General inspection and vital signs
How to look a patient over from the bedside and record pulse, blood pressure, temperature, breathing, oxygen saturation and NEWS2.
- General inspection is the part of the examination that starts the moment you see the patient: appearance, posture, behaviour, hands and face. It is done before you touch the patient, and it often gives the diagnosis.
- Vital signs are temperature, pulse, blood pressure, respiratory rate, oxygen saturation and the level of consciousness. They are measured in everyone and tracked on an early warning score.
- A few habits set the standard: measure blood pressure in both arms at the first visit and in both postures when symptoms suggest it; palpate the pulse before an automated blood pressure; use a cuff that fits the arm.
- Present the findings in the same order every time, lead with the abnormal finding, state the negatives that matter, and end with a working diagnosis.
- A normal set of observations does not exclude a sick patient, and a single abnormal sign is only a clue: judge the whole patient.
By the end of this page you should be able to:
- Carry out a systematic general inspection from first sight to vital signs in the correct order.
- Elicit and recognise the common signs: pallor, jaundice, cyanosis, clubbing, oedema, dehydration and cachexia.
- Measure temperature, pulse, blood pressure (including cuff choice, both arms and standing), respiratory rate and oxygen saturation correctly.
- Calculate and interpret BMI and apply NEWS2 and its escalation thresholds.
- Present a set of findings aloud and in the notes in the standard order, normal example and abnormal examples.
The general inspection and vital signs are the first clinical encounter: quiet, non-invasive observations made before the focused examination of any system. They serve three purposes: to triage (is this person sick now?), to suggest a diagnosis from the whole-body clues, and to establish a baseline that later measurements can be compared against. They belong in every assessment, whether the complaint is chest pain, abdominal pain, or an incidental finding.
The setting matters. Measure in a warm, quiet room, with the patient seated or lying comfortably, the arm supported at heart level, and no conversation during the reading: talking during blood pressure measurement raises systolic pressure by a measurable amount.[3] Remove sleeves, support the back, and keep the feet on the floor. The examination is introduced, consented, chaperoned where indicated, and carried out with hand hygiene and appropriate exposure.
Introduce yourself, confirm identity, take consent, and explain what you will do. Offer a chaperone for intimate exposure and document it. Wash or gel the hands, and wear gloves only when contact with body fluids is expected. Expose the patient adequately but maintain dignity: shirt off for a full examination, trousers loosened for the legs, and the shoes off for height and weight. Position: sitting for most of the examination, lying flat or at 45 degrees for the cardiovascular part, standing when you test for postural change. Have the equipment ready and working, and check that blood pressure devices are validated, maintained and calibrated.[2]
Work from the door to the bed, then to the vital signs. Numbering helps you not to skip, and repeating the same order in every patient makes omissions obvious.
- First impressions at the door. Greet the patient and watch them answer: speech, breathing effort, colour, posture and gait. Count the respiratory rate subtly while the patient thinks you are taking the pulse. Note whether they look well or ill, distressed, anxious, confused, or in pain.
- General appearance and habitus. Height, weight and body shape; obesity or cachexia; facial and body hair; skin colour; distress, diaphoresis or wasting.
- Hands. Shape, nails and skin: clubbing, leuconychia, koilonychia, splinter haemorrhages, tar staining, Janeway lesions, Osler nodes, palmar erythema, wasting of the thenar eminence.
- Face and eyes. General expression, facial asymmetry, jaundice in the sclera, conjunctival pallor, xanthelasma, moon face, exophthalmos, ophthalmoplegia; mouth and tongue for central cyanosis, dryness, anaemia.
- Neck and chest general. Central cyanosis, tracheal position, visible pulsation, respiratory rate and effort, scars, cachexia.
- Peripheral circulation and hydration. Temperature of hands, capillary refill, skin turgor, mucous membranes, jugular venous pressure if seated up, ankle oedema and warmth.
- Vital signs in order. Temperature, pulse, blood pressure in both arms, respiratory rate, oxygen saturation; then NEWS2.
