General examination: what the doctor evaluates and why it is important

A general examination is the first systematic contact with a patient, allowing them to assess the severity of their condition, identify life-threatening situations, and plan a diagnostic approach. A properly performed examination reduces the risk of missing urgent conditions and saves time at subsequent stages. In modern practice, a general examination relies on standardized steps: focusing on threats to the airway, breathing, and circulation, recording vital signs, early risk stratification, and timely escalation of care. [1]

The key principle is consistency: from rapid threat identification to deeper insight. In acute situations, structured approaches and early warning scales are used, which improve teamwork and the quality of information transfer. Where appropriate, the National Early Warning Scale version 2 is used, which standardizes the assessment of acuity using a set of physiological parameters. [2]

Another principle is to measure what can be measured. Even "visual" findings should preferably be translated into numerical values: pain scales, oxygen saturation levels, body mass index, waist-to-height ratio, Glasgow Frailty Scale scores, and Clinical Frailty Scale scores. This simplifies follow-up and communication between specialists. [3]

Finally, safety is essential: proper technique for measuring blood pressure and temperature, validation of devices, maintaining privacy, and the presence of an accompanying person when necessary. Technological errors create systematic biases that lead to incorrect decisions. [4]

Preparation and safety of measurements

Before the examination, ensure conditions for accurate measurements are met: the patient rests for at least 5 minutes, sits in a chair with back support, feet flat on the floor, and the cuff is level with the heart and is of the appropriate size. Talking, crossing legs, and taking measurements immediately after physical activity are prohibited. Device validation is used to ensure repeatability of readings, and the arm and position are recorded. [5]

Body temperature, respiratory rate, pulse rate, oxygen saturation, and blood pressure are measured using standard methods. Factors that distort results are carefully considered, including cold extremities, nail polish, anemia, and arrhythmia. Borderline values are confirmed by repeated measurements and correlation with the clinical picture. [6]

Oxygen saturation is assessed using a pulse oximeter, taking into account limitations such as signal quality, skin pigmentation, perfusion, and the device's method of calculating saturation. If hypoxemia is suspected, low values are confirmed clinically and, if necessary, by gas analysis. [7]

Documentation is mandatory: time, body position, limb used, cuff size, device type, and associated conditions are indicated. This improves data comparability and reduces the risk of false interpretations at subsequent visits. [8]

Vital signs: norms, technique, interpretation

Vital signs form the foundation of a "general examination." For an adult at rest, lower ranges are used as a guide, but context is taken into account: age, fitness, anemia, fever, pregnancy, medications. No single value should guide a clinical decision without consideration of symptoms and physical examination. [9]

Table 1. Basic vital signs in adults

Parameter	Landmarks of an adult at rest	Notes for interpretation
Temperature	36.5-37.3 °C	Evaluate trends and daily fluctuations. [10]
Respiratory rate	12-20 per minute	Tachypnea is an early marker of deterioration. [11]
Pulse	60-100 per minute	Rhythm and content are important. [12]
Blood pressure	90-120 systolic and 60-80 diastolic	Follow the measurement procedure. [13]
Oxygen saturation	≥95% at room air	Assess together with clinical and perfusion data. [14]

When measuring blood pressure, scientifically proven rules are followed: improper fit, an incorrectly sized cuff, and talking during the procedure systematically overestimate systolic readings. Oscillometric devices reduce human error but require validation and proper use. [15]

Tachycardia, tachypnea, and declining oxygen saturation often precede hypotension and significant clinical symptoms. These changes are incorporated into early warning systems, which summarize these changes into a risk score and provide criteria for increased monitoring and resuscitation. [16]

Early risk stratification: standardized scales

In emergency departments and prehospital settings, the National Early Warning Scale version 2 is used to standardize monitoring. It includes six parameters: respiratory rate, oxygen saturation, systolic pressure, pulse, temperature, and level of consciousness or confusion. The total score determines the frequency of re-evaluation and the threshold for escalation. [17]

When sepsis is suspected, particularly in adults outside of pregnancy, updated guidelines from the National Institute for Healthcare Quality emphasize the use of the National Early Warning Score for initial assessment of severity and decision-making speed. A high score requires rapid identification of the source of infection, early initiation of antimicrobial therapy if signs of severity are present, and strict monitoring. [18]

Scores do not replace clinical judgment. They serve as a trigger for team communication, patient routing, and documenting dynamics. In cases of low perfusion, anemia, chronic lung disease, and in the elderly, interpretation of scores requires caution and contextual adjustment. [19]

Table 2. Components of the National Early Warning Scale version 2 and semantic guidelines

