The General Principles of Physical Examination

📋 Key Information Summary

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General inspection begins before touching the patient — first impressions (appearance, posture, body habitus, nutrition, distress) yield diagnostic clues in up to 50% of cases before any formal examination begins.
Always take a systematic approach: First impressions → Vital signs → Hands & nails → Hydration assessment → Regional/systemic examination.
Normal adult vital signs: Pulse 60–100 bpm, BP <120/80 mmHg, temperature 36.1–37.2 °C, respiratory rate 12–20 breaths/min, SpO₂ ≥ 95% on room air.
Abnormal vital signs demand escalation. A NEWS2 (National Early Warning Score 2) ≥ 7 triggers urgent medical review; score 5–6 warrants urgent assessment within 60 minutes.
Clubbing (loss of Lovibond angle ≥ 180°) suggests lung cancer, bronchiectasis, cystic fibrosis, interstitial lung disease, infective endocarditis, or inflammatory bowel disease.
Koilonychia (spoon nails) is classically associated with iron-deficiency anaemia; leukonychia (white nails) may indicate hypoalbuminaemia or zinc deficiency.
Hands reveal systemic disease: nicotine staining, palmar erythema (liver disease/pregnancy), Dupuytren's contracture, splinter haemorrhages, Osler nodes, Janeway lesions, and tremor all carry specific diagnostic weight.
Hydration assessment uses three evidence-based clinical signs with the best diagnostic accuracy: delayed skin turgor (positive LR 2.5–4.5), dry mucous membranes (LR 2.0–3.5), and sunken eyes (LR 2.4–4.0).
Severe dehydration (>9% in adults) is a medical emergency. Present with hypotension, tachycardia, altered mental status, and oliguria — requires IV crystalloid resuscitation and urgent senior review.
Capillary refill time (CRT) > 2 seconds is a reliable peripheral perfusion marker in adults; CRT > 3 seconds in children warrants urgent assessment.
Peripheral cyanosis indicates local vasoconstriction or low cardiac output; central cyanosis (tongue/lips) signals significant hypoxaemia (PaO₂ typically <55 mmHg, SpO₂ <85%).
Clinical dehydration scales in children (WHO 3-point, Clinical Dehydration Scale) and adults (Gorelick score) have modest sensitivity/specificity; laboratory markers (serum osmolality, urea, creatinine) supplement but do not replace bedside assessment.
Auscultatory gap: a silent interval during cuff deflation may cause underestimation of systolic BP; always palpate the radial pulse while inflating to estimate systolic pressure first.
Documentation must be timely and structured. Use a head-to-toe format; record vital signs using the ISBAR or Modified Early Warning Score (MEWS) framework when escalating concerns.

Introduction & Australian Epidemiology

The general physical examination is a foundational clinical skill that enables the clinician to formulate differential diagnoses, assess illness severity, and guide further investigation. A systematic approach — beginning with first impressions, proceeding through vital signs, and extending to targeted peripheral signs — allows rapid clinical decision-making at the bedside.

In Australia, the general examination underpins acute care in emergency departments (which see >8.8 million presentations annually according to the Australian Institute of Health and Welfare, AIHW 2023), hospital inpatient medicine, and primary care, where approximately 160 million Medicare-subsidised GP consultations occur each year. Errors in vital sign documentation and escalation remain a leading contributor to preventable patient deterioration and cardiac arrest, with the Australian Commission on Safety and Quality in Health Care (ACSQHC) mandating the use of standardised early warning score systems (e.g., NEWS2) in all Australian hospitals under the National Safety and Quality Health Service (NSQHS) Standards.

This article covers four key domains: first impressions and general appearance, vital signs assessment, hand and nail examination, and hydration assessment with evidence-based clinical examination techniques. Each section integrates Australian clinical guidelines, PBS-listed pharmacology where relevant, and considerations for priority populations including Aboriginal and Torres Strait Islander peoples.

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Scope note: This article addresses the general principles of the physical examination. Regional/systemic examination techniques (cardiovascular, respiratory, abdominal, neurological, musculoskeletal) are covered in their respective topic-specific articles on this site.

First Impressions — General Appearance

The experienced clinician forms diagnostic hypotheses within the first 30–60 seconds of encountering a patient. General inspection — performed before any formal examination — yields a wealth of clinical information. Hamptom et al. (1975) demonstrated that first impressions alone led to the correct diagnosis in a significant proportion of medical outpatients.

