Introduction to General Examination of Patient (Head-to-Toe)

Purpose and Principles of the Clinical Examination

A head-to-toe physical examination is a systematic method used by midwives to collect objective data about a patient's health status. The primary purpose is to establish a baseline, identify any actual or potential health deviations, and monitor changes in the patient's condition over time. Midwives perform these assessments during antenatal booking clinics, labor admissions, and postnatal wards.

Several guiding principles ensure the examination is both safe and effective:

• Privacy and Comfort: Always ensure the examination room is warm, well-lit, and private, using screens and proper draping.
• Consent and Communication: Explain every step to the woman in a language she understands before touching her body.
• Head-to-Toe Progression: Move systematically from the head downward to avoid missing any body system or repeatedly changing the patient's position.
• Infection Prevention: Practice standard precautions, including hand hygiene before and after contact, and use gloves when touching mucous membranes or broken skin.

Performing the General Survey

The general survey begins the very moment you lay eyes on the patient, even before you start asking detailed clinical questions or checking vital signs. It is an overall impression of the patient's physical state, mental alertness, and general health.

Key components evaluated during a general survey include:

1. Apparent State of Health: Does the patient look acutely ill, frail, comfortable, or in distress?
2. Level of Consciousness: Is the woman alert, oriented to time and place, drowsy, or unresponsive?
3. Skin Color and Nutritional Status: Note signs of pallor, jaundice, cyanosis, or obvious wasting and obesity.
4. Postural and Motor Activity: Observe gait, involuntary movements, posture, and whether the patient protects a painful body part.
5. Hygiene and Grooming: Assess personal cleanliness, clothing appropriateness for the weather, and general presentation.

In midwifery practice, a sudden change in the general survey—such as a pregnant woman becoming unusually restless or pale—often serves as an early warning sign of hemorrhage or shock, prompting immediate intervention.

Core Physical Assessment Techniques

Physical examination relies on four fundamental clinical techniques performed in a specific sequence for most body systems, except the abdomen where auscultation precedes palpation.

• Inspection: Active, focused visual scrutiny of the body. Look closely at symmetry, color, lesions, swelling, and deformities before touching anything.
• Palpation: Using the sense of touch to feel for texture, temperature, moisture, swelling, tenderness, and masses. Use the fingertips for fine discrimination and the palm or ulnar surface for vibrations.
• Percussion: Striking the body surface lightly with fingers to produce sound waves. The resulting tone helps determine if underlying tissue is air-filled, fluid-filled, or solid.
• Auscultation: Listening to sounds produced inside the body—such as heartbeats, bowel sounds, and breath sounds—typically using a stethoscope.

Assessing the Head, Eyes, Ears, Nose, and Throat

Beginning at the top of the body, the assessment of the head and neck provides vital clues about hydration, chronic illness, and infection.

• Head and Face: Inspect the skull for symmetry, lumps, or tenderness. Check facial expressions and symmetry of facial movements to rule out nerve palsies.
• Eyes: Inspect the conjunctiva for pallor (a key indicator of anemia in pregnancy) and the sclera for yellow discoloration (jaundice). Check pupil reaction to light.
• Ears and Nose: Note any discharge, external lesions, or nasal congestion.
• Mouth and Throat: Inspect the lips, gums, and tongue. Look for bleeding gums, which are common in pregnancy due to hormonal changes, and check the tonsils and pharynx for redness or exudate.

Common misconception: Midwives sometimes skip checking the conjunctiva because they rely entirely on packed cell volume blood tests. Clinical pallor remains a rapid, essential bedside screening tool.

Respiratory and Cardiovascular System Checks

Evaluating the chest involves assessing how well the heart and lungs are functioning to support both the mother and the developing fetus.

Respiratory assessment involves observing the rate, depth, and rhythm of breathing. Count respirations discreetly so the patient does not alter her breathing pattern. Listen with a stethoscope for normal vesicular breath sounds and note any wheezes, crackles, or shortness of breath.

Cardiovascular assessment centers on checking pulse rate and rhythm at the radial artery, measuring blood pressure accurately, and auscultating heart sounds. Identify the apex beat and listen for the distinct 'lub-dub' sounds (S1 and S2). In pregnancy, a soft systolic murmur is often normal due to increased plasma volume, but any loud or diastolic murmur requires medical referral.

Abdominal Examination Sequence

Unlike other body systems where auscultation comes last, abdominal examination follows a strict sequence of Inspection, Auscultation, Percussion, and Palpation.

Auscultation is performed before touching the abdomen because pressing or rubbing the skin can alter bowel motility and artificially increase or decrease bowel sounds.

• Inspection: Check for contour, symmetry, scars, striae, and visible distension or fetal movements.
• Auscultation: Listen in all four quadrants for bowel sounds using the diaphragm of the stethoscope.
• Percussion: Assess for areas of tympany (air-filled areas) or dullness (solid organs or fluid).
• Palpation: Begin with light palpation to detect superficial tenderness or muscle guarding, followed by deeper palpation if appropriate to assess organ size or uterine contours.

Musculoskeletal and Neurological Spot Checks

Musculoskeletal and neurological checks evaluate mobility, reflexes, and central nervous system function. In routine midwifery, these checks are especially critical during antenatal care for women with hypertensive disorders to screen for impending eclampsia.

• Extremities: Inspect limbs for symmetry, muscle bulk, joint swelling, and range of motion. Assess for dependent edema in the lower legs and ankles, noting whether pitting edema is present.
• Reflexes: Test deep tendon reflexes, particularly the patellar (knee-jerk) reflex. Hyperactive reflexes suggest central nervous system irritability and high risk for seizures.
• Gait and Balance: Observe how the patient walks to ensure stability and coordination.

Documentation and Reporting Findings

An examination is clinically incomplete until all findings are accurately recorded. Good documentation provides a legal record and ensures safe continuity of care between healthcare shifts.

Record findings promptly using clear, objective, and professional language. Avoid vague terms like "patient looks fine"; instead, describe specific observations such as "alert, orientated, skin pink, clear breath sounds bilaterally." Report any abnormal or critical findings—such as severe pallor, absent breath sounds, or hyperactive reflexes—to the attending doctor or senior midwife immediately.