General Examination - Bailey & Love and S Das

How to Set Up the Examination

• Perform in natural daylight (artificial light may miss faint jaundice)
• Patient should remove all clothing and be covered with a gown
• Female patients must have a nurse attendant
• Patient lies flat, hips and knees extended (a pillow allowed for comfort)
• For palpation, flex the hips and knees to relax abdominal muscles
• Proceed in a systematic sequence: inspection → palpation → percussion → auscultation

Components of General Examination

1. General Assessment of Illness

• In a severely ill patient, prioritize - proceed rapidly to local examination and begin treatment rather than spending time on less important findings.
• Note whether the patient looks well, ill, or moribund.
• A cachectic patient with abdominal discomfort and a lump strongly suggests GI malignancy.

2. Mental State and Level of Consciousness

3. Build and State of Nutrition

• Obesity may point to hypothyroidism, Cushing's syndrome, or metabolic syndrome.
• Cachectic/wasted appearance with abdominal complaint suggests malignancy.
• Endocrine abnormalities (acromegaly, myxoedema, Marfan's) are recognizable from build alone.
• Record weight and BMI in elective settings (Bailey & Love).

4. Attitude (Posture/Decubitus)

5. Skin Color - Pallor, Cyanosis, Jaundice

Pallor (Anaemia)

• Causes: Massive haemorrhage, shock, intense emotion, anaemia (from any cause).
• Look for koilonychia (spoon-shaped nails) in iron deficiency anaemia.
• Chronic inflammatory/malignant swellings cause anaemia (low Hb%).

Cyanosis

• Peripheral cyanosis: Nail beds, tip of nose, skin of palms and toes.
• Central cyanosis: Tongue (key differentiator - tongue is spared in peripheral cyanosis), plus above sites.

Jaundice

• Colour ranges from faint yellow (viral hepatitis) to dark olive-green (obstructive jaundice - due to biliverdin accumulation).
• Scratch marks on skin = obstructive jaundice (bile acid retention → pruritus).
• Distinguish from hypercarotinaemia (carotene staining): sclera is NOT icteric in hypercarotinaemia; it mainly affects the face, palms, and soles.
• In deep/longstanding jaundice, a greenish tint appears in sclerae and skin.

6. Oedema

• Pitting oedema: Pit remains after pressure release - cardiac failure, hypoalbuminaemia (liver disease, nephrotic syndrome), venous obstruction.
• Non-pitting (brawny) oedema: No pit - lymphoedema (filariasis), myxoedema.
• Note: oedema is better seen in the ankles and feet in ambulant patients; in bedridden patients, check the sacral region.
• Also note periorbital oedema (nephrotic syndrome, angioedema).

7. Lymphadenopathy

• Cervical (anterior and posterior chains), submandibular, submental, pre/post-auricular
• Axillary (central, anterior, posterior, medial, apical)
• Inguinal
• Virchow's node (left supraclavicular lymphadenopathy) - suggests intra-abdominal malignancy (Bailey & Love)

8. Hands

9. Head and Neck

• Eyes: Jaundice (sclerae), pallor (conjunctivae), exophthalmos (hyperthyroidism), Kayser-Fleischer rings (Wilson's disease), Horner's syndrome (apical lung/neck pathology)
• Face: Cushingoid facies, myxoedematous face, acromegalic features, malar flush (mitral stenosis)
• Neck: Thyroid enlargement, jugular venous pressure (JVP) for cardiac status, cervical lymphadenopathy, carotid pulsations
• Left supraclavicular node (Troisier's sign / Virchow's node) = intra-abdominal malignancy

10. Vital Signs

Pulse

• Rate (normal: 60-100/min), rhythm (regular/irregular), volume (full/thready), character (bounding/collapsing)
• Tachycardia: shock, infection, pain, anaemia, hyperthyroidism
• Bradycardia: hypothyroidism, raised ICP, heart block

Blood Pressure

• Both arms (differ by >10 mmHg = vascular pathology)
• Hypertension: renal disease, endocrine causes
• Hypotension + tachycardia = shock; note pulse pressure

Respiratory Rate

• Normal: 12-18 breaths/min
• Tachypnoea: pulmonary pathology, metabolic acidosis, pain, sepsis
• Cheyne-Stokes respiration: uraemia, raised ICP, cardiac failure

Temperature

• Normal: 37°C (98.6°F)
• Fever patterns help diagnosis: hectic fever = abscess; low-grade evening fever = tuberculosis
• Hypothermia: severe shock, hypothyroidism

11. Specific Examination in Suspected Malignancy (S Das)

1. Pulmonary metastasis: Enquire about cough, haemoptysis, chest pain; examine for consolidation and pleural effusion
2. Hepatic metastasis: Examine liver for enlargement and nodularity
3. Peritoneal metastasis: General abdominal examination
4. Bony metastasis: Examine spine, pelvis, trochanters of femora, skull for tenderness

12. Lymph Node Examination for Cause

• Always examine ALL lymph node groups
• Generalized lymphadenopathy = systemic disease (lymphoma, leukaemia, HIV, TB)
• Regional lymphadenopathy = local cause in drainage area

Summary Checklist: General Examination Sequence

1. General assessment of illness (well/unwell/moribund)
2. Mental state and level of consciousness
3. Build, nutrition, body habitus, weight/BMI
4. Attitude and posture in bed
5. Skin: pallor, cyanosis (peripheral vs. central), jaundice
6. Oedema: ankles/feet, sacrum
7. Hands: clubbing, koilonychia, palmar erythema, flap
8. Head and neck: eyes, face, thyroid, JVP, lymph nodes
9. Vital signs: pulse, BP, RR, temperature
10. Lymph node groups: cervical, axillary, inguinal
11. If malignancy: lung, liver, abdomen, bones
12. Specific system examination based on chief complaint

• S Das - A Manual on Clinical Surgery, 13th Edition, Chapter 1 (History & Physical Examination) and Chapter 3 (General Examination)
• Bailey & Love's Short Practice of Surgery, 28th Edition, Chapter 63 (Abdominal Examination and General Examination)

Head-to-Toe Examination: Complete Sequential Guide

Based on S Das (Manual on Clinical Surgery) & Bailey and Love

Key rule: The patient lies flat, adequately exposed, in natural light. Examine each region completely before moving on - you cannot come back.

BEFORE YOU START (Patient Positioning & Setup)

• Natural daylight (artificial light misses faint jaundice)
• Patient fully undressed, covered by gown
• Lying flat, hips/knees extended (pillow allowed)
• Female patient: nurse attendant mandatory
• Start the moment the patient walks in (gait, posture, distress)

1. GENERAL FIRST IMPRESSION (Standing/Entering)

2. HEAD

Eyes

• Conjunctiva (lower lid): Pallor = anaemia - pull down lower lid and look at palpebral conjunctiva
• Sclera: Jaundice (ask patient to look down at feet, open eyelid wide) - yellow = early; greenish-yellow = late/obstructive
• Pupils: Size, equality, reaction to light, accommodation reflex (PERLA)
• Eye movements: 3rd, 4th, 6th cranial nerves
• Exophthalmos: Hyperthyroidism
• Periorbital oedema: Nephrotic syndrome, angioedema
• Visual fields: Confrontation test
• Fundoscopy: Optic disc, papilloedema, hypertensive/diabetic changes

Ears

• Lobule of ear: Look for jaundice here (a sensitive site)
• Discharge, tophi (gout)

Nose

• Tip of nose: Pallor, cyanosis, jaundice (all visible here)
• Nasal flaring: Respiratory distress

Face/Skin

• Facies: Cushingoid (moon face, plethora), myxoedematous (puffy, dull), acromegalic (jaw protrusion), malar flush (mitral stenosis)
• Pigmentation: Addison's (buccal), Peutz-Jeghers (perioral)
• Skin colour: Pallor, cyanosis, jaundice, cherry-red (CO poisoning), scratch marks (obstructive jaundice = bile acid retention)

3. MOUTH AND THROAT

• Lips: Colour (cyanosis/pallor), pigmentation (Peutz-Jeghers syndrome), angular stomatitis (B12/iron deficiency), herpes labialis
• Teeth and gums: Dental hygiene, bleeding gums (scurvy), spongy gums
• Tongue:
  • Colour: Pallor (anaemia), central cyanosis (blue tongue = TRUE central cyanosis - key differentiator from peripheral)
  • Moisture: Dry tongue = dehydrated
  • Papillae: Smooth bald tongue = B12 deficiency/iron deficiency/GI disorders
  • Leukoplakia: White opaque patches on dorsum
  • Undersurface and sides: Ulcers (especially at tongue margins - carcinoma)
  • Furring: Infection, heavy smoking
  • Midline rhomboid area: Median rhomboid glossitis
• Undersurface of tongue: Jaundice visible here
• Soft palate: Movement (9th/10th cranial nerve)
• Tonsils: Enlargement, exudate
• Buccal mucosa: Pallor, pigmentation

S Das: The tongue is key - central cyanosis makes the tongue blue; peripheral cyanosis does NOT affect the tongue.

4. NECK

Lymph Nodes

• Submental → submandibular → anterior cervical chain → posterior cervical chain → pre-auricular → post-auricular → occipital
• Left supraclavicular (Virchow's/Troisier's node): If enlarged = intra-abdominal malignancy (Bailey & Love)
• Note: hard, irregular, non-tender = malignancy; soft, tender = infection

Neck Veins (JVP)

• Jugular venous pressure: Raised in cardiac failure, SVC obstruction
• Normal: <4 cm above sternal angle at 45°

Thyroid

• Inspect for swelling (ask patient to swallow - thyroid moves up)
• Palpate: Size, consistency, nodularity, tenderness
• Percuss for retrosternal extension
• Auscultate for bruit (hyperthyroidism)

Carotid Pulses

• Palpate each side separately (never both simultaneously)
• Bruit on auscultation

Trachea

• Position: Central or deviated? (Note - will reassess tracheal position at thorax too)

Neck Movements

• Restriction: Cervical spine pathology, meningism (Kernig's/Brudzinski's)
• Neck stiffness: Meningitis

Cranial Nerves (relevant to neck)

• 7th (facial): Smile, raise eyebrows, close eyes tight, show teeth
• 11th (accessory): Trapezius and sternomastoid power
• 12th (hypoglossal): Tongue protrusion - deviates to side of lesion

5. HANDS AND UPPER LIMBS

Do this BEFORE moving to the chest. The hands contain a wealth of systemic signs.

Nails (examine both hands together)

Palms and Hands

Pulse (Radial)

• Rate: Count for 1 full minute (normal 60-100/min)
• Rhythm: Regular / irregularly irregular (AF) / regularly irregular
• Volume: Full and bounding (sepsis, hyperthyroidism) / thready (shock)
• Character: Collapsing/water-hammer (aortic regurgitation) - feel with forearm elevated
• Radio-radial delay: Aortic coarctation / subclavian artery stenosis
• Radio-femoral delay: Aortic coarctation

Arms

• Power, tone, reflexes: Biceps (C5/6), triceps (C7), supinator (C5/6)
• Sensation: Test in dermatomal pattern
• Axillae: Lymph nodes - central, anterior, posterior groups; skin rash/hidradenitis
• Joints: Elbows, wrists - swelling, tenderness, range of motion
• Blood pressure: Both arms (difference >10 mmHg = vascular/structural cause)

6. THORAX (CHEST)

Inspection

• Type of chest: Barrel (COPD), pigeon (rickets), funnel (pectus excavatum), kyphoscoliosis
• Respiratory rate: Normal 12-18/min - count for 1 minute without patient knowing
• Breathing pattern: Cheyne-Stokes (uraemia, cardiac failure, raised ICP), Kussmaul (metabolic acidosis), abdominal vs. thoracic breathing
• Symmetry of chest movement: Reduced on side of pathology
• Intercostal recession: Severe respiratory distress
• Dilated veins: SVC obstruction (flow upward), IVC obstruction (flow downward)
• Visible pulsations: Apex beat, aortic aneurysm
• Breasts (both sexes): Shape, skin changes, nipple retraction/discharge, asymmetry, scars
• Spine: Kyphosis, scoliosis, gibbus

Palpation

• Tracheal position: Central vs. deviated (to same side = collapse/fibrosis; to opposite = large effusion/pneumothorax)
• Apex beat: Normally 5th intercostal space, mid-clavicular line; displaced outward = cardiomegaly
• Chest expansion: Hands around chest - thumbs meet at midline, should move symmetrically 2-3 cm
• Vocal fremitus: "99" - increased = consolidation; absent/reduced = effusion/pneumothorax
• Tenderness: Rib fractures, Tietze's

Percussion

• Lungs: Resonant (normal) / dull (consolidation, effusion, collapse) / stony dull (effusion) / hyperresonant (pneumothorax)
• Cardiac border: Left border (3rd/4th/5th ICS)
• Liver dullness: Lower right chest (reduced = pneumoperitoneum!)
• Retrosternal thyroid: Dullness over manubrium

Auscultation - Lungs

• Breath sounds: Vesicular (normal) / bronchial (consolidation) / absent (effusion, pneumothorax)
• Added sounds: Crackles (fine = pulmonary oedema/fibrosis; coarse = bronchiectasis), wheeze (obstruction), pleural rub
• Vocal resonance: "99" - increased (consolidation), absent (effusion)

Auscultation - Heart

• Aortic area (2nd right ICS): Aortic stenosis murmur (ejection systolic, radiates to neck)
• Pulmonary area (2nd left ICS): Pulmonary stenosis; splitting of S2
• Tricuspid (lower left sternal border): Tricuspid murmurs
• Mitral (apex - 5th ICS MCL): Mitral stenosis (mid-diastolic, low-pitched rumble), mitral regurgitation (pan-systolic, radiates to axilla)
• Heart sounds: S1, S2; S3 (gallop = cardiac failure); S4 (stiff LV)
• Pericardial rub: Both systolic and diastolic, scratchy, positional

Temperature is recorded here - 37°C normal; >38°C fever; <36°C hypothermia. Record on chart.

7. ABDOMEN

Inspection (patient lying flat, knees/hips can be flexed for palpation)

• Contour: Flat, scaphoid (hollow = starvation), distended (fat/fluid/flatus/foetus/faeces/full bladder)
• Umbilicus: Central/displaced; everted (ascites, large mass); inverted (normal); Sister Mary Joseph's nodule (peritoneal mets)
• Skin: Scars (note location - gives clue to past surgery), striae, dilated veins (caput medusae = portal hypertension; flow away from umbilicus), hernias (ask patient to cough/strain)
• Grey Turner's sign: Bruising of flanks = retroperitoneal haemorrhage (severe pancreatitis, leaking AAA)
• Cullen's sign: Bruising around umbilicus = severe pancreatitis, ruptured ectopic, liver trauma (blood tracks along ligamentum teres)
• Visible peristalsis: Gastric outlet obstruction (left to right), intestinal obstruction (ladder pattern)
• Visible pulsation: Aortic aneurysm (midline pulsation)
• Movement with respiration: Absent chest movement with breathing = peritonitis

Palpation

• Light palpation first: Tenderness, guarding (voluntary vs. involuntary), rigidity (board-like = peritonitis)
• Deep palpation: Organomegaly, masses
• Liver: Start from RIF, move up; measure in cm below costal margin; note edge (smooth/irregular/nodular), surface, tenderness
• Spleen: Start from RIF, palpate toward left costal margin; cannot get above it; moves with respiration; notch on medial border
• Kidneys: Bimanual ballottement (loin to loin); can get above (unlike spleen); moves on respiration
• Bladder: Midline suprapubic mass, dull to percussion
• Aorta: Pulsatile midline mass (expansile = aneurysm)
• Abdominal reflexes: Stroke each quadrant toward umbilicus - absent in UMN lesions
• Rebound tenderness: Press slowly, release quickly; wince = peritoneal irritation (Blumberg's sign)
• Murphy's sign: Arrest of inspiration on palpation RUQ = acute cholecystitis

Percussion

• Liver dullness: Right side, upper and lower borders
• Spleen dullness: Left side
• Shifting dullness: Ascites - dull flanks, tympanic centre; shift when patient turns
• Fluid thrill: Large ascites
• Resonance over bowel

Auscultation

• Bowel sounds: Present/absent (absent = ileus/peritonitis; high-pitched tinkling = obstruction)
• Vascular bruits: Renal artery (laterally, above umbilicus), aortic bruit

Hernial Orifices

• Inguinal (deep and superficial ring): Ask patient to cough - impulse?
• Femoral ring
• Umbilicus
• Previous scars: Incisional hernia

Inguinal Lymph Nodes

• Horizontal group: Drains perineum, anus, external genitalia, lower limb
• Vertical group: Drains lower limb

Genitalia

• Males: Testes (size, consistency, tenderness, transillumination of scrotal swelling), epididymis, spermatic cord, phimosis
• Females: Gynaecological examination if indicated (with chaperone)

Rectal Examination (PR)

• Tone of sphincter, masses, tenderness (boggy = pelvic abscess), prostate (males - size/consistency), cervix/uterus (females), blood on glove
• Never omit in: rectal bleeding, change in bowel habit, pelvic pain, retention of urine

8. LOWER LIMBS

General

• Skin: Colour (pallor, cyanosis, gangrene), hair distribution (absent = arterial disease), varicose veins (tortuous dilated superficial veins), lipodermatosclerosis, venous eczema, pigmentation (haemosiderin)
• Muscle wasting: Thigh and calf comparison (measure circumference)
• Varicose veins: Distribution (long/short saphenous system), Trendelenburg test, cough impulse at saphenofemoral junction

Oedema

• Press firmly over dorsum of foot, medial malleolus, lower shin, then sacrum (if bedridden) for 5 seconds
• Pitting oedema: Pit remains = cardiac failure, hypoalbuminaemia, venous obstruction
• Non-pitting (brawny) oedema: No pit = lymphoedema (filariasis), myxoedema

Pulses - Vascular Assessment

• Femoral pulse: Femoral triangle, below inguinal ligament
• Popliteal pulse: Knee flexed, palpate deep in popliteal fossa with both thumbs
• Posterior tibial: Behind medial malleolus
• Dorsalis pedis: Lateral to extensor hallucis longus tendon on dorsum of foot
• Note: absent pulses → Buerger's test, ankle-brachial pressure index (ABPI)

Neurological

• Power: Hip flexion/extension, knee flexion/extension, ankle dorsi/plantarflexion (L2-S2)
• Tone: Spasticity (UMN) vs. flaccidity (LMN)
• Reflexes: Knee jerk (L3/4), ankle jerk (S1/2), plantar response (Babinski - extensor = UMN)
• Sensation: Light touch, pin-prick, vibration (128 Hz tuning fork on medial malleolus), proprioception (big toe)
• Coordination: Heel-shin test

Joints

• Hips, knees, ankles: Swelling, tenderness, range of movement, crepitus
• Gout: First MTP joint (podagra), tophi

9. BACK AND SPINE (Before asking patient to sit up)

• Spinal curvature: Kyphosis, lordosis, scoliosis
• Vertebral tenderness: Percuss each vertebra with fist - TB spine (gibbus at T12/L1), metastasis
• Paravertebral muscle spasm
• Sacroiliac joints: Press over each SIJ - ankylosing spondylitis
• Costovertebral angle tenderness: Renal disease (punch tenderness)
• Sacral oedema: Check sacral pad for pitting oedema (bedridden patients)

10. COMPLETION

Always end with:

1. Temperature: If not already done
2. Urinalysis: Naked eye and dipstick (colour, sugar, protein, blood, ketones)
3. Specific examination if malignancy suspected (S Das):
   • Chest: Pulmonary metastasis (consolidation, effusion)
   • Liver: Hepatomegaly, nodular
   • Abdomen: Peritoneal metastasis
   • Spine/skull/pelvis/trochanters: Bony tenderness

QUICK REFERENCE CARD

HEAD → EYES → EARS → NOSE → MOUTH/TONGUE/THROAT
↓
NECK → Lymph nodes → JVP → Thyroid → Trachea → Cranial nerves
↓
HANDS → Nails → Palms → Pulse → BP → Arms → Axillae
↓
CHEST → Inspect → Palpate (apex, expansion, tactile fremitus)
      → Percuss → Auscultate (lungs + heart)
      → Breasts + Temperature
↓
ABDOMEN → Inspect → Palpate (light→deep, organs)
         → Percuss → Auscultate
         → Hernial orifices → Inguinal LN → Genitalia → PR
↓
LOWER LIMBS → Skin → Oedema → Pulses → Neuro → Joints
↓
BACK/SPINE → Curvature → Vertebral tenderness → SIJ → Renal angle
↓
COMPLETE → Urinalysis → Document vitals → Provisional diagnosis

• Eyes - lower palpebral conjunctiva for pallor, sclera for jaundice
• Mouth/tongue - the tongue is the single site that distinguishes central from peripheral cyanosis (tongue turns blue only in central)
• Neck - left supraclavicular node (Virchow's/Troisier's) is marked separately as it signals intra-abdominal malignancy
• Wrist - radial pulse site with rate, rhythm, volume and character assessment
• Chest - apex beat, lung fields, heart sound areas all mapped
• Abdomen - Grey Turner's (flanks) and Cullen's (umbilicus) signs are marked at their precise sites
• Ankle/medial malleolus - primary site for pitting oedema in ambulant patients
• Foot - dorsalis pedis and posterior tibial pulses for peripheral vascular assessment