---

Definition of Significant (Unintentional) Weight Loss

Core Definition

• Harrison's Principles of Internal Medicine (22nd ed., 2025): "Clinically important weight loss is defined as the loss of >5% of body weight over a period of 6-12 months."
• Symptom to Diagnosis (4th ed.): "Significant unintentional weight loss is defined as >5% loss of usual body weight in the last 6-12 months."
• Merck Manual: "Weight loss is typically considered clinically important if it exceeds 5% of body weight or 5 kg over 6 months."
• Mayo Clinic Proceedings: ">10 lb (4.5 kg) or more than 5% of usual body weight over 6-12 months."

---

Severity Grading (AND/A.S.P.E.N. Malnutrition Criteria)

---

Additional Thresholds in Context

---

Key Clinical Notes

• Documentation matters: Up to 25-50% of patients who report weight loss have not actually lost weight. Always verify with prior weight records, clothing/belt size change, or corroborating history from family. - Symptom to Diagnosis, p. 9984
• Obesity can mask loss: Significant loss of lean body mass may be hidden in patients with preexisting obesity or edema (e.g., heart failure, CKD). - Merck Manual
• Frailty syndrome: In the elderly, unintentional weight loss is one of five components of frailty (alongside weakness, slowness, low activity, and exhaustion) - it carries significantly increased morbidity and mortality. - Symptom to Diagnosis, p. 9975
• Mortality risk: Significant weight loss is associated with increased all-cause mortality within 1-2 years. - Harrison's, p. 1387
• Cause matters for prognosis: No identifiable cause is found in up to 25% of cases; these patients generally have a better prognosis than those with a known cause, particularly malignancy.

---

General Physical Examination of a Surgical Patient

---

Structure of Physical Examination

1. General Survey - overall systemic assessment
2. Local Examination - examination of the affected part/region
3. General Examination - head-to-toe systemic examination (for diagnosis, anaesthetic fitness, and metastasis)

---

A. General Survey

"Physical examination starts when the patient enters the clinic." - S. Das, p. 9

1. General Assessment of Illness

• Assess severity immediately on first contact
• In severely ill patients, focus on rapid diagnosis to institute prompt treatment
• Never waste time on less important findings when the patient is critical

2. Mental State and Level of Consciousness

3. Build and State of Nutrition

• Note cachectic appearance (suggests malignancy of GI tract)
• Endocrine abnormalities may be obvious from build (e.g., Cushing's, acromegaly)
• Obesity increases anaesthetic and surgical risk

4. Attitude (Position/Posture)

• Peritonitis: patient lies still, afraid to move
• Colic (biliary/ureteric/intestinal): patient is restless, tosses on the bed
• Meningitis: neck retraction and rigidity
• Fractured neck of femur: helpless posture with externally rotated, shortened limb

5. Gait

• Pain, bone/joint abnormalities, muscle/neurological disease, structural abnormalities, psychiatric disease
• Waddling gait: bilateral CDH, bilateral coxa vara
• Trendelenburg gait: muscle dystrophy, polio, unilateral coxa vara, Perthes' disease, hip arthritis

6. Facies

• Facies hippocratica: generalized peritonitis (sunken eyes, pinched nose, cold sweaty skin)
• Risus sardonicus: tetanus
• Mask face: Parkinsonism
• Moon face: Cushing's syndrome
• Adenoid facies: hypertrophied adenoids

7. Decubitus (Position in Bed)

• In cerebral irritation: patient lies curled up on his side, away from light

---

B. Colour of the Skin (PICLE Mnemonic)

Pallor

• Seen in: massive haemorrhage, shock, anaemia, intense emotion
• Look at: lower palpebral conjunctiva, lips/cheeks mucosa, nail beds, palmar creases

Cyanosis

• Defined: bluish/purplish tinge from >5 g/dL reduced haemoglobin in skin vessels
• Central cyanosis: reduced arterial O₂ saturation - look at tongue, lips
• Peripheral cyanosis: poor perfusion - look at fingertips, nail beds
• Note: cyanosis is not detectable in severe anaemia (insufficient Hb)

Jaundice

• Yellow discolouration of skin and sclera due to raised bilirubin
• Best seen in natural daylight (artificial light may miss faint jaundice)
• Look at: sclera (earliest), mucous membranes, skin
• Types to differentiate: pre-hepatic, hepatic, post-hepatic (obstructive - surgical jaundice)

