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

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