- Pain. Location, quality and severity on a 0-to-10 scale, if not already done.
- Height, weight, BMI. Measured, not estimated, when weight matters.
- Summary. State the key abnormal findings and the working diagnosis before you move to the system examination.
Order of the general inspection and vital signs
- First impressions at the doorAppearance, speech, breathing, colour, gait
- General appearance and habitusHeight, weight, cachexia, obesity
- HandsNails, clubbing, colour, tar staining, splinter haemorrhages
- Face and eyesJaundice, pallor, cyanosis, expression
- Neck, chest, circulationRespiratory rate, trachea, JVP, capillary refill
- Hydration and oedemaSkin turgor, mucosa, ankle swelling
- Vital signsTemperature, pulse, blood pressure, respiratory rate, SpO2, NEWS2
- Pain score and BMIQuantify pain; measure height and weight
- SummaryState the leading abnormality and plan
| Sign | How to elicit it | What the finding means |
|---|---|---|
| First impressions (well / ill, distressed, confused, in pain) | Watch the patient at rest and while talking; note posture, breathing effort, colour and affect. | Sets urgency and directs the rest of the examination; confusion or air hunger suggests serious illness. |
| Cachexia (wasting) | Look for loss of fat and muscle, prominent bones, loose skin, temporal wasting. | Chronic illness, malignancy, malabsorption, or severe under-nutrition; distinguish from thin but well people. |
| Obesity | Judge and measure; BMI 25 to less than 30 overweight, 30 or more obesity, under 18.5 underweight, 18.5 to less than 25 normal.[9] | Cardiometabolic risk; affects cuff choice and drug dosing. |
| Pallor | Inspect conjunctiva, lips, tongue, nail beds and palms; palmar creases in darker skin. | Suggests anaemia; the conjunctiva and lip are the most reliable sites for visual assessment.[4] |
| Jaundice | Look at the sclera in natural light; check gums and palate. | Raised bilirubin from liver, bile duct or haemolysis disease; look for other clues (stigmata of liver disease, scratch marks, dark urine). |
| Cyanosis (central) | Look at lips, tongue and oral or sublingual mucosa in good light. | Severe hypoxaemia (or methaemoglobin / sulfhaemoglobin); central sites matter, and it is hard to see in dark skin; inspect buccal mucosa and tongue.[6] |
| Cyanosis (peripheral) | Look at nail beds, ear lobes and fingertips. | Slow circulation (cold, shock, peripheral vascular disease); warms with warming, unlike central. |
| Clubbing | Elkin / Schamroth: place dorsal surfaces of the terminal phalanges together and look for a diamond-shaped window. | Chronic hypoxaemic lung disease, endocarditis, cirrhosis, inflammatory bowel disease, congenital heart disease; check for hypertrophic osteoarthropathy.[5][6] |
| Oedema | Press firmly over a bony prominence (shin or ankle) and watch for indentation that remains; check the sacrum in bedbound patients; weigh. | Fluid or sodium overload (heart, kidney, liver, venous) or local venous or lymphatic disease; record distribution and grade. |
| Hydration (low) | Dry mucous membranes, dry skin, thirst, tachycardia, prolonged capillary refill, orthostatic change, cold peripheries. | Hypovolaemia or dehydration; beware in older adults where skin turgor is unreliable.[7] |
| Hydration (high) | Peripheral oedema, dyspnoea, weight gain, raised JVP, basal crackles. | Fluid overload, commonly cardiac or renal.[7] |
| Hands (tar staining) | Staining of fingertips; ask about smoking. | Current or past cigarette smoking; raises cardiopulmonary concern. |
| Pulse: rate | Count for 60 seconds, or 30 seconds times 2 if regular; count twice and reconcile. | Normal adult 60 to 100 beats per minute; tachycardia or bradycardia.[8] |
| Pulse: rhythm | Feel for regularity; listen for 60 seconds if irregular. | Regular, regularly irregular or irregularly irregular; atrial fibrillation is irregularly irregular. |
| Pulse: volume and character | Feel with two fingertips; describe as weak / thready / bounding / collapsing. | Weak in shock; collapsing pulse in aortic regurgitation; radio-femoral delay in coarctation. |