Icterus (Jaundice of Sclera)

• Detectable when bilirubin >2 mg/dL

Skin Colour Changes

• Vitiligo, pigmentation changes, petechiae, ecchymosis, spider naevi

---

C. Vital Signs

• Continued: fluctuation <1°C, never touches normal
• Remittent: daily fluctuation >2°C
• Intermittent: fever for only a few hours - quotidian (daily), tertian (alternate day), quartan (every 3 days)

Pulse Assessment

• Rate: counted for 1 full minute
• Rhythm: regular or irregular
• Volume: full/bounding (sepsis, hyperthyroidism) or low (shock, cardiac failure)
• Character: water-hammer pulse (aortic regurgitation), plateau pulse (aortic stenosis)
• Radio-femoral delay: coarctation of aorta

---

D. Hands (Peripheral Signs)

• Clubbing: lung cancer, empyema, liver cirrhosis, IBD, cyanotic heart disease
• Koilonychia (spoon nails): iron deficiency anaemia
• Leuconychia: hypoalbuminaemia (chronic liver disease, malnutrition)
• Palmar erythema: chronic liver disease
• Dupuytren's contracture: liver cirrhosis, epilepsy (phenytoin)
• Tremor: liver failure (flapping tremor), thyrotoxicosis
• Spider naevi on dorsum of hand: liver disease

---

E. Head and Neck

• Eyes: anaemia (conjunctival pallor), jaundice (scleral icterus), Horner's syndrome (ptosis, miosis, anhidrosis - Pancoast tumour, carotid dissection)
• Oral cavity: mucosal pallor, ulcers, dentition (anaesthetic risk), leukoplakia
• Neck lymph nodes: particularly the left supraclavicular (Virchow's node / Troisier's sign) - suggests intra-abdominal or thoracic malignancy
• JVP: raised in cardiac failure, SVC obstruction
• Thyroid: enlarge, nodular - surgical thyroid disease

---

F. General Examination (Systemic)

Lymph Nodes

• Cervical (anterior, posterior, submandibular, supraclavicular)
• Axillary
• Inguinal
• For each node note: size, shape, consistency (soft/firm/hard), tenderness, fixity to skin or deep structures, matting

Oedema

• Pitting oedema of feet/ankles: cardiac failure, hypoalbuminaemia, deep venous obstruction
• Non-pitting: lymphoedema, myxoedema
• Assess: pitting (press for 30 seconds), distribution, bilateral vs unilateral

Dehydration

• Look at: skin turgor (pinch test), sunken eyes, dry tongue, dry mucous membranes, decreased urine output
• Surgical significance: must be corrected before elective surgery

---

G. Purposes of General Examination (S. Das Classification)

1. For diagnosis and differential diagnosis - e.g., examine knee and ankle jerks + Argyll Robertson pupil in retention of urine to diagnose tabes dorsalis; examine scrotum in RIF pain to exclude torsion testis
2. For anaesthetic fitness - cardiovascular and respiratory status must be assessed
3. For detection of metastasis - in malignant swellings: chest (lung mets), liver (hepatic mets), abdomen (peritoneal mets), spine/pelvis/skull (bony mets)
4. For associated conditions - e.g., in syphilitic swelling, look for other syphilitic stigmata; in TB ulcer, examine all lymph node groups

---

H. Systematic Organ Examination (Where Relevant)

Cardiovascular

• Precordial examination, heart sounds, murmurs
• Peripheral pulses - for vascular disease assessment
• JVP - for fluid status

Respiratory

• Chest expansion, tracheal position
• Percussion, auscultation for consolidation/effusion (lung metastasis, aspiration risk)

Abdomen

• Inspection (scars, distension, visible peristalsis, dilated veins)
• Palpation (organomegaly, masses, tenderness, guarding, rigidity)
• Percussion (ascites - shifting dullness, fluid thrill)
• Auscultation (bowel sounds)
• Per rectum examination is mandatory in all surgical abdominal cases
• Bailey & Love: "In the elective setting the patient's weight and body mass index are also recorded." - p. 1076

Genitalia and Hernial Orifices

• Never miss examining hernial orifices in a patient with intestinal obstruction
• Scrotum/testis in RIF pain (torsion testis can mimic appendicitis)