Systematic General Inspection

When approaching the patient, observe from the end of the bed or across the room before announcing your presence. Assess the following domains:

Domain	What to Assess	Diagnostic Significance
General appearance	Level of consciousness, distress, pain, affect, eye contact	Altered consciousness → delirium, metabolic encephalopathy, stroke; acute distress → PE, pneumothorax, MI
Weight & body habitus	Underweight, normal, overweight, obese; central vs peripheral fat distribution	Cachexia → malignancy, chronic disease, malnutrition; truncal obesity → Cushing syndrome, metabolic syndrome
Posture & mobility	Sitting, lying, tripod position, antalgic posture, guarding	Tripod → severe COPD/exertional dyspnoea; rigidity → Parkinson disease, NMS; opisthotonus → meningitis, tetanus
Nutritional status	Muscle wasting (temporal, deltoid, quadriceps), subcutaneous fat (triceps, clavicular), oedema	Temporal wasting → cancer/malnutrition; generalised oedema → nephrotic syndrome, liver failure, CCF
Facial appearance	Plethora, pallor, malar flush, moon facies, exophthalmos, xanthelasma, pallor of conjunctivae	Moon facies → Cushing; exophthalmos → Graves disease; xanthelasma → hyperlipidaemia
Odour	Ketotic (fruity), uraemic, hepatic fetor, faecal, alcohol, cigarette	Ketotic → DKA; uraemic → advanced CKD; hepatic fetor → liver failure
Surroundings & aids	Walking frame, wheelchair, oxygen, IV lines, catheter, medication charts	Contextualises functional status and current treatment

Body Mass Index (BMI) Classification

BMI (weight in kg ÷ height in m²) is used as a screening tool. The World Health Organization (WHO) classification is standard in Australian clinical practice:

Category	BMI (kg/m²)	Clinical Notes
Underweight	< 18.5	Consider malnutrition screening (MNA-SF), eating disorder, malignancy
Normal	18.5 – 24.9	Healthy range for most adults
Overweight	25.0 – 29.9	Lifestyle counselling, cardiovascular risk assessment
Obese (Class I)	30.0 – 34.9	Screen for T2DM, OSA, NAFLD; consider pharmacotherapy
Obese (Class II)	35.0 – 39.9	Multidisciplinary input; metabolic surgery assessment
Obese (Class III)	≥ 40.0	Severe obesity; specialist weight management referral

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Limitations of BMI: BMI does not distinguish between lean and fat mass, does not account for fat distribution, and may overestimate body fat in muscular individuals. Use waist circumference (>94 cm men / >80 cm women for increased cardiometabolic risk) and clinical judgement in conjunction with BMI. For Aboriginal and Torres Strait Islander adults, action thresholds for waist circumference may differ (see ATSI section).

Vital Signs

Vital signs are objective, quantifiable physiological measurements that serve as the earliest detectable indicators of clinical deterioration. The ACSQHC mandates that all patients in Australian hospitals have vital signs measured using a standardised approach and scored with an early warning system (NEWS2 or equivalent) as part of the Recognising and Responding to Acute Deterioration standard (NSQHS Standard 8).

Normal Adult Vital Sign Ranges

Parameter	Normal Range (Adult)	Measurement Technique
Heart rate	60–100 bpm	Radial pulse palpation for ≥ 30 seconds (60 sec if irregular); confirm with apical pulse if arrhythmia suspected
Blood pressure	< 120/80 mmHg (optimal)	Seated, rested ≥ 5 min, appropriate cuff size (bladder encircles 80% of arm), arm at heart level; average of 2 readings
Temperature	36.1–37.2 °C (tympanic/axillary)	Tympanic or temporal artery preferred in hospital; axillary acceptable (add 0.5 °C for approximation); oral if afebrile and cooperative
Respiratory rate	12–20 breaths/min	Count for 60 seconds while appearing to take radial pulse; do NOT inform the patient (reactive tachypnoea)
Oxygen saturation (SpO₂)	≥ 95% (room air)	Pulse oximetry on warm, well-perfused digit; avoid nail polish, cold extremities, COHb/MetHb interference

Pulse Assessment

Assess the pulse systematically — the mnemonic "RRCCCS" is used in Australian medical education:

Rate — beats per minute (bradycardia <60, tachycardia >100 bpm)
Rhythm — regular, regularly irregular (e.g., second-degree heart block), irregularly irregular (e.g., atrial fibrillation)
Character — amplitude and waveform (bounding in CO₂ retention/aortic regurgitation, thready in shock)
Collapsing — raise patient's arm above head; a rapid rise and fall suggests aortic regurgitation
Symmetry — compare radial and femoral pulses (radio-femoral delay in coarctation of the aorta); compare both radials (asymmetry in aortic dissection, subclavian stenosis)