| Pulse: both arms and radio-radial delay | Feel both radial pulses together; compare. | Radio-radial delay suggests subclavian stenosis or aortic arch disease. |
| Temperature | Measure orally / tympanically / axillary consistently; note method. | Normal average about 36.9 C tympanic (converted to oral equivalent); fever threshold 37.8 C in the quoted study.[8] Febrile illness and hypothermia. |
| Blood pressure: technique | Seated, relaxed, arm supported at heart level, appropriate cuff, measure both arms; if postural symptoms, supine then standing after one minute.[2][3] | Accurate diagnosis of hypertension and of postural hypotension. |
| Blood pressure: threshold | Repeat in clinic if 140/90 mmHg or more; confirm with ABPM / HBPM (daytime average 135/85 or more). | Diagnosis of hypertension.[2] |
| Postural change | Difference between lying or seated and standing at one minute. | Fall of systolic 20 or more, or diastolic 10 or more defines postural hypotension.[2] |
| Respiratory rate | Count breaths for 60 seconds without the patient knowing; note effort and accessory muscles. | Normal 12 to 20 breaths per minute at rest; tachypnoea or bradypnoea.[8] |
| Oxygen saturation (SpO2) | Pulse oximeter on a warm, well-perfused finger on air; check trace quality. | Usually 95 percent or more on air; use Scale 2 for hypercapnic respiratory failure target 88 to 92 percent.[1] |
| NEWS2 | Score respiration, oxygen saturation, systolic blood pressure, pulse, consciousness, temperature; add 2 for supplemental oxygen. | Aggregate 0 to 4 low, 5 to 6 medium (key threshold for urgent review), 7 or more high / emergency; a score of 3 in one parameter is an urgent trigger.[1] |
| Pain score | Ask the patient to rate 0 (no pain) to 10 (worst imaginable), using faces or verbal scale if needed. | Quantifies and tracks pain; the number needed for analgesia titration.[10] |
Present findings aloud in the same order in every patient, so you do not forget anything and the listener follows you. The order is: general state and appearance; hands and face; vital signs; then the system you examined. Lead with the most important abnormal finding, then the supporting findings, then the negatives that matter (what you looked for and did not find), then a one-line summary with a working differential.
Rules of delivery:
- Be specific and numerical: "pulse 98 per minute, irregularly irregular" instead of "tachycardic irregular pulse".
- Describe size, site and quality, not just presence: "a 6 cm tender liver".
- State the negatives that exclude the serious alternative: "no radio-radial delay", "no cyanosis or clubbing", "jugular venous pressure not raised".
- Use "on air" or "on 2 litres of oxygen" with saturations, and "lying and standing" with blood pressure.
- End with a provisional diagnosis and the next tests, not with a list of signs.
Writing in the notes uses the same order and style: full sentences or labelled entries, units in every number, and the word "unremarkable" only after saying what was normal. Avoid abbreviations that another reader will not understand.
A spoken presentation has three parts: a headline, the evidence, and the plan.
- Headline: "This is a 62-year-old retired builder who looks unwell and tachycardic."
- Evidence: "He is cachectic and mildly jaundiced; his hands are warm and clubbed; pulse 104, irregularly irregular; blood pressure 118/72 in both arms; temperature 37.6; respiratory rate 22; saturation 91 percent on air; NEWS2 7."
- Plan: "I think he is a sick man with chronic hypoxemic lung disease and an infection; I would get a chest radiograph and an ECG before deciding on antibiotics."
All patient details below are invented and illustrative.
Normal. "Mrs Evans is a 54-year-old teacher who looks well and comfortable. Hands and face are normal, no pallor, jaundice, cyanosis or clubbing. Pulse 72 regular; blood pressure 124/78 in both arms; temperature 36.8; respiratory rate 14; saturation 98 percent on air; NEWS2 0. Pain nil; BMI 24."