---

Summary Mnemonic: "GETS HELP + LOCAL"

---

---

Complete Abdominal Examination in Surgery

---

Prerequisites / Patient Positioning

• Patient lies flat on back (supine), arms by the side, legs extended, head on one pillow
• For palpation: hips and knees are flexed to relax the abdominal muscles
• Expose from nipples to saphenous openings (groin) - so that inguinal and femoral rings are fully visible
• Examine in good light, preferably natural daylight
• Warm hands before palpation
• Always examine from the right side of the patient
• Gain patient's confidence; ask them to point to the site of pain first, and start palpation furthest from pain

---

Surface Anatomy: Nine Regions of the Abdomen

• Upper horizontal = Transpyloric line (midway between xiphisternum and umbilicus)
• Lower horizontal = Transtubercular line (level of iliac tubercles, ~2 inches behind ASIS)
• Vertical lines through mid-inguinal points bilaterally

---

I. INSPECTION

1. Hernial Orifices (FIRST - never miss)

• Examine inguinal, femoral, umbilical, and other hernial sites first
• Ask patient to cough - a cough impulse = hernia
• Irreducible/strangulated hernias are a common cause of acute abdomen

2. Contour of the Abdomen

• Central distension = small bowel obstruction
• Peripheral distension = large bowel obstruction
• Distension in volvulus appears immediately
• In peritonitis, the abdomen may look scaphoid due to protective muscle contraction

3. Movement with Respiration

• Normal: abdominal wall moves freely with breathing
• Absent/sluggish = diffuse peritoneal irritation (perforation, haemorrhage into peritoneum)
• Localized restriction = underlying inflammation (acute cholecystitis RUQ, appendicitis RIF)

4. Skin of Abdomen

• Grey Turner's sign: bruising/discolouration of flanks = retroperitoneal haemorrhage (acute haemorrhagic pancreatitis, leaking AAA)
• Cullen's sign: bluish discolouration around umbilicus = periumbilical haemorrhage (acute pancreatitis, ruptured ectopic pregnancy, liver trauma). Blood tracks via ligamentum teres.
• Caput medusae: dilated veins radiating from umbilicus = portal hypertension
• Dilated veins: direction of flow differentiates portal hypertension (flow away from umbilicus) vs SVC/IVC obstruction
• Redness, blisters at site of pain = patient has been applying hot packs
• Striae (stretch marks), surgical scars, pigmentation

5. Scars from Previous Surgery

• Midline laparotomy, Kocher's incision (RUQ - for cholecystectomy), McBurney's (RIF - appendix), Pfannenstiel (suprapubic - gynaecological), loin (renal)

6. Visible Peristalsis

• Watch patiently for peristaltic waves
• "Ladder pattern" = small bowel obstruction
• Left-to-right wave = pyloric obstruction (carcinoma/pyloric stenosis)
• Right-to-left wave = transverse colon obstruction
• Best seen in thin patients

7. Pulsations

• Visible epigastric pulsation = abdominal aortic aneurysm (leaking AAA presents with acute abdominal pain)

8. Umbilicus

• Position: normally central and slightly inverted
• Everted = ascites, large intra-abdominal mass, obesity
• Displaced upward = pelvic mass
• Displaced downward = liver/upper abdominal mass
• Sister Mary Joseph's nodule: hard nodule at umbilicus = metastatic intra-abdominal malignancy

9. Scrotum (routine)

• Malignancy of testis may metastasize to para-aortic lymph nodes producing a retroperitoneal mass
• Strangulated hernias visible in scrotum

---

II. PALPATION

Technique

• Hands must be warm
• Volar (flexor) surfaces of fingers are used - never the fingertips to poke
• Forearm horizontal at level of abdomen, whole palm lightly placed, movement at MCP joints only (never interphalangeal)
• Begin away from site of pain and proceed toward it
• Watch patient's face for signs of discomfort throughout
• Start with superficial palpation, proceed to deep palpation
• Ask patient to breathe through open mouth to help relax muscles

A. Superficial Palpation

Muscle Guard (Rigidity)

• Involuntary muscle rigidity (true guarding) = underlying parietal peritonitis - the key finding
• Voluntary rigidity = patient tenses due to fear; disappears on expiration and when patient's confidence is gained
• To differentiate: use two-handed technique - one hand feels muscle tone, the other applies gentle steady pressure

