at 2 mmHg/second
  5. Systolic = first Korotkoff sound (Phase 1)
  6. Diastolic = disappearance of sound (Phase 5)
• Take in BOTH arms on first visit - >10 mmHg difference is significant (subclavian stenosis, aortic dissection)
• Postural BP: Take lying and standing (after 2 minutes standing) - drop >20 mmHg systolic / >10 mmHg diastolic = orthostatic hypotension
• Normal: <120/80 mmHg

D. Respiratory Rate

• Technique: Count breaths for a full 60 seconds while appearing to check the pulse (patients alter breathing if they know you are watching)
• Count chest/abdominal movement as one breath
• Normal: 12-20 breaths/min
• Observe: Depth (shallow/deep), rhythm, use of accessory muscles, symmetry
• Tachypnoea (>20/min): pneumonia, PE, acidosis, pain, anxiety
• Bradypnoea (<12/min): opioids, sedatives, brainstem lesion

E. Oxygen Saturation (SpO2)

• Method: Pulse oximeter on finger (ensure warm, well-perfused digit; remove nail polish)
• Normal: ≥95% on room air
• <94% = significant hypoxaemia requiring investigation
• Note: unreliable in CO poisoning (falsely normal), severe anaemia, peripheral vasoconstriction

F. Weight, Height, BMI

• Waist circumference >102 cm (men) / >88 cm (women) = metabolic risk

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STEP 3 - SKIN (Head-to-Toe Inspection)

Pallor

• Where to look: Lower palpebral conjunctiva (pull down lower eyelid), palmar creases, tongue, nail beds
• Conjunctival pallor = most reliable sign of anaemia
• Palmar crease pallor: significant when pallor visible in creases themselves

Jaundice (Icterus)

• Where to look: Sclerae first (earliest and most sensitive), then skin, then hard palate
• Best assessed in natural daylight
• Scleral icterus detectable when serum bilirubin > ~35 µmol/L (2 mg/dL)
• Note: carotenaemia causes yellow skin but spares the sclerae

Cyanosis

• Central cyanosis visible when deoxy-Hb > 5 g/dL

Oedema

• Technique: Press firmly with thumb for 5-10 seconds over bony prominence (dorsum of foot, medial malleolus, shin, sacrum in bedridden)
• Pitting oedema: Pit persists after pressure release
• Grading:
  • 1+ : Trace, slight pit, rebounds quickly
  • 2+ : Pit rebounds in <15 seconds
  • 3+ : Deep pit, rebounds in 15-30 seconds, limb appears swollen
  • 4+ : Very deep pit, takes >30 seconds, gross swelling
• Sacral oedema: Always check in bedridden patients (dependent area)
• Non-pitting oedema: lymphoedema, myxoedema (hypothyroidism)

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STEP 4 - HANDS

Nails

Clubbing - How to Grade

Palms and Fingers

Temperature and Moisture

• Warm, moist: Thyrotoxicosis, fever, anxiety
• Warm, dry: Normal, vasodilated
• Cold, clammy: Shock, anxiety, sympathetic activation
• Dry, rough: Hypothyroidism

Tremor

• Ask patient to extend arms with fingers spread - observe for:
  • Fine tremor (thyrotoxicosis, anxiety, beta-agonists)
  • Resting tremor (Parkinson's) - disappears on movement
  • Asterixis (liver flap) - negative myoclonus; ask patient to cock wrists back with arms extended, count 15 seconds - flapping = hepatic encephalopathy, CO2 retention, uraemia

