General Examination (Clinical Physical Examination)

1. General Appearance (First Impression)

• Level of consciousness - is the patient alert, confused, drowsy, or in distress?
• Nutritional status - obese, normal, thin, or cachectic/emaciated (prominent cheekbones, wasted soft tissues, especially over the buttocks)
• Body habitus - Marfanoid, achondroplastic, cushingoid
• Apparent age vs. stated age - premature ageing suggests chronic illness
• Posture and movement - does the patient lie flat comfortably, or do they prefer sitting up? (orthopnoea), are they writhing (colic) or still (peritonitis)?
• Distress level - in pain, breathless, or comfortable at rest
• Skin colour - pale, yellow, cyanotic, or deeply pigmented
• Odour - uraemic fetor (urine smell), foetor hepaticus (liver failure), acetone (DKA), alcohol

• Neuroanatomy through Clinical Cases, 3rd Ed., p. 32

2. Vital Signs

• GOLDMAN-CECIL MEDICINE, 26th Ed.

3. Examination of the Hands

Nails

• Clubbing - loss of nail bed angle (Schamroth's sign); seen in chronic lung disease, bronchiectasis, lung malignancy, cyanotic congenital heart disease, infective endocarditis, inflammatory bowel disease, cirrhosis
• Koilonychia (spoon-shaped) - iron deficiency anaemia
• Leukonychia (white nails) - hypoalbuminaemia / chronic liver disease
• Splinter haemorrhages - infective endocarditis (also trauma)
• Beau's lines (transverse ridges) - any severe systemic illness
• Nail-fold telangiectasia - connective tissue disease (SLE, dermatomyositis)

Peripheral Cyanosis

• Barash's Clinical Anesthesia, 9th Ed., p. 3141

Palms

• Pallor of palmar creases - anaemia (significant when Hb <7-8 g/dL)
• Palmar erythema - chronic liver disease, pregnancy, thyrotoxicosis, RA
• Dupuytren's contracture - liver disease, familial

Joints & Muscles

• Swollen joints - rheumatoid arthritis
• Muscle wasting of small muscles (interossei, thenar/hypothenar) - indicates protein depletion, T1 nerve root lesion, or motor neurone disease
• Tremor - fine (thyrotoxicosis, anxiety), coarse (Parkinson's), flapping asterixis (liver/renal failure, CO2 retention)

Other Hand Signs

• Xanthomata (tendon deposits) - hypercholesterolaemia
• Osler's nodes (tender red nodules in fingertips) - infective endocarditis
• Janeway lesions (non-tender haemorrhagic macules on palms) - infective endocarditis
• Capillary refill time - normally <2 seconds; >2s suggests poor perfusion

4. Upper Limb (Proceeding proximally)

• Wrist pulse - radial artery (60 seconds for rate, note rhythm and volume)
• Blood pressure - measure in the brachial artery
• Forearm & elbow - psoriatic plaques (elbows), gouty tophi, rheumatoid nodules, lymph nodes (epitrochlear - enlarge in lymphoma, secondary syphilis)
• Axillary lymph nodes - palpated with the patient's arm supported at the elbow

5. Head & Face

Eyes

• Scleral icterus (jaundice) - bilirubin deposits; first detectable at bilirubin ~35 µmol/L
• Conjunctival pallor - anaemia; pull down lower eyelid and inspect conjunctiva
• Xanthelasma (yellow plaques around eyelids) - hypercholesterolaemia
• Exophthalmos (proptosis) - Graves' disease / hyperthyroidism
• Kayser-Fleischer rings (golden-brown corneal rings) - Wilson's disease
• Corneal arcus - hyperlipidaemia (significant if <50 years old)
• Pupil size and reactivity - neurological assessment

Face

• Malar flush (butterfly rash) - SLE or mitral stenosis
• Acromegalic features (prominent brow, jaw, large tongue) - acromegaly
• Moon face + buffalo hump - Cushing's syndrome
• Cushingoid features - chronic steroid use
• Facial oedema - superior vena cava obstruction, nephrotic syndrome

Mouth

• Lip cyanosis - central cyanosis (check tongue)
• Angular stomatitis - iron/B2/B12 deficiency
• Glossitis (smooth red tongue) - B12, folate, iron deficiency
• Aphthous ulcers - IBD, Behcet's disease
• Gum hypertrophy - phenytoin, leukaemia, cyclosporin
• Foetor - hepatic (musty/sweet), uraemic (urine), ketotic (fruity)

6. Neck

• JVP (Jugular Venous Pressure) - assessed at 45° with the patient semi-recumbent; normal is <3-4 cm above sternal angle; raised in right heart failure, SVC obstruction, cardiac tamponade
• Carotid pulse - assess character (slow rising in aortic stenosis, collapsing in aortic regurgitation)
• Thyroid gland - inspect from the front (ask patient to swallow - thyroid moves up), then palpate from behind; percuss for retrosternal extension; auscultate for bruit (thyrotoxicosis)
• Lymphadenopathy (see below)

7. Lymph Node Examination

1. Cervical chain (anterior and posterior)
2. Submandibular & submental
3. Pre- and post-auricular
4. Occipital
5. Supraclavicular - particularly the left supraclavicular (Virchow's node / Troisier's sign) - suggests intra-abdominal malignancy (stomach, pancreas, colon)
6. Axillary
7. Inguinal
8. Epitrochlear

• Bailey and Love's Short Practice of Surgery, 28th Ed., p. 1076

8. Oedema

• Pre-tibial region / medial malleolus - peripheral oedema
• Sacrum - in bedbound patients

9. Skin (Dermatological Survey)

• Jaundice - yellow skin + sclera; pre-hepatic (haemolysis), hepatic, post-hepatic (obstructive - pale stools, dark urine, itch)
• Pigmentation - Addison's disease (buccal + skin creases), haemochromatosis (bronze)
• Rashes - purpura/petechiae (thrombocytopenia, meningococcaemia, vasculitis); ecchymoses (bleeding diathesis)
• Spider naevi - >5 in distribution of SVC suggests chronic liver disease
• Grey Turner's sign (flank bruising) and Cullen's sign (periumbilical bruising) - retroperitoneal haemorrhage (severe pancreatitis, leaking AAA)
• Skin turgor - reduced in dehydration

10. Summary: Sequence of General Examination

1. First impression (end of bed) → general appearance, distress, colour
2. Vital signs → T, P, BP, RR, SpO2, weight/BMI
3. Hands → nails (clubbing, koilonychia), peripheral cyanosis, pallor, palmar erythema, tremor, joints
4. Upper limb → pulse (rate, rhythm, volume), BP, epitrochlear nodes, axilla
5. Head & face → eyes (icterus, pallor, xanthelasma, exophthalmos), face (rash, cushingoid), mouth (cyanosis, ulcers, glossitis)
6. Neck → JVP, carotid, thyroid, cervical/supraclavicular lymph nodes
7. Skin survey → jaundice, pigmentation, rash, spider naevi
8. Lower limbs → oedema (ankles, sacrum), peripheral pulses
9. → Proceed to systemic examination (Respiratory / CVS / GI / Neurological)

Key Mnemonics

• J - Jaundice (haemolytic, hepatic, obstructive)

• Palmar crease pallor + conjunctival pallor = anaemia

• Chronic lung disease (COPD, bronchiectasis, CF, fibrosing alveolitis)
• Lung cancer / mesothelioma
• Ulcerative colitis / Crohn's disease
• Bronchiectasis
• Bacute Infective endocarditis
• Inflammatory bowel disease
• Not just lungs - cyanotic congenital heart disease, cirrhosis
• Gut (liver cirrhosis)

General Appearance in ABCDE Format

A - Age / Alertness / Affect

• Does the patient look their age, older (chronic illness, smoking, malnutrition), or younger?

• Alert and oriented? Or drowsy, confused, agitated, stuporous, comatose?
• Use AVPU: Alert / Verbal / Pain / Unresponsive (quick bedside tool)
• Use GCS (E + V + M) for a scored assessment

• Anxious, distressed, flat, tearful, euphoric, uncooperative?
• Is the patient in obvious pain (grimacing, guarding, restless)?
• Speaking in full sentences (good) vs. short bursts (respiratory distress)?

Example: "Alert and oriented, anxious-appearing woman who appears older than her stated age."

B - Build / Body Habitus

• Marfanoid - tall, long limbs, arachnodactyly (Marfan's, homocystinuria)
• Cushingoid - central obesity, moon face, buffalo hump (Cushing's / steroid use)
• Acromegalic - large jaw, prominent brow, large hands
• Achondroplastic - disproportionate short stature, normal trunk
• Turner's - short stature, webbed neck, wide carrying angle

Example: "Cachectic build with visible temporal wasting and prominent clavicles."

• GOLDMAN-CECIL MEDICINE, 26th Ed.

C - Colour / Complexion

• Barash's Clinical Anesthesia, 9th Ed., p. 3141

Example: "Moderately jaundiced with icteric sclerae. No central cyanosis."

D - Decubitus (Position) / Distress

• Comfortable at rest vs. mild / moderate / severe distress
• Diaphoretic (sweating profusely) - suggests high sympathetic drive: ACS, sepsis, hypoglycaemia, pain
• Use of accessory muscles - respiratory distress

Example: "Sitting upright in the orthopnoeic position, in moderate respiratory distress, sweating."

E - Environment / Extra findings (Surroundings)

Example: "Patient is on 4L O2 via nasal cannulae, attached to a cardiac monitor. Urinary catheter draining concentrated amber urine."

Quick Summary Card

Example Full Documentation

"This is a 62-year-old male who appears older than his stated age (A). He is of cachectic build with visible temporal wasting (B). He is centrally cyanosed with peripheral pallor and mild jaundice noted in the sclerae (C). He is sitting upright in the orthopnoeic position, in moderate respiratory distress, using accessory muscles, and diaphoretic (D). He is receiving 6L O2 via a non-rebreather mask, attached to a cardiac monitor, with a urinary catheter draining dark oliguria and an IV cannula in situ in the left antecubital fossa (E)."