• In thoracic disease mimicking rigidity: rigidity diminishes on expiration; in peptic perforation, rigidity persists throughout respiration

Tenderness

• Ask patient to point to site of pain first (Pointing test)
• Maximum tenderness = site of diseased viscus
• McBurney's point: junction of lateral 1/3 and medial 2/3 of right spino-umbilical line (ASIS to umbilicus) - acute appendicitis
• Murphy's point: tip of 9th costal cartilage on lateral margin of right rectus - acute cholecystitis
• Boas's sign: hyperaesthesia/tenderness behind right shoulder tip (referred pain) - acute cholecystitis
• Spread of tenderness: e.g., in appendicitis if LIF is also tender = spreading peritonitis - demands immediate surgery

Rebound Tenderness (Blumberg's Sign)

• Press firmly, hold, then suddenly release hand - pain on release = peritoneal irritation
• Gentler alternative: percussion tenderness (same information, less distressing)
• Also: ask patient to cough - sudden twinge = peritoneal irritation
• Bed-shaking test (Bapat): gently shake foot-end of bed - pain at site of inflamed organ = early peritonitis

B. Deep Palpation - Organ Examination

Liver

• Start palpation from right iliac fossa, move upward toward right costal margin with each expiration
• Normal liver not palpable (or just felt in thin people)
• Enlarged liver: note - lower border, surface (smooth vs nodular), consistency (soft/firm/hard), tenderness, pulsatility
• Moves well with respiration (distinguishes from retroperitoneal mass)
• Percussion of upper border: normally at 5th intercostal space (right midclavicular line)
• Liver span = distance between upper and lower borders (normal ~12-13 cm)
• Surgical causes of hepatomegaly: metastases (hard, nodular), hepatocellular carcinoma, hydatid cyst, liver abscess, hepatitis

Gallbladder

• Normally not palpable
• Palpable gallbladder: acute cholecystitis (tender), mucocele, empyema, carcinoma
• Courvoisier's Law: a palpable, non-tender gallbladder + jaundice = obstructive jaundice due to carcinoma of the head of pancreas (NOT gallstones, because gallstones cause a fibrotic contracted gallbladder)
• Murphy's Sign: patient takes deep breath while examiner presses below right costal margin at MCL; sudden arrest of inspiration due to pain = positive = acute cholecystitis

Spleen

• Start from right iliac fossa, move toward left costal margin
• Enlarges toward the RIF along a line from left 9th rib to RIF
• Has a notch on its medial border (pathognomonic)
• Moves with respiration
• Cannot get above it (distinguishes from left renal mass)
• Not bimanually ballottable (distinguishes from kidney)
• Dull to percussion (no resonant band of colon above it)
• Surgical causes: portal hypertension, lymphoma, tropical splenomegaly, haemolytic anaemia

Kidneys (Bimanual Ballottement)

• Bimanual palpation: one hand behind in the loin (renal angle), one hand on anterior abdomen
• A palpating push from behind causes the kidney to be ballottable (felt to bounce against anterior hand)
• Kidneys move slightly with respiration (unlike liver/spleen which move well)
• Can get above an enlarged kidney (cannot get above spleen)
• Band of resonance over the kidney (colon loops in front) - differentiates from spleen
• Renal angle tenderness: CVA (costovertebral angle) tenderness on fist percussion = renal pathology (pyelonephritis, calculus, hydronephrosis)

Urinary Bladder

• Palpated in hypogastrium as a smooth, rounded, centrally placed dull mass
• A distended bladder dull to percussion from pubis upward

Abdominal Mass (If Present - SITE SMTCC)

1. Site (which region)
2. Size (in cm, 3 dimensions)
3. Shape (regular/irregular, margins)
4. Surface (smooth, nodular, bosselated)
5. Consistency (soft, firm, hard, fluctuant, cystic)
6. Tenderness
7. Mobility / Fixity - to skin, to underlying structures, on respiration
8. Pulsatility - expansile (AAA) vs transmitted pulsation
9. Resonance (bowel loops over surface = resonant)
10. Insinuation (ability to get fingers above mass - helps determine origin)

---

III. PERCUSSION

• Dull note: solid organs (liver, spleen), masses, full bladder, ascites, faeces
• Resonant note: gas-filled bowel loops
• Tympanitic: excessively gas-filled bowel (obstruction, paralytic ileus)

Specific Percussion Signs

• Upper border of liver dullness: normally 5th ICS right MCL
• Loss of liver dullness (resonance where dullness expected) = gas under diaphragm = hollow viscus perforation (perforated peptic ulcer). Percuss in right midaxillary line, ~3 inches above costal margin.

