The general check-up

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chapter 17 The general check-up

More is missed by not looking than by not knowing.

INTRODUCTION AND OVERVIEW

Many patients will present without a specific symptom or disease, instead requesting a ‘general check-up’. Other patients, presenting with undifferentiated symptoms and signs, will need a more thorough history and examination than would normally be the case for most presentations. For your schedule to run smoothly, you will need to ensure that reception staff allow adequate time for new patients and for those who request a general check-up. This should average about 45 minutes to an hour and will usually require a follow-up appointment for discussion of results and health advice.

MOTIVATORS

It is worth ascertaining the patient’s motivation for their appointment, to ensure that you address the underlying reason for their presentation on this occasion. Some possible reasons:

• Their partner or a family member is concerned about an aspect of their health.
• They require a medical report for insurance or employment purposes.
• They are approaching a milestone birthday or event and want to assess their state of health.
• They feel non-specifically unwell and want to exclude disease.
• They have a friend or family member recently diagnosed with a health problem such as a cancer, diabetes or a cardiac event.
• They have become aware of a family history of disease for which they want to be screened.
• They have seen or heard a public health message and have decided to act on it.
• They have a health concern such as depression or sexual dysfunction, but they feel uncomfortable talking about it and are ‘checking you out’ to see if they trust you enough to discuss it with you.

HOW OFTEN?

How often a person should have a medical check-up depends on their age and general health status.

• Babies—should be opportunistically examined at the first encounter with a GP. This is often at the time of the first immunisation at 2 months, then again at 4 months, 6 months, 12 months and 18 months.
• Children and adolescents—preschoolers should have a comprehensive check-up every 6–12 months; older children and adolescents, once a year.
• Adults—if there are no specific health problems, annually.

HISTORY

As in all areas of medical care, a comprehensive history is the foundation of quality practice. Questions that probe the patient’s physical, emotional and spiritual wellbeing will be required, to form a picture of their overall health.

New patients should be encouraged to collate and bring with them any previous documentation, including specialists’ or allied health professionals’ reports, investigation results, X-rays, CT scans, MRIs and hospital discharge summaries. They should also be asked to bring any bottles or packets of prescribed or over-the-counter (OTC) medications, supplements or herbal medicines they are taking. This will enable you to check ingredients and doses of combination preparations.

ELEMENTS OF THE HISTORY

Elements of the history are as follows:

• establish patient’s reason for appointment
• current symptoms and health concerns
• past medical history—including any hospitalisations and significant diagnoses
• obstetric (female)—date of last normal menstrual period; frequency and duration of periods; obstetric history: number of pregnancies, deliveries (vaginal and caesarean), premature births, neonatal deaths, ectopic pregnancies, miscarriages, terminations, infertility, continence
• occupation(s)—present and past, including any occupational exposures to toxins, chemicals or pollutants
• family medical history—including age and cause of death of first- and second-degree relatives. Ask particularly about heart disease, asthma, diabetes, cancers and depression
• medication—prescription, OTC remedies and supplements and self-medication including dosage, frequency and route of administration. Women often need to be prompted about the oral contraceptive pill, many not viewing it as ‘medication’
• past and current use of recreational drugs—type, route of administration and frequency of use
• lifestyle—type of work, working hours, how they spend their leisure time, recent travel
• emotional health—moods; sleep pattern; relationships; attitude to work; signs of depression; level of satisfaction with job; family; friends; anxiety; use of alcohol, caffeine, tobacco or other drugs to alter mood
• sleep pattern—sleep latency, time of retiring to bed and waking, and total hours of sleep. Is it interrupted? Snoring or breathing pattern while sleeping, daytime sleeping and tiredness
• exercise routine—type, time, intensity, preferences for types of activity
• diet, nutrition—appetite, digestion, breakfast, snacks, lunch, dinner, fluid intake. For accuracy, this may require a food diary to be kept for several days to a week to indicate types and amounts of foods eaten
• for babies—feeding patterns and difficulties. Is the child breastfed? What formula if they are bottle-fed? Solids?
• smoking—past or current tobacco use. Did they ever smoke? How much and for how long? When did they quit? If still smoking, are they considering quitting?
• alcohol—frequency, type, amount (recorded as standard drinks per day and number of days per week or month)
• sexual history—current partner(s), new partner(s), previous sexual partner(s), previous testing for sexually transmissible infections, unprotected intercourse, sexual functioning, contraception
• immunisation—routine and travel vaccinations, with dosages and dates according to the relevant standard vaccination schedule
• previous check-ups and investigations—dates and results of previous Pap smears, prostate-specific antigen (PSA) tests, blood glucose, lipids, ECGs, chest X-rays etc.

GENERAL PHYSICAL EXAMINATION

Despite some medical debate about its value, the comprehensive physical examination is a core clinical skill essential to the integrative approach to healthcare, described in the Medical Journal of Australia as ‘the doctor’s best kept secret—powerful, portable, fast, cheap, durable, reproducible and fun’.1 It is about confirming the normal and looking for the abnormal. It will interact with and complement the medical history, which will have revealed areas that may require special attention and is an absolute prerequisite to further investigation of symptoms and signs.

Before you commence:

• Observe the patient’s demeanour, body habitus, facial expressions, mobility and gait as they enter the room, take a seat and transfer from chair to examination couch.
• Check that you have everything you need, so you do not have to interrupt the consultation to go hunting for an essential piece of equipment.
• Ensure that you have the patient’s (or, for children, their parent’s) permission to proceed with the examination.
• Allow the patient to remove their own clothes without your assistance, unless they request that you assist.

It is also important to explain to the patient what you are doing throughout the examination. The sequence in which you conduct the examination will depend on your training and on any particular issues raised by the history.

BABIES

• Measurements—length, weight, head circumference. Check against percentile chart for age.
• Head—shape, fontanelles.
• Ears—external canals, eardrums. Does the baby startle to noise?
• Eyes—fix and follow? Strabismus? Check lenses for signs of cataract.
• Mouth—tongue tie, thrush, teething.
• Skin—jaundice, rashes, birthmarks.
• Heart—check for murmurs.
• Lungs—breath sounds, respiratory rate and effort.
• Abdomen—liver, spleen, umbilicus.
• Hips and legs—check for congenital dislocation of the hips.
• Genitalia—check for inguinal hernia. In boys, check both testes in the scrotum, look for hydrocele.
• Developmental assessment checked against appropriate age milestones.
• Moro reflex (normal if bilateral and present from birth to 4 months).
• Immunisation status.

CHILDREN

• Height and weight, chart percentiles.
• Blood pressure and heart rate. Check for murmurs.
• Teeth, gums, tongue and throat.
• Reflexes.
• Eyes, ears, nose.
• Skin.
• Lungs.
• Abdomen.
• Fine motor development, e.g. ability to pick up small objects, write or tie shoes.
• Gross motor development, e.g. ability to walk, climb stairs, skip or jump.
• Spinal alignment—for signs of curvature (scoliosis).
• Genitalia, confirming a normal level of maturation, and checking for hernia or other possible problems.
• Check immunisation status.

ADOLESCENTS

(see Ch 56, Adolescent health and development.)

• Physical examination—as for adults.
• Check stage of sexual maturation.

ADULTS

• General demeanour, body shape, facial expression, vocal tone, gait, tremor.
• Colour—pallor, florid, peripheral or central cyanosis.
• Weight (kg).
• Height (cm).
• Waist and hip measurements (cm).
• BMI and waist–hip ratio (< 1.0 for women and 0.9 for men).
• Blood pressure (sitting and standing). If elevated on first reading, ask the patient to take a deep breath in and out and allow themselves to relax back in their chair. Then repeat. The blood pressure will often settle once the initial performance anxiety passes.
• Temperature.
• Pulse—rate, character and rhythm.
• Auscultation—heart sounds, murmurs.
• Jugular venous pressure.
• Precordial movement.
• Arterial pulses.
• Lungs—air entry, chest expansion, rhonchi, rales.
• Genitalia—male: urethra, testes, STI check; female: gynaecological examination including speculum, Pap smear if required and swabs for STI including Chlamydia if indicated.
• Breast examination (female).
• Abdomen—liver, spleen, masses, tenderness or guarding, rebound, distension, digital rectal examination (DRE), inguinal nodes, axillary nodes.
• Hernias—check with patient standing, lying and straining with head lifted off the pillow.
• Eyes—acuity, pupils, fundi, eye movements, colour perception (Ishihara chart).
• Ears, nose and throat:

• ears—hearing, screening, ear canals, tympanic membranes
• nose—airway
• tongue—mouth, throat, teeth
• thyroid—check for goitre or thyroid nodule
• cervical, axillary and inguinal lymph nodes
• cranial nerve examination.

• Neurological examination:

• deep tendon reflexes (upper limb and lower limb)
• cranial nerves
• gait
• muscle strength
• coordination
• sensory perception.

• Spinal movement—scoliosis, forward flexion, extension, rotation, neck range of motion.
• Joints—signs of joint swelling, inflammation or limitation of movement; single or multiple joint involvement.
• Skin—lesions, rashes, birthmarks, naevi (dermatoscope for greater detail of suspicious lesions), nails, hair, scalp.
• Urinalysis—collect midstream at the time of examination and observe macroscopically for blood, sediment and clarity.
• Dipstick test for white cells, red cells, nitrites, glucose and microalbuminuria.
• Resting ECG.
• Mental state examination:

• appearance
• attitude
• behaviour
• mood and affect
• speech
• thought process
• thought content
• perceptions
• cognition
• insight
• judgment.

• Mini mental state examination (MMSE) if screening for dementia/memory:

• time and place of the test
• remembering a list of words
• arithmetic (e.g. serial sevens)
• language use
• language comprehension
• basic motor skills.

INVESTIGATIONS

Investigations will depend on the patient’s age, gender, personal and family medical history, health behaviours and any relevant findings on history and examination. Guidelines also change and evolve as evidence emerges of the costs and benefits of individual case-finding or population screening.

A comprehensive medical check-up may require referral for:

• electrocardiogram (exercise)
• intraocular pressure (tonometry) and retinal examination
• laboratory tests—full blood examination
• iron studies—iron, ferritin
• liver function tests—bilirubin, albumin, total protein, alkaline phosphatase, alanine transferase (ALT), aspartate aminotransferase (AST), gamma glutamyl transferase (GGT)
• kidney function tests—blood urea, creatinine, calcium, sodium, potassium, glomerular filtration rate (GFR), microalbuminuria
• diabetes screening (fasting blood glucose)
• HIV and hepatitis B and C serology
• prostate-specific antigen (PSA) testing for males
• lipid profile—total cholesterol, HDL, LDL, triglycerides
• thyroid function tests T4, TSH (thyroid-stimulating hormone)
• stool for occult blood (or colonoscopy, depending on age and family history of bowel cancer)
• chest X-ray
• 24-hour ambulatory blood pressure monitoring if resting BP is elevated on successive readings
• osteoporosis screening—peripheral bone densitometry (DEXA); vitamin D
• female—mammogram, pelvic ultrasound, CA-125
• audiometry
• mini mental state assessment—if signs of short-term memory loss
• biopsy or referral for suspicious skin lesions.

PREVENTIVE INTERVENTIONS

Armed with the results of your history, examination and investigations, the follow-up consultation is the opportunity to formulate a health management plan or to provide advice on preventive health measures. Any features of concern need to be addressed and interventions discussed.

Preventive strategies will depend on the patient’s age and state of health (see chapters on babies and children (Ch 55), adolescents (Ch 56), pregnancy and antenatal care (Ch 54) and the elderly (Ch 57)) and can have a powerful effect on reducing the future risk of chronic disease.

Interventions might include:

• smoking cessation advice
• discussion of safe alcohol drinking limits
• physical activity plan (see Ch 9)
• healthy weight and waist measurement, and weight management plan
• nutrition advice, including appropriate diet and supplements
• medication review, including potential side effects and interactions
• immunisation update
• sexual safety counselling where appropriate
• advice on sun protection, skin self-examination and adequate sun exposure
• advice on oral hygiene and referral for dental check.

RESOURCES

Talley NJ, O’Connor S. Clinical examination: a systematic guide to physical diagnosis. 6th edn. Sydney: Elsevier, 2010.

REFERENCE

1 Reilly BM, Smith CA, Lucas BP. Physical examination: bewitched, bothered and bewildered. (Editorial) Med J Aust. 2005;182(8):375-376.

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