Structured general examination with mnemonic
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general examination clinical mnemonic structured approach JACCOL PPPACC
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general examination mnemonic "PICCLE" OR "CLIP" OR "built nourishment" pallor icterus cyanosis clubbing lymphadenopathy edema clinical medicine
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Structured General Examination with Mnemonics
The general examination (also called "general survey") is the first part of any clinical physical examination. It gives an overview of the patient's overall state before system-specific examination begins.
The Primary Mnemonic: PICCLE
P - I - C - C - L - E
| Letter | Parameter |
|---|---|
| P | Pallor |
| I | Icterus (Jaundice) |
| C | Cyanosis |
| C | Clubbing |
| L | Lymphadenopathy |
| E | Edema |
(A variant is PICCKLE which adds K for Koilonychia)
Broader Mnemonic for the Complete General Examination: "BAN MaGic FaT PPVD"
Many textbooks organize the full general examination under the following headings:
Full Structured Breakdown
1. GENERAL APPEARANCE (First Impression)
- Built - Tall/short, obese/thin, proportionate
- Nourishment - Well-nourished, malnourished, cachectic
- Decubitus / Attitude - How is the patient lying? (still in peritonitis, restless in colic)
- Facies - Characteristic face (myxoedema facies, Cushingoid, acromegalic, Parkinsonian)
- Gait - If ambulatory (waddling, Trendelenburg, antalgic, scissors)
- Mental state / Consciousness - GCS, orientation (time, space, person)
2. PICCLE - The Core Signs
P - Pallor
- Look at: conjunctivae, tongue, palmar creases, nail beds
- Grading: Mild / Moderate / Severe
- Causes: Iron deficiency, B12/folate deficiency, haemolysis, chronic disease, blood loss
I - Icterus (Jaundice)
- Look at: sclera first (earliest sign), skin, sublingual mucosa
- Best assessed in daylight (artificial light can miss faint yellow tinge - S Das)
- Grading: Mild / Moderate / Deep jaundice
- Types: Pre-hepatic, Hepatic, Post-hepatic (obstructive)
C - Cyanosis
- Central - Tongue + lips (low SaO2, lung/heart disease, reduced diffusion)
- Peripheral - Extremities only (poor perfusion, cold, Raynaud's)
- Look at: tongue, lips, fingertips, nail beds
C - Clubbing
| Grade | Feature |
|---|---|
| Grade 1 | Softening/sponginess of the nail bed |
| Grade 2 | Obliteration of the Lovibond angle (nail fold angle >180°) |
| Grade 3 | Parrot-beak / drumstick deformity |
| Grade 4 | Hypertrophic pulmonary osteoarthropathy (HPOA) - periostitis of long bones |
- Causes: 3C3R - Congenital heart disease, Chronic lung disease (e.g. bronchiectasis, empyema), Cirrhosis; Crohn's, Cancer (GI), Celiac
L - Lymphadenopathy
- Examine: cervical (anterior/posterior), submandibular, axillary, inguinal, epitrochlear
- Note: Size, consistency (soft/firm/hard/matted), tenderness, mobility
- Hard, non-tender, matted = malignancy; Tender, soft = reactive/infective
E - Edema
- Look at: feet, ankles, sacrum (bedridden), periorbital
- Pitting vs Non-pitting edema
- Grading: +1 to +4 pitting scale
- Causes: CCF, hypoalbuminaemia, nephrotic, venous obstruction, lymphoedema
3. VITAL SIGNS
A simple mnemonic: "TPRB" (or "BP TROP")
| Parameter | Normal Range |
|---|---|
| T - Temperature | 36.5-37.5°C (oral); axilla ~1°F lower |
| P - Pulse | Rate, rhythm, volume, character, vessel wall condition |
| R - Respiration | Rate, depth, pattern (Cheyne-Stokes, Kussmaul) |
| B - Blood Pressure | Both arms; postural drop if indicated |
| SpO2 | Oxygen saturation |
| BMI | Weight/Height² in elective settings |
4. SKIN & NAILS (Additional findings)
- Pigmentation - Addison's (buccal mucosa), haemochromatosis
- Rashes / Eruptions - Note distribution
- Skin turgor / Dehydration - Tenting of skin, dry tongue, sunken eyes
- Koilonychia - Spoon-shaped nails (iron deficiency)
- Leukonychia - White nails (hypoalbuminaemia