Blood Pressure — Technique & Pitfalls

Cuff size matters: An undersized cuff overestimates BP by 10–40 mmHg; an oversized cuff underestimates. The bladder should encircle ≥ 80% of the arm circumference.
Auscultatory gap: A silent interval between systolic and diastolic Korotkoff sounds may occur in hypertension, aortic stenosis, and elderly patients. Palpate the systolic pressure first to avoid missing true systolic BP.
Postural (orthostatic) hypotension: Defined as a drop of ≥ 20 mmHg systolic or ≥ 10 mmHg diastolic within 3 minutes of standing. Measure BP supine then standing. Common in elderly, dehydration, autonomic neuropathy, antihypertensive medications.
Hypertensive urgency vs emergency: BP > 180/120 mmHg without end-organ damage = urgency (gradual oral reduction over 24–48 h); with end-organ damage (encephalopathy, AKI, pulmonary oedema, aortic dissection) = emergency (IV therapy, ICU admission).

Temperature & Fever Assessment

Classification	Core Temperature	Clinical Considerations
Hypothermia	< 35.0 °C	Elderly, exposure, hypothyroidism, sepsis (paradoxical); use low-reading thermometer
Normal	36.1–37.2 °C	Diurnal variation (lowest 04:00, peak 18:00)
Low-grade fever	37.3–38.0 °C	Viral illness, drug reaction, post-operative, autoimmune
Moderate fever	38.1–39.0 °C	Infection likely; SIRS criteria met
High fever	39.1–41.0 °C	Serious bacterial infection, malaria, meningitis, malignant hyperthermia, NMS
Hyperpyrexia	> 41.0 °C	Medical emergency — active cooling, exclude NMS, serotonin syndrome, thyroid storm

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Immunocompromised patients: Fever may be absent in severe sepsis in immunosuppressed patients (neutropenic patients, the elderly, those on corticosteroids). Any single abnormal vital sign in an immunocompromised patient should trigger a low threshold for sepsis workup and empirical antibiotics per eTG Antibiotic guidelines.

Respiratory Rate — The Forgotten Vital Sign

The respiratory rate is the single most sensitive vital sign predictor of clinical deterioration, yet it is the most commonly omitted measurement in Australian hospitals (Cretikos et al., 2008). An elevated respiratory rate (>20 breaths/min) is an independent predictor of cardiac arrest, ICU admission, and death within 24 hours.

Tachypnoea (>20/min): Respiratory failure, PE, metabolic acidosis (Kussmaul breathing), anxiety, pain, fever, pneumonia
Bradypnoea (<12/min): Opioid toxicity, raised intracranial pressure, hypothyroidism, CNS depression
Abnormal patterns: Cheyne-Stokes (CCF, brain injury), Kussmaul (DKA, uraemic acidosis), ataxic/Biot's (brainstem lesion)

Oxygen Saturation (SpO₂)

Pulse oximetry estimates arterial oxygen saturation using photoplethysmography. It is available at the bedside in all Australian hospitals and most GP practices.

Normal: ≥ 95% on room air at sea level
Hypoxaemia: SpO₂ < 90% (PaO₂ ≈ <60 mmHg) — requires supplemental oxygen
COPD target: 88–92% (avoid hyperoxia-driven hypercapnia); use Venturi mask for controlled FiO₂
Limitations: Carbon monoxide poisoning (COHb falsely elevates SpO₂ — use co-oximetry); methaemoglobinaemia (SpO₂ plateaus at ~85%); poor perfusion (hypothermia, shock, Raynaud's); dark skin pigmentation (SpO₂ may be slightly overestimated — recent evidence from Sjoding et al., 2020)

NEWS2 (National Early Warning Score 2)

NEWS2 is endorsed by the ACSQHC and is the standard early warning scoring system in Australian hospitals. It assigns a weighted score (0–3) to each vital sign parameter:

Score	Respiratory Rate	SpO₂ Scale 1	SpO₂ Scale 2 (COPD)	Air/O₂	Systolic BP	Heart Rate	Temperature	Consciousness
3	≤ 8	≤ 91%	≤ 83%	—	≤ 90	≤ 40	≤ 35.0	—
2	—	92–93%	84–85%	Any O₂	91–100	41–50	35.1–36.0	—
1	—	94–95%	86–87%	—	101–110	51–90	36.1–38.0	—
0	12–20	≥ 96%	88–92%*	Air	111–219	—	—	Alert
1	21–24	—	93–94%	—	—	91–110	38.1–39.0	—
2	25+	—	95–96%	—	≥ 220	—	≥ 39.1	CVPU: C/V/P/U**
3	—	—	≥ 97%	—	—	≥ 131	—	—

*COPD target range 88–92% scores 0 on Scale 2. **C = Confusion, V = Voice, P = Pain, U = Unresponsive (AVPU). Any response other than Alert scores 3.