Abnormal (infection). "Mr Okafor is a 70-year-old man who looks ill and dehydrated. He is sweaty and peripherally shut down with cold hands. Pulse 108 regular, thready; blood pressure 88/52 lying (84/50 standing), both arms equal; temperature 38.7; respiratory rate 26; saturation 94 percent on 2 litres; NEWS2 9; pain score 3 (back). He is oliguric in the bag."
Abnormal (cardiac). "Ms Chen is a 60-year-old woman with peripheral and facial oedema and raised jugular pressure. Pulse 90 irregularly irregular with no radio-radial delay; blood pressure 152/92 lying and 132/84 standing; temperature 36.6; respiratory rate 18; saturation 96 percent on air; NEWS2 1. BMI 28."
Abnormal (respiratory). "Mr Adeyemi is a 68-year-old smoker with central cyanosis of the lips and tongue and clubbed fingers. Pulse 88 regular; blood pressure 130/80 both arms; temperature 37.2; respiratory rate 22; saturation 89 percent on air; reduced peak flow; NEWS2 4."
- Rushing past the general inspection because the complaint is "specific"; the diagnosis is often in the first five seconds.
- Taking an automated blood pressure without palpating the pulse first: automated devices are inaccurate in atrial fibrillation.[2]
- Using the wrong cuff size, or an arm circumference over 42 cm without a conical cuff, which distorts the reading.[3]
- Measuring only one arm, or only once, or leaving the sleeve under the cuff.
- Telling the patient their blood pressure while you take it, or letting them talk; this raises the reading.[3]
- Measuring standing blood pressure too early (less than one minute) or not at all when dizziness is reported.
- Estimating rather than counting respiratory rate; patients change their breathing if they know you are watching.
- Forgetting saturation "on air" and documenting without it; then you cannot judge improvement.
- Relying on skin pallor in dark-skinned patients; use conjunctiva, mucosa and palms.
- Calling clubbing from a single thickened nail without checking the nail-bed angle and Schamroth.
- Writing "observations normal" without the numbers.
- Treating NEWS2 as the patient: the score guides, it does not replace judgement, and it is not validated in all settings.
- General inspection runs from first sight to the summary; repeat the same order in every patient.
- Observe before you touch; count respiration while taking the pulse.
- Pallor: conjunctiva and lip are the best visual sites; severe anaemia may be missed elsewhere.[4]
- Cyanosis: central means lips and tongue (severe hypoxaemia); peripheral means nail beds (slow flow); both behave differently in anaemia and in dark skin.[6]
- Clubbing: Schamroth sign; first ask what it is telling you (lung, heart, liver, bowel).
- Dehydration: dry mouth, tachycardia, prolonged capillary refill and orthostatic change; skin turgor is unreliable in older adults.[7]
- Blood pressure: quiet, seated, supported arm, correct cuff, both arms at first visit; more than 15 mmHg between arms repeats and uses the higher arm.[2][3]
- Postural hypotension: systolic fall of 20 or more, or diastolic fall of 10 or more, after standing at least one minute.[2]
- Pulse 60 to 100 and respiratory rate 12 to 20 at rest in adults; temperature averages 36.9 C and fever threshold 37.8 C in the quoted study; saturation 95 percent or more on air.[8]
- BMI uses adult cut-offs: under 18.5 underweight, 18.5 to less than 25 normal, 25 to less than 30 overweight, 30 or more obesity.[9]
- NEWS2 aggregates six parameters plus 2 for oxygen, with urgent thresholds at 5 or more and emergency at 7 or more, and any single 3 is an urgent trigger.[1]
- Pain is a vital sign: record 0 to 10.[10]
- Present findings numerically, lead with the abnormal, state negatives, end with a differential.
- Numbers need the units and the conditions (on air, lying / standing) or they are useless.
Answer each one in your head first, then open the answer.