Component	What is being assessed	Why is it important?
Respiratory rate	Acceleration with deterioration of gas exchange	Often the earliest signal.[20]
Saturation	Hypoxemia in respiratory and circulatory failure	Prone to artifacts. [21]
Systolic pressure	Hypotension in sepsis, blood loss, cardiogenic shock	Proper technique is needed. [22]
Pulse	Response to pain, hypovolemia, hypoxia	Rhythm and regularity are important. [23]
Temperature	Marker of inflammation and sepsis	Look at the trends. [24]
Consciousness	Confusion as a sign of threat	Escalation threshold. [25]

Level of consciousness and cognitive status

Level of consciousness is a critical part of the general examination. The Glasgow Consciousness Scale assesses eye opening, speech, and motor responses, with a total score ranging from 3 to 15. An additional index, including pupillary light reactivity, enhances prognostic capabilities in acute neurological conditions. Record the best responses and list each component. [26]

A short "4 Signs" test is used to screen for delirium in adults, particularly the elderly, and in emergency departments. It takes approximately 2 minutes and requires no special training. The scale has been validated in dozens of studies, is well suited for patient flow, and is recommended by clinical guidelines. A positive screening requires diagnosis of the underlying cause and correction of the factors being addressed. [27]

Frailty in the elderly is assessed using the Clinical Frailty Scale (CFS) on a scale of 9, ranging from "very robust" to "terminally ill." Scores of 5 and above are associated with increased risk of complications, the need for a comprehensive geriatric assessment, and a reassessment of the intensity of interventions. Incorporate this assessment into care and discharge planning. [28]

Table 3. Neuro-geriatric instruments in general examination

Tool	What does it measure?	Threshold guidelines and application
Glasgow scale	Level of consciousness	Score 3-15; dynamics are critical. [29]
Pupil-adjusted index	Severity in acute neurology	Enhances predictive accuracy. [30]
The 4 Signs Test	Delirium and cognitive impairment	≥3 points - probable delirium, assessment of causes is required. [31]
Clinical Frailty Scale	Functional vulnerability	≥5 points - indication for a comprehensive geriatric assessment. [32]

Pain: Quantification and Communication

Pain is an independent diagnostic and prognostic factor. Adults are most often offered a numeric scale from 0 to 10, which is well-validated, easy to use, and sensitive to change. It is important to record the location, nature, factors that increase and decrease pain, as well as the impact on sleep and activity. [33]

For children and patients with difficulty verbalizing, a face scale, in which the patient selects a picture reflecting the intensity of the pain, is suitable. This instrument is designed as a self-assessment and should not be completed by others. For repeated assessments, use the same instrument to accurately track changes. [34]

The choice of scale depends on the context: visual analog, verbal, or numeric. For auditing and statistics, a numeric scale is more convenient, as the data is easily aggregated. In hospital settings, it is advisable to record a target pain level and an individual pain management plan. [35]

Table 4. Pain scale landmarks

Scale	Range	The usual interpretation	Notes
Numerical in adults	0-10	1-3 mild, 4-6 moderate, 7-10 strong	Validated and sensitive to changes. [36]
Facial pictograms	0-10 by step 2	Self-esteem of children and adults with verbalization difficulties	Use as a self-assessment tool. [37]

Body type, nutrition, and obesity risks

Body mass index remains the primary benchmark for assessing nutritional status in adults. Classic BMI thresholds from the Centers for Disease Control and Prevention (CDC) facilitate common language and data comparison. However, BMI does not reflect fat distribution and muscle mass, so it should be supplemented with other metrics. [38]

Waist-to-height ratio is a simple indicator of central obesity and metabolic risk. Current guidelines recommend using waist-to-height ratio thresholds: below 0.5 as a safe range, 0.5-0.59 as increased risk, and 0.6 and above as high risk. These thresholds apply to adults of various heights and body types. [39]

Validated malnutrition risk screening tools, such as the Hospital Nutritional Risk Screening Scale or the Unified Malnutrition Screening Scale, are used for hospitalized patients. These tools are simple, predict adverse outcomes, and facilitate timely initiation of nutritional support. [40]

Table 5. Body mass index and central obesity

Indicator	Category	Threshold
Body mass index	Underweight	<18.5 [41]
Body mass index	Normal weight	18.5-24.9 [42]
Body mass index	Excess weight	25.0-29.9 [43]
Body mass index	Obesity grade 1	30.0-34.9 [44]
Body mass index	Obesity grade 2	35.0-39.9 [45]
Body mass index	Obesity grade 3	≥40.0 [46]
Waist-to-height ratio	"Healthy" central fat mass	0.40-0.49 [47]
Waist-to-height ratio	Increased risk	0.50-0.59 [48]
Waist-to-height ratio	High risk	≥0.60 [49]

Skin, nails, visible signs of systemic diseases

Cyanosis, jaundice of the sclera, pallor, and signs of dehydration and infection are often noticeable at first glance. Central cyanosis is associated with an increase in reduced hemoglobin in capillary blood to threshold values and depends on the total hemoglobin level. In anemia, cyanosis may be unnoticeable even in the presence of severe hypoxemia. [50]