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NEWS2 escalation thresholds (ACSQHC):
• NEWS ≥ 7: Emergency response — urgent or emergency clinical review, continuous monitoring, consider ICU/CCU.
• NEWS 5–6: Urgent review within 60 minutes, increase monitoring frequency to minimum 1-hourly.
• NEWS 1–4: Minimum 4–6 hourly monitoring; assess for change in clinical context.
• Score of 3 in any single parameter: Urgent clinical review regardless of aggregate score.

Hands & Nails

The hands are one of the most information-rich areas of the physical examination. Systematic inspection of the dorsum, palm, nails, and fingers reveals signs spanning cardiovascular, respiratory, hepatic, haematological, endocrine, rheumatological, and infective conditions.

Nail Signs

Sign	Description	Differential Diagnoses
Clubbing	Loss of the normal Lovibond angle (angle between nail plate and proximal nail fold) — now ≥ 180°. Assess Schamroth's window test (loss of the diamond-shaped gap between opposed nail plates). Bulbous enlargement of the fingertip.	Respiratory: Lung cancer (most common cause), bronchiectasis, cystic fibrosis, interstitial lung disease, empyema, mesothelioma Cardiovascular: Infective endocarditis, cyanotic congenital heart disease Gastrointestinal: Inflammatory bowel disease (Crohn > UC), coeliac disease, hepatic abscess Other: Thyroid acropachy (Graves), hypertrophic osteoarthropathy
Koilonychia	Spoon-shaped concavity of the nail plate; the nail is thin, brittle, and scooped out.	Iron-deficiency anaemia (most common), haemochromatosis, Plummer-Vinson syndrome, fungal infection, occupational (detergents), normal variant in infants
Leukonychia	White discolouration of the nail plate. True (in the nail matrix) vs apparent (in the nail bed).	True: Zinc deficiency, arsenic poisoning, hereditary Apparent (half-and-half nails): Hypoalbuminaemia (nail bed pallor proportional to albumin <20 g/L); Terry's nails in cirrhosis, CCF, T2DM; Muehrcke's lines (paired white bands) in nephrotic syndrome/hypoalbuminaemia
Splinter haemorrhages	Linear, dark-red/brown streaks in the nail bed following the longitudinal axis of the nail.	Infective endocarditis (proximal nail bed, multiple fingers), vasculitis, trauma (distal, single nail — most common cause), psoriasis, trichinosis
Beau's lines	Transverse depressions in the nail plate representing a temporary arrest of nail growth.	Systemic illness (severe infection, MI, chemotherapy), zinc deficiency; timing can be estimated by nail growth rate (~0.1 mm/day → 6 months for full nail regrowth)
Pitting	Small punctate depressions in the nail plate.	Psoriasis (most common; coarse, irregular pitting), alopecia areata, eczema, Reiter syndrome
Onycholysis	Separation of the nail plate from the nail bed, starting distally.	Psoriasis, thyrotoxicosis, fungal infection, trauma, drug-induced (tetracyclines, retinoids)

Clubbing — Grading

Grade 1 (Mild)

Fluctuation of Nail Bed

Softening of the nail bed with increased fluctuation on bimanual examination. Lovibond angle beginning to increase.

May be the earliest clinical sign; Schamroth's window narrowing

Grade 2 (Moderate)

Parrot Beak Appearance

Loss of the Lovibond angle (≥ 180°). Increased convexity of the nail plate. Drumstick appearance of the fingertip.

Schamroth's window obliterated; strongly associated with intrathoracic pathology

Grade 3 (Severe)

Hypertrophic Osteoarthropathy

Gross clubbing with painful periostitis of the distal long bones (shin, forearm). Radiographic subperiosteal new bone formation.

Often associated with bronchogenic carcinoma (Pancoast tumour) or cyanotic heart disease