A patient has pulse 118 irregularly irregular, no radio-radial delay, blood pressure 94/58, temperature 37.9, respiratory rate 24, saturation 92 percent on air, NEWS2 not yet calculated. List the findings in presentation order and state the NEWS2.
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Lead with the abnormal: "Pulse 118, irregularly irregular, with no radio-radial delay; blood pressure 94/58; temperature 37.9; respiratory rate 24; saturation 92 percent on air." Score on the chart: respiration 2, saturation 2, blood pressure 2, pulse 2, temperature 0 for 37.9 C, consciousness 0, oxygen 0 because on air; total 8, which is 7 or more and therefore high risk. State the likely differentials (sepsis, hypovolaemia, arrhythmia) and the plan.
What is the correct standing blood pressure and the definition of postural hypotension?
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When symptoms suggest it, measure lying (or seated if needed) and again after at least one minute standing. A fall of systolic 20 mmHg or more, or diastolic 10 mmHg or more, defines postural hypotension. Use the arm with the higher reading thereafter.[2]
A woman with darker skin has suspected anaemia. You cannot see pallor of the skin. What do you do?
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Do not rely on skin colour. Inspect the palpebral conjunctiva, lips, tongue, nail beds and palms; the conjunctiva and lip are the most reliable sites, and the palmar creases help. Arrange a full blood count.[4]
A patient is breathless and cyanosed centrally with clubbed fingers. Where does the cyanosis show and what does clubbing add?
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Central cyanosis shows in the lips, tongue and oral or sublingual mucosa, and means severe hypoxaemia or an abnormal haemoglobin. Clubbing of the fingers, confirmed by a positive Schamroth sign, points to chronic hypoxaemic lung disease (or other chronic causes) and raises the likelihood of lung cancer or interstitial disease.[5][6]
During a routine check a man has blood pressures of 152/90 in the right arm and 132/88 in the left, both repeated. What do you conclude and what do you do next?
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The difference is 20 mmHg, still more than 15 on repeat, so use the arm with the higher reading for subsequent measurements, check pulses for subclavian or aortic arch disease, and assess cardiovascular risk. Do not manage from the lower arm.
General inspection belongs with the system examinations and with presenting a case. Related pages in this library (titles; links added once verified): cardiac physical examination, respiratory examination, investigation of anaemia, dehydration and fluid balance, hypertensive disease.
- Royal College of Physicians. National Early Warning Score (NEWS) 2. RCP; December 2017. Accessed .
- National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. NICE guideline NG136; published 28 August 2019, last updated 26 February 2026. Accessed .
- Mihailidou AS et al. Measuring blood pressure accurately. Australian Prescriber 2026;49:50. Accessed .
- Horibata K, Kondo S, Hashimoto S, Takemura Y. An observational study to determine the optimal physical evaluation site for detecting anemia. Journal of General and Family Medicine 2025. Accessed .
- Sarkar M, Mahesh DM, Rawat A. Digital clubbing. Lung India 2012;29(4):354-362. Accessed .
- Contributors to the Springer / PMC chapter. The Airway and the Lungs (in Clinical Examination Skills in the Adult Critically Ill Patient). Springer 2018; chapter in PMC7122865. Accessed .
- Nagalingam K, Whiting L, Farrington K, Migliozzi J, Pattison N. Clinical Assessment of Fluid Status in Adults With Acute Kidney Injury: A Scoping Review. Journal of Renal Care 2025. Accessed .
- Han HM et al. A big data analysis of fever threshold and vital sign characteristics using tympanic temperature in hospitalized patients. Scientific Reports 2024; published 8 November 2024. Accessed .
- Alafif NW et al. Body mass index and health-related lifestyle behaviors among university students in Saudi Arabia. Frontiers in Public Health 2026. Accessed .
- Serce Z et al. Comparison of four unidimensional pain scales and women's preferences during the first stage of labor. BMC Pregnancy and Childbirth 2026. Accessed .
Educational content for medical students and doctors. It is not a substitute for clinical judgement or local guidelines.