It is useful to distinguish between central and peripheral cyanosis. Central cyanosis is detected on the uvula and mucous membranes, while peripheral cyanosis is detected on the fingers and auricles and is associated with peripheral vasoconstriction and decreased blood flow. Interpretation is combined with saturation, perfusion, and skin temperature. [51]

Finger clubbing is a sign of chronic hypoxia and a number of systemic diseases. The finger profile, Lovibond angle, and Shamroth's sign are assessed. An angle greater than 180 degrees and the disappearance of the "diamond-shaped window" when juxtaposing the nail plates are diagnostic markers for finger clubbing. [52]

Table 6. Quick landmarks based on visible features

Sign	Where to watch	What does it mean?
Central cyanosis	Tongue, mucous membranes	Hemoglobin-dependent hypoxemia. [53]
Peripheral cyanosis	Fingers, ears	Peripheral vasoconstriction, low cardiac output. [54]
Clubbing	Finger profile	Lovibond angle >180 degrees, Shamroth's sign is positive. [55]

Edema, peripheral perfusion and hydration

Peripheral edema is assessed visually and by palpation, with gradation based on the depth of the "pit" and the recovery time. The classic four-point scale is widely used, but has limitations in reproducibility, so in doubtful cases, it is advisable to document the depth and recovery time in seconds. [56]

Capillary refill remains a simple marker of peripheral perfusion. It is normally up to 2 seconds in a warm room. Significantly prolonged refill time correlates with hypovolemia, severe infection, and organ dysfunction, although accuracy is affected by skin temperature and lighting. [57]

Table 7. Gradation of peripheral edema

Degree	Depth of the "hole"	Recovery time	Key remark
1+	up to 2 mm	instantly	Light "pressing". [58]
2+	2-4 mm	up to 15 seconds	Moderate severity. [59]
3+	4-6 mm	up to 60 seconds	The limb is full and swollen. [60]
4+	6-8 mm	over 60 seconds	Gross tissue deformation. [61]

Hydration assessment is comprehensive: skinfold, mucous membranes, turgor, respiratory rate, pulse rate, blood pressure, urine output, sodium concentration, and serum osmolality. Osmolality is the "gold standard," but in acute situations, rapid clinical markers and vital sign dynamics are important. [62]

General Inspection Red Flags and Escalation

Any of the following signs should prompt an urgent assessment and possible escalation of care: severe dyspnea, oxygen saturation below the patient's usual range, persistent hypotension, altered level of consciousness, mottled skin, oliguria, rapidly progressing rash, or signs of sepsis. Combined, these findings constitute a high early warning score and require immediate response. [63]

If sepsis is suspected, the approach is "early to recognize, early to treat": prompt identification of the source, correction of hypotension, oxygen, collection of samples for microbiology, initiation of antibiotic therapy if signs of severity are present, and ongoing monitoring. The 2024 update clarifies the use of the National Early Warning Scale in Adults in acute hospitals and emergency services. [64]

In elderly and frail patients, small deviations in vital signs can be clinically significant. Assessment using the Clinical Frailty Scale and delirium screening can help detect deterioration and develop a personalized monitoring and discharge plan. [65]

Table 8. Typical red flags and actions

Sign	Possible explanation	Actions
Respiratory rate is increased, saturation is decreased	Acute respiratory failure	Oxygen, reassess, call senior physician. [66]
Systolic pressure is reduced, pulse rate is increased	Hypovolemia, sepsis, arrhythmia	Fluid therapy, testing, monitoring. [67]
Altered consciousness, delirium	Hypoxia, metabolic causes, infection	Screening "4 signs", correction of causes. [68]

Documentation, communication and continuity

Each finding during a general examination should be linked to the time and conditions of measurement. The protocol records vital signs, assessments using the scales used, and interpretation, along with an action plan. This allows for objective monitoring of progress and justification for changes in tactics. [69]

Communication between specialists is based on standardized formulations and numerical values. The use of scores based on the Early Warning Scale, Glasgow Fragility Scale, Clinical Fragility Scale, and Pain Scale improves consistency and reduces the risk of errors. Regular reassessment using the same scales increases the reliability of observation. [70]

When a patient is discharged or transferred to another specialty, key parameters from the last examination, trends, red flags, unresolved issues, and a follow-up plan are communicated. This speeds up the detection of deterioration and improves patient safety. [71]

A short general inspection checklist

1. Safety and preparation of measurements. 2) Vital signs and their technique. 3) Early risk stratification using standardized scales. 4) Neuro-assessment and delirium. 5) Pain as a “fifth” sign. 6) Body habitus and nutritional risks. 7) Skin, cyanosis, clubbing. 8) Edema and perfusion. 9) Documentation of results and action plan. [72]