Hand Colour & Vascular Signs

Sign	Distribution	Differential Diagnoses
Cyanosis (peripheral)	Fingers, toes, earlobes, nose tip; disappears with warming	Low cardiac output, peripheral vascular disease, cold exposure, Raynaud's phenomenon, shock
Cyanosis (central)	Tongue, lips, mucous membranes; does NOT disappear with warming	Significant hypoxaemia (PaO₂ <55 mmHg, SpO₂ <85%): pneumonia, PE, pulmonary oedema, R→L shunt, methaemoglobinaemia
Pallor	Palmar creases (compare to surrounding skin), nail beds, conjunctivae	Anaemia (Hb <90 g/L for palmar pallor), shock, peripheral vasoconstriction
Jaundice	Best seen in sclerae (bilirubin >35 μmol/L), sublingual mucosa, palms (particularly in darker-pigmented skin)	Hepatic disease, haemolysis, biliary obstruction, Gilbert syndrome, carotenaemia (sclerae spared)
Palmar erythema	Thenar and hypothenar eminences; spares the centre of the palm	Liver disease/cirrhosis (hyperdynamic circulation), pregnancy, rheumatoid arthritis, thyrotoxicosis, polycythaemia; bilateral in physiological variants
Nicotine staining	Index and middle fingers (dominant hand), teeth	Active tobacco smoking; prompts smoking cessation counselling (PBS: nicotine replacement therapy — Nicabate®, Nicorette®)

Other Important Hand Signs

Osler nodes: Painful, erythematous nodules on fingertips/palms — immune complex vasculitis in infective endocarditis
Janeway lesions: Painless, erythematous macules on palms/soles — septic emboli in acute infective endocarditis (S. aureus)
Dupuytren's contracture: Palmar fibromatosis causing flexion deformity of ring and little fingers — associated with alcohol use disorder, liver disease, epilepsy (phenytoin), diabetes mellitus
Heberden's nodes: Bony swelling at DIP joints — osteoarthritis
Bouchard's nodes: Bony swelling at PIP joints — osteoarthritis
Swan-neck deformity: PIP hyperextension + DIP flexion — rheumatoid arthritis, SLE
Boutonnière deformity: PIP flexion + DIP hyperextension — rheumatoid arthritis
Tremor: Rest tremor (4–6 Hz) → Parkinson disease; postural/intention tremor (8–12 Hz) → essential tremor; flapping tremor (asterixis) → hepatic encephalopathy, CO₂ retention, uraemia
Ulnar deviation / Z-deformity: Advanced rheumatoid arthritis
Thenar wasting: Median nerve lesion (carpal tunnel syndrome); Hypothenar/interosseous wasting: Ulnar nerve lesion (T1 radiculopathy, motor neuron disease)

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Clubbing requires urgent investigation: New or unexplained clubbing — particularly in a smoker — mandates a chest X-ray (Medicare item 58500) and CT chest (Medicare item 56301) to exclude bronchogenic carcinoma, mesothelioma, or interstitial lung disease. Refer to respiratory medicine urgently.

Hydration Assessment & Evidence-Based Clinical Examination

Dehydration is one of the most common reasons for emergency department presentations in Australia, particularly in the elderly, paediatric patients, and those with acute gastroenteritis. Accurate clinical assessment of hydration status is critical for guiding fluid management. However, no single clinical sign has sufficient sensitivity or specificity in isolation; a combination of signs is required for reliable assessment.

Evidence-Based Clinical Signs of Dehydration

The systematic review by McGee et al. (1999) and subsequent meta-analyses (Defined by Hooper et al., Cochrane 2015) identified the following clinical signs with their diagnostic performance:

Clinical Sign	Positive Likelihood Ratio	Negative Likelihood Ratio	Reliability
Delayed skin turgor (abdominal skin pinch > 2 seconds)	2.5 – 4.5	0.3 – 0.6	Moderate (age-dependent; unreliable in elderly due to reduced skin elasticity)
Dry mucous membranes (tongue, buccal mucosa)	2.0 – 3.5	0.3 – 0.7	Moderate (mouth breathing and anticholinergic drugs cause false positives)
Sunken eyes	2.4 – 4.0	0.3 – 0.6	Good in children; less reliable in elderly/obese
Dry axillae	2.8	0.4	Good — one of the most reliable single signs in adults
Capillary refill time > 2 seconds	1.5 – 3.0	0.4 – 0.7	Variable (affected by temperature, ambient conditions)
Tachycardia	1.3 – 2.5	0.5 – 0.8	Low specificity (many causes of tachycardia)
Sunken fontanelle (infants only)	5.1	0.6	Good specificity in infants with open fontanelle
Weakness / dizziness on standing	1.5 – 2.0	0.6	Low (non-specific)
Oliguria (<0.5 mL/kg/h in adults)	1.5 – 4.0	0.4 – 0.7	Moderate — requires catheter for accurate measurement

Classification of Dehydration

Mild Dehydration

3–5% Body Weight Loss

Thirst, slightly dry mucous membranes, normal skin turgor, normal vital signs, normal urine output. No postural hypotension.

