PR5134 Chap.7 General Examination and Vital Signs
General Examination and Vital Signs
Observation precedes measurement
General examination begins with deliberate observation of movement, demeanour, expression, appearance and distress. Vital signs add measurements whose meaning depends on preparation, technique and context.
Describe what was seen or measured before interpreting it, and document enough method for another clinician to judge whether the result can be compared with the next one.
Validate before concluding
Unexpected values should be checked against technique, circumstances and the patient's condition before a conclusion is built on them.
Observe without labelling
Write the movement, posture, expression or behaviour that was seen before compressing it into an interpretation.
Descriptions can be compared and challenged. Broad labels can introduce assumptions and make later readers uncertain about the underlying evidence.
Prepare the measurement
Equipment, patient position, recent activity, measurement site and observation interval affect the result. Use a suitable method and record the contextual factor that changes interpretation.
Technique is part of the clinical evidence, not a hidden preliminary.
Check plausibility
Compare the value with the general impression, symptoms and other observations. A mismatch may indicate method error, changing physiology or an incomplete picture.
Repeat appropriately when conditions can be improved, while escalating promptly when the patient's state makes waiting unsafe.
Preserve comparability
A trend requires values obtained under sufficiently comparable conditions. Record meaningful differences in site, position, activity or equipment.
Do not average a weak measurement with a better repeat merely to create a tidy number.
Handover the action threshold
State what direction of change matters, when the next observation is due and which symptom or value requires earlier action. This makes monitoring usable and prevents a normal-looking single value from overruling a concerning clinical picture.
What this chapter covers
- 01
General survey before contact
- 02
Description before interpretation
- 03
Pulse and respiratory technique
- 04
Temperature site and context
- 05
Repeat, escalation and documentation
Worked example · free
Rechecking a post-exertion pulse
- 2Calculate the initial rate.
- 2State context and validation steps.
- 2Name repeat and escalation logic.
Key terms
- General Survey
- A deliberate observation of the patient before focused examination.
- Vital Sign
- A measured physiological indicator interpreted with technique and context.
- Measurement Context
- The circumstances that affect how a recorded value should be understood.
General Examination and Vital Signs FAQ
Why describe before interpreting appearance?
Description preserves observable evidence and reduces bias. A phrase such as paused after standing can be checked and related to symptoms, while a broad label such as frail compresses several assumptions that may not be justified.
When should a vital sign be repeated?
Repeat when technique, equipment, recent activity, positioning or an unexpected mismatch with the clinical picture may have affected the result. A concerning patient should still be escalated appropriately rather than reassured by one apparently ordinary value.
What should vital-sign documentation include?
Record the value, relevant method and site, patient position or circumstances when they matter, associated observations, any repeat measurement and the action taken. This lets the next clinician compare like with like.
Assessment move
For each vital sign, rehearse a five-part chain: preparation, technique, plausibility, context and action. Use invented values only after the method is correct, and recompute every printed calculation. Begin with a written description of movement, appearance and distress that avoids diagnostic labels. Add one measurement and document its method, patient position, site and relevant circumstances.
Create a mismatch between the value and the general impression, then decide whether to repeat, seek another observation or escalate. Do not average an unreliable value with a better repeat. State why one should guide action. Build a short handover that preserves comparability across time and names the threshold for earlier review.
Ask a partner which measurement should be repeated and why; any missing answer reveals context that the record failed to carry forward. Construct an error table with one preparation error, one equipment error, one technique error and one transcription error for each observation you practise. For every row, state whether the error biases the value, makes it uninterpretable or merely needs contextual documentation.
Rehearse describing the general examination before seeing any numbers, then reveal the values and note which interpretations legitimately change. Swap the order on another case to notice how an early number can anchor later observation. When practising respiratory rate or pulse, count from an invented observation record and show the conversion explicitly rather than trusting mental arithmetic.
Create two readings that differ because position or recent activity changed, and explain why they are not automatically a trend. A peer should be able to reconstruct the method from your handover without guessing the site, device or patient condition. Close by choosing the smallest safe next action: accept a plausible observation, repeat under corrected conditions, obtain a related measure or escalate.
The justification matters more than collecting another number by habit.
