General, Physical And Systemic Examination. By Azmi Zeenat Ajmal Bsc 2 nd Year 3 rd Semester (OT And AT)
General History: Name Age Occupation Address Identifying data Chief complaints History of the present illness Past medical history Family history Medications and allergies Social history
History of present illness: Symptoms characterization: Onset and duration Quality of pain (e.g. sharp, dull, throbbing) Severity of pain Timing and progression (“is the pain constant or intermittent? Worst at the morning or night time?”) Has this happened before?
General appearance: General state of health: Healthy/ill/comfortable/distressed Body posture Height (tall or short) Weight (obese or lean) Mascular /asthenic/ cachexic BMI Facial feature/expression Speech (tone or voice)
General examination or Inspection of a patient : General examination is actually the first step of physical examination and key component of diagnostic approach. It is the the visual examination of the patients general appearance.
General Examination/Inspection: Drowsiness in eyes Skin ( cynosis ) Eyes ( if pallor or icterus) Mouth ( cynosis ) Nails (clubbing) Oedema (swelling or inflammation) Hands and arms (scars, pain)
Vital Signs: Vital signs are a group of most crucial medical signs that indicate the status of the body’s vital functions. Blood pressure: 120/80 +-10 mmhg Pulse rate: 60-100 beats/min Respiration rate: 12-20 breaths/min Temperature: 36-37 degrees celcius SpO2 (Saturation of peripheral oxygen): 95-100%
Systemic Examination Systemic examination reviews the major systems of the body like the, Central Nervous System Respiratory System Cardiovascular System Gastrointestinal System
Generally there are 4 parts of physical examination: Inspection: Visual examination Palpation: Feeling for signs Percussion: Tapping for signs, used when doing a lung, heart, or a gut examination. Auscultation: Listening for sounds within the body using a stethoscope.