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STEP 5 - FACE AND HEAD

Eyes

Mouth

• Lips: Central cyanosis, angular stomatitis (B12/iron deficiency), herpes labialis
• Gums: Hypertrophy (phenytoin, ciclosporin, leukaemic infiltration), bleeding, lead line
• Teeth: Dental hygiene (endocarditis risk), notching (Hutchinson's teeth = congenital syphilis)
• Tongue:
  • Glossitis (smooth, beefy red) = B12/folate/iron deficiency
  • Macroglossia = hypothyroidism, amyloid, acromegaly
  • Deviation on protrusion = CN XII palsy (to weak side)
  • Central cyanosis (underside of tongue)
• Breath odour: Uraemic fetor (ammoniacal, "fishy") = renal failure; hepatic fetor (sweet/musty/"fetor hepaticus") = liver failure; ketotic (pear drops/acetone) = diabetic ketoacidosis; faeculent = bowel obstruction

Face - Specific Facies

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STEP 6 - NECK

Jugular Venous Pressure (JVP)

• Position: Patient at 45° reclined, head slightly turned to left
• Which vein: Internal jugular (runs between the two heads of SCM), preferred over external jugular
• Technique:
  1. Look for the biphasic pulsation between the clavicle and the ear
  2. JVP pulsates - can be obliterated by gentle pressure at the base of the neck (carotid pulse cannot)
  3. JVP rises with abdominal pressure (hepatojugular reflux)
  4. Measure vertical height of the meniscus above the sternal angle (angle of Louis)
• Normal: <4 cm above sternal angle at 45°
• Elevated JVP: Heart failure, pericardial effusion/tamponade, constrictive pericarditis, SVC obstruction, fluid overload
• JVP waveform: a wave (atrial contraction); c wave (tricuspid closure); x descent; v wave (venous filling); y descent

Thyroid Gland

• Inspection: Ask patient to swallow a sip of water - thyroid moves upward on swallowing; note midline vs. lateral, size
• Palpation: Stand behind the patient; use both hands with fingertips on the gland, ask to swallow again
  • Note: size, consistency (soft/firm/hard), surface (smooth/nodular), tenderness, tracheal position
• Percussion: For retrosternal extension - percuss over manubrium
• Auscultation: Bell of stethoscope over the gland - bruit = hyperthyroidism (increased vascularity)

Lymph Nodes

1. Submental
2. Submandibular
3. Pre-auricular (parotid)
4. Post-auricular (mastoid)
5. Occipital
6. Anterior cervical chain (along anterior border of SCM)
7. Posterior cervical chain (along posterior border of SCM)
8. Supraclavicular - especially left side (Virchow's node / Troisier's sign = abdominal malignancy)
9. Axillary (support patient's arm with your arm; examine all five groups)
10. Epitrochlear
11. Inguinal (horizontal and vertical chains)

Hard, non-tender, fixed, matted nodes = malignancy; Soft, tender = reactive (infection); Rubbery = lymphoma

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STEP 7 - EYES (Fundoscopy - when indicated)

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STEP 8 - ADDITIONAL GENERAL SIGNS

Dehydration Assessment

Mental Status (Assess Throughout)

• AVPU: Alert / Voice / Pain / Unresponsive
• GCS (formal, if altered):
  • Eyes (4), Verbal (5), Motor (6) - maximum 15, minimum 3
• Orientation: Ask name, date, place
• Mood and affect: Observe during conversation

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QUICK-REFERENCE: GPE SEQUENCE AT A GLANCE

STEP 1:  End-of-bed observation → general appearance, distress, built
STEP 2:  Vital signs → Temp → Pulse → BP → RR → SpO2 → Weight/Height/BMI
STEP 3:  Skin → Pallor, Jaundice, Cyanosis, Oedema
STEP 4:  Hands → Nails (clubbing, koilonychia, etc.) → Palms → Temperature → Tremor
STEP 5:  Face & Head → Eyes → Mouth/Tongue → Specific facies
STEP 6:  Neck → JVP → Thyroid → Lymph nodes (cervical/axillary/inguinal)
STEP 7:  Fundoscopy (if indicated)
STEP 8:  Additional → Hydration → Capillary refill → Mental status
        ↓
     SYSTEMIC EXAMINATION (CVS → Resp → Abdomen → Neuro → MSK)

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KEY "NEVER MISS" SIGNS IN GPE

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