Setting: Community / GP management — oral rehydration

Moderate Dehydration

6–9% Body Weight Loss

Definite thirst, dry mucous membranes, delayed skin turgor (>2 s), sunken eyes, tachycardia, postural hypotension (systolic BP drop ≥20 mmHg), reduced urine output, mild confusion in elderly.

Setting: ED assessment — oral or IV fluids; monitor closely

Severe Dehydration

>9% Body Weight Loss

Hypotension (systolic BP <90 mmHg), marked tachycardia (HR >120), very dry mucous membranes, profoundly sunken eyes, absent tears, skin tenting, oliguria/anuria, altered consciousness, cold peripheries, CRT >4 seconds.

Setting: Medical emergency — IV crystalloid resuscitation, senior review, consider ICU

Paediatric Dehydration — WHO Clinical Dehydration Scale

The WHO 3-point scale is widely used in Australian paediatric emergency departments:

Parameter	No / Mild (Score 0)	Moderate (Score 1)	Severe (Score 2)
General appearance	Well, alert	Restless, irritable	Lethargic, unconscious
Eyes	Normal	Sunken	Very sunken
Mucous membranes	Moist	Dry	Very dry
Tears	Present	Decreased	Absent

Interpretation: Score 0–1 = no/mild dehydration (ORS at home); Score 2–4 = moderate dehydration (observe in ED, trial ORS or IV fluids); Score 5–8 = severe dehydration (immediate IV resuscitation with 0.9% NaCl 20 mL/kg bolus).

Laboratory Markers Supporting Clinical Assessment

Marker	Normal Range	Dehydration Pattern
Serum osmolality	275–295 mOsm/kg	>295 in hypertonic dehydration (water loss > Na loss); <275 in hypotonic dehydration
Serum urea	3.0–8.0 mmol/L	Elevated (pre-renal azotaemia); urea:creatinine ratio >100:1 suggests pre-renal cause
Serum creatinine	60–110 μmol/L (M)	Rising creatinine = acute kidney injury (KDIGO criteria)
Serum sodium	135–145 mmol/L	Hypernatraemia (pure water loss); hyponatraemia (hypotonic fluid loss or SIADH)
Serum lactate	< 2.0 mmol/L	>2.0 = tissue hypoperfusion; >4.0 = significant hypovolaemic shock
Urine specific gravity	1.005–1.030	>1.030 = concentrated urine (dehydration); <1.005 = dilute (overhydration/SIADH)

Initial Fluid Management of Dehydration

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Australian fluid resuscitation guidelines:
Adults: 0.9% sodium chloride 500–1000 mL IV bolus over 15–30 minutes; reassess clinically; repeat as needed. In sepsis: 30 mL/kg within first 3 hours (Surviving Sepsis Campaign).
Children: 0.9% sodium chloride 20 mL/kg IV bolus over 15–20 minutes; reassess and repeat up to 60 mL/kg in the first hour if signs of shock persist.
Oral rehydration: Gastrolyte® (PBS listed) or WHO ORS formula — preferred for mild-moderate dehydration with intact consciousness and no vomiting.

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Gastrolyte Effervescent

Gastrolyte® · Oral rehydration salts

Composition NaCl 3.5 g, KCl 1.5 g, NaHCO₃ 2.5 g, glucose 20 g per litre (WHO ORS formula)

Adult dose 1–2 tablets dissolved in 200 mL water; 200–400 mL after each loose stool or vomiting episode

Paediatric dose 1 tablet per 200 mL; small frequent sips — 50–100 mL/kg over 4 hours for moderate dehydration

PBS status ✔ PBS General Benefit

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Sodium Chloride 0.9%

Normal saline · IV crystalloid

Adult dose 500–1000 mL IV bolus over 15–30 min for resuscitation; maintenance 1–2 L/24h

Paediatric dose 20 mL/kg IV bolus over 15–20 min; repeat PRN

Renal adjustment Caution in oliguric/anuric renal failure — risk of fluid overload and hypernatraemia

PBS status ✔ PBS General Benefit (hospital supply)

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Hartmann's Solution (Ringer's Lactate)

Hartmann's® · Balanced crystalloid

Composition Na⁺ 131, K⁺ 5, Ca²⁺ 2, Cl⁻ 111, lactate 29 mmol/L

Adult dose 500–1000 mL IV bolus over 15–30 min; preferred in sepsis (SMART trial, Semler 2018)

Paediatric dose 20 mL/kg IV bolus over 15–20 min

Renal adjustment Contains potassium 5 mmol/L — use with caution in hyperkalaemia and severe renal impairment

PBS status ✔ PBS General Benefit (hospital supply)

Capillary Refill Time (CRT)

Press on the sternum or fingertip for 5 seconds with enough pressure to blanch the skin, then release and count the seconds until colour returns.