• Traube's space (6th-10th rib, left midaxillary line) - normally resonant (stomach/colon)
• Dullness of Traube's space = splenomegaly

• In supine position, percuss from umbilicus outward to flank - note where it becomes dull
• Keep finger at that point, ask patient to turn to that side - wait 30 seconds
• The dull note shifts to resonant (fluid shifts away) = shifting dullness = ascites
• Requires minimum 500 mL of fluid to be detected

• For massive ascites
• Assistant places edge of hand firmly on midline (blocks transmission through fat)
• Examiner taps one flank - other hand on opposite flank feels a fluid thrill
• Requires at least 2-3 litres of fluid

• Dullness above symphysis pubis = full bladder or pelvic mass

---

IV. AUSCULTATION

"A student should be familiar with normal peristaltic sounds by studying them in healthy abdomen first." - S. Das, p. 466

• Auscultate before palpation (palpation stimulates bowel sounds)
• Apply stethoscope gently for at least 30 seconds (listen for bowel sounds)

---

V. SPECIAL TESTS

---

VI. PER RECTAL (PR) EXAMINATION

"No examination of an acute abdominal case is complete without the digital examination of the rectum." - S. Das, p. 466

Indications

• Mandatory in all acute abdominal cases
• All cases of GI bleeding, change in bowel habit, suspected pelvic/rectal pathology

Technique

• Left lateral position (or knee-chest / dorsal lithotomy for females)
• Inspect perianal area first: fissure, fistula, haemorrhoids, tags, excoriation
• Lubricate gloved finger and insert gently

Findings and Significance

---

VII. PER VAGINAL (PV) EXAMINATION (in females)

• Purulent discharge + bilateral fornix tenderness = acute salpingitis / PID
• Cervical excitation (cervical motion tenderness): any movement of cervix initiates severe pain = ruptured ectopic pregnancy or pelvic peritonitis
• Soft cervix = ruptured ectopic gestation
• Mass in fornix = ovarian cyst, tubo-ovarian abscess, ectopic pregnancy

---

VIII. EXTRA-ABDOMINAL EXAMINATION (When Abdominal Findings are Insufficient)

1. Chest - Basal pleurisy/pneumonia can cause referred upper abdominal pain
2. Spine - Pott's disease (TB spine) causes abdominal pain
3. Hip - Psoas abscess from Pott's disease may present as RIF swelling
4. Genitalia - Torsion testis mimics acute appendicitis (RIF pain in teenage boys)
5. Nervous system - Examine knee/ankle jerks, Argyll Robertson pupil - Tabes dorsalis (gastric crisis)

---

Summary: Complete Abdominal Examination Sequence

Expose: Nipples → Groin
Position: Supine (palpation: flex knees)

1. INSPECTION
   → Hernial orifices (FIRST)
   → Contour, distension
   → Respiratory movement
   → Skin signs (Grey Turner, Cullen, caput medusae, scars)
   → Visible peristalsis
   → Pulsations, umbilicus

2. PALPATION
   → Superficial (all 9 regions, away from pain first)
   → Tenderness, guarding, rigidity
   → Rebound tenderness
   → Deep palpation: Liver → Gallbladder → Spleen → Kidneys → Bladder → Masses

3. PERCUSSION
   → Liver dullness (upper and lower borders)
   → Splenic dullness (Traube's space)
   → Shifting dullness (ascites)
   → Free gas under diaphragm (loss of liver dullness)

4. AUSCULTATION
   → Bowel sounds (silent vs metallic tinkling)
   → Succussion splash
   → Vascular bruits

5. SPECIAL TESTS (as indicated)
   → Murphy's, Rovsing's, Psoas, Obturator, etc.

6. PER RECTAL (MANDATORY in acute abdomen)
   → Inspect perianal area
   → Digital rectal examination

7. PER VAGINAL (in females)

8. EXTRA-ABDOMINAL (chest, spine, hernial orifices, genitalia, CNS)