The conscious state: any decrease in this must be taken seriously, causes ranging from drug use to head injury.

 The temperature: the temperature is traditionally taken with a thermometer, but temperature-sensitive strips and sensors are available. Leave the thermometer in place for at least 3 min. The normal body temperatures are: oral 36.6°C; rectal or ear (tympanic membrane) 37.4°C; and axillary 36.5°C. Body temperature is usually slightly higher in the evenings. In most adults, an oral temperature above 37.8°C or a rectal or ear temperature above 38.3°C is considered a fever (pyrexia). A child has a fever when ear temperature is 38°C or higher.

 The pulse: this can be measured manually or automatically (Fig. 2.1). The pulse can be recorded from any artery, but in particular from the following sites:

 infants, 140 beats/min

 adults, 60–80 beats/min.

 exercise

 anxiety or fear

 fever

 some cardiac disorders

 hyperthyroidism and other disorders.

 The blood pressure: this can be measured with a sphygmomanometer (Fig. 2.2), or one of a variety of machines. With a sphygmomanometer the procedure is as follows: seat the patient; place the sphygmomanometer cuff on the right upper arm, with about 3 cm of skin visible at the antecubital fossa; palpate the radial pulse; inflate the cuff to about 200–250 mmHg or until the radial pulse is no longer palpable; deflate the cuff slowly while listening with the stethoscope over the brachial artery on the skin of the inside arm below the cuff; record the systolic pressure as the pressure when the first tapping sounds appear; deflate the cuff further until the tapping sounds become muffled (diastolic pressure); repeat; record the blood pressure as systolic/diastolic pressures (normal values about 120/80 mmHg, but these increase with age).

 Weight: weight loss is seen mainly in starvation, malnutrition, eating disorders, cancer (termed cachexia), HIV disease (termed ‘slim disease’), malabsorption and tuberculosis and may be extreme as in emaciation. Obesity is usually due to excessive food intake and insufficient exercise.

 Hands: conditions such as arthritis (mainly rheumatoid or osteoarthritis) (Figs 2.3 and 2.4) and Raynaud phenomenon (Ch. 56; Fig. 2.3), which is seen in many connective tissue diseases, may be obvious. Disability, such as in cerebral palsy, may be obvious (Fig. 2.5).

 Skin: lesions, such as rashes – particularly blisters (seen mainly in skin diseases, infections and drug reactions), pigmentation (seen in various ethnic groups, Addison disease and as a result of some drug therapy).

 Skin appendages: nail changes, such as koilonychia (spoon-shaped nails) – seen in iron deficiency anaemia, hair changes, such as alopecia, and finger clubbing (Fig. 2.6), seen mainly in cardiac or respiratory disorders. Nail beds may reveal the anxious nature of the nail-biting person (Fig. 2.7).