Normal CRT: < 2 seconds (adults), < 3 seconds (children)
Delayed CRT (2–4 s): Dehydration, early shock, hypothermia, peripheral vascular disease
Markedly delayed CRT (>4 s): Significant hypovolaemia or cardiogenic shock — urgent intervention required
Limitations: Ambient temperature, patient age, site of measurement (sternal preferred in children per APLS guidelines)

Special Populations

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Pregnancy

Vital signs in pregnancy: Heart rate increases by 10–20 bpm by the third trimester. Systolic BP decreases by 10–15 mmHg in the second trimester before returning to pre-pregnancy levels in the third trimester. BP ≥ 140/90 mmHg is abnormal at any gestation — assess for pre-eclampsia (proteinuria, visual disturbance, RUQ pain, elevated LFTs).

Respiratory rate: Mild tachypnoea (up to 20/min) is physiological due to increased tidal volume and progesterone-driven respiratory drive.

Peripheral oedema: Mild bilateral ankle oedema is common in pregnancy; unilateral oedema or asymmetric oedema warrants Doppler ultrasound to exclude DVT.

Jaundice: In pregnancy, jaundice may indicate pre-eclampsia/HELLP syndrome, acute fatty liver of pregnancy, or cholestasis of pregnancy (pruritus predominant) — urgent obstetric and medical review.

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Paediatrics

Age-adjusted vital signs are essential: Neonates (HR 120–160, RR 30–60), infants (HR 100–150, RR 25–40), toddlers (HR 90–130, RR 20–30), school-age (HR 70–110, RR 18–25).

Paediatric Early Warning Score (PEWS): Used in Australian paediatric hospitals to detect deterioration; assesses cardiovascular, respiratory, and neurological domains.

Fontanelle assessment: A sunken anterior fontanelle is a specific sign of dehydration in infants; a bulging fontanelle suggests raised ICP (meningitis, hydrocephalus) — urgent investigation.

Skin turgor: Assess on the abdomen (not the forearm — unreliable in children due to elastic skin).

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Elderly

Blunted physiological responses: Fever may be absent in elderly patients with serious infection (up to 30% of bacteraemic elderly patients are afebrile). Tachycardia may be absent due to medications (beta-blockers, calcium channel blockers) or sick sinus syndrome.

Postural hypotension: Very common in the elderly — multifactorial (autonomic dysfunction, polypharmacy, dehydration). Always assess lying and standing BP; a drop ≥ 20/10 mmHg is diagnostic.

Skin turgor is unreliable: Age-related loss of skin elasticity renders turgor assessment inaccurate. Use alternative signs: dry axillae, tongue dryness, urine output, and laboratory markers.

Delirium screening: Altered vital signs + acute confusion = delirium until proven otherwise. Use the 4AT or CAM screening tool; assess for infection, medication effects, constipation, urinary retention, and metabolic causes.

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Renal Impairment

Fluid assessment is critical: Distinguish between pre-renal (dehydration → raised urea:creatinine ratio) and intrinsic renal causes. In CKD patients, dry weight is often unknown — trend monitoring of BP, weight, and oedema is essential.

Hypertension: Common and often undertreated in CKD. Target BP <130/80 mmHg per Kidney Health Australia guidelines (or <140/90 in patients over 80).

Fluid overload: Bibasal crackles, raised JVP, peripheral oedema, and weight gain in dialysis patients — assess dry weight and ultrafiltration requirements.

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Hepatic Impairment

Stigmata of chronic liver disease: Spider naevi (>5 in the distribution of the SVC), palmar erythema, gynaecomastia, testicular atrophy, caput medusae, jaundice, ascites, hepatomegaly or small shrunken liver.

Signs of portal hypertension: Ascites (shifting dullness, fluid thrill), splenomegaly, prominent abdominal wall veins (caput medusae), haemorrhoids.

Hepatic encephalopathy: Asterixis (flapping tremor), confusion, altered sleep cycle — grade using West Haven criteria. Assess for precipitants (infection, GI bleed, constipation, electrolytes).

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Immunocompromised

Masked presentation: Immunosuppressed patients (chemotherapy, transplant recipients, high-dose corticosteroids, HIV/AIDS with low CD4) may not mount a fever or inflammatory response even with serious infection.

Low threshold for sepsis workup: Any single abnormal vital sign in a neutropenic patient (ANC <0.5 × 10⁹/L) should trigger blood cultures, lactate, and empirical broad-spectrum antibiotics per eTG Antibiotic guidelines (e.g., piperacillin-tazobactam 4.5 g IV TDS).

Oral examination: Mucositis (chemotherapy), oral candidiasis, HSV reactivation, oral Kaposi sarcoma (HIV) — inspect the oral cavity routinely.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of chronic disease, infectious disease, and acute illness compared to non-Indigenous Australians. The gap in life expectancy remains approximately 8 years for males and 8.6 years for females (AIHW, 2023). A culturally safe, trauma-informed approach to the physical examination is essential.

Cultural safety & communication

Always explain the purpose of each examination step before proceeding. Some patients may prefer a same-gender clinician. Avoid assumptions about health literacy. Use Aboriginal Health Workers (AHWs) and Aboriginal Liaison Officers (ALOs) as cultural brokers. Ask about Sorry Business or cultural obligations that may affect attendance and consent.

Rheumatic heart disease (RHD)

RHD disproportionately affects Aboriginal and Torres Strait Islander children and young adults, particularly in the Northern Territory, Queensland, and Western Australia. The ARF/RHD register (RHDAustralia) mandates secondary prophylaxis. Cardiac auscultation for murmurs is a critical component of the examination in at-risk populations. New heart murmurs in a young Indigenous person should prompt urgent echocardiography.

Chronic kidney disease (CKD)

Indigenous Australians are 3.8 times more likely to have CKD than non-Indigenous Australians. Regular screening with eGFR and urine ACR is essential (Medicare item 66503). Fluid overload assessment (oedema, BP, weight) is particularly relevant in remote communities with limited dialysis access.

Diabetes & diabetic complications

Type 2 diabetes prevalence is 3–4 times higher in Indigenous Australians. Examine hands for peripheral neuropathy (monofilament testing, 10 g Semmes-Weinstein), feet for ulcers, and assess for Charcot arthropathy. Diabetic renal disease screening and cardiovascular risk assessment (absolute cardiovascular risk calculator, Australian guidelines) are critical.

Scabies & skin infections

Scabies and secondary bacterial skin infections (Group A Streptococcus → impetigo → post-streptococcal glomerulonephritis and RHD) are highly prevalent in remote communities. Skin inspection is a vital component of the general examination. Treat index cases AND contacts (ivermectin 200 μg/kg PO, PBS Authority Required; or permethrin 5% cream, PBS General Benefit).

Trachoma

Australia is the only high-income country where endemic trachoma persists, exclusively in remote Aboriginal communities. Examine the upper tarsal conjunctiva for follicles and scarring in children and adults in endemic regions. Refer to the National Trachoma Surveillance and Reporting Unit for management protocols.

Body habitus & waist circumference

Action thresholds for waist circumference differ: >90 cm for Indigenous men and >80 cm for Indigenous women (lower than general population thresholds) to reflect elevated cardiometabolic risk at lower waist circumferences. Use these thresholds in cardiovascular risk assessment.

Remote & rural access

Specialist access is limited in remote communities. Telehealth (Medicare items 99200–99215) and the Royal Flying Doctor Service enable remote consultations. Clinical examination skills are particularly critical where laboratory and imaging resources are limited. The clinician's hands, eyes, and clinical acumen are the primary diagnostic tools.

📚 References

1. Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London: RCP; 2017.
2. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021. Standard 8: Recognising and Responding to Acute Deterioration.
3. Cretikos MA, Bellomo R, Hillman K, Chen J, Finfer S, Flabouris A. Respiratory rate: the neglected vital sign. Med J Aust. 2008;188(11):657–659.
4. Hooper L, Abdelhamid A, Attreed NJ, et al. Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people. Cochrane Database Syst Rev. 2015;(4):CD009647.
5. McGee S, Abernethy WB III, Simel DL. Is this patient hypovolemic? JAMA. 1999;281(11):1022–1029.
6. Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial bias in pulse oximetry measurement. N Engl J Med. 2020;383(25):2477–2478.
7. World Health Organization (WHO). The treatment of diarrhoea: a manual for physicians and other senior health workers. 4th rev. ed. Geneva: WHO; 2005.
8. Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults (SMART trial). N Engl J Med. 2018;378(9):829–839.
9. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023.
10. RHDAustralia (ARF/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: RHDAustralia; 2020.
11. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand. Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation. 2018.
12. Kidney Health Australia. Chronic Kidney Disease Management in Primary Care. 4th ed. Melbourne: Kidney Health Australia; 2020.
13. Hamptom JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J. 1975;2(5969):486–489.
14. Advanced Life Support Group (ALSG). Advanced Paediatric Life Support: The Practical Approach. 6th ed. Hoboken: Wiley-Blackwell; 2016.
15. Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Crit Care Med. 2018;46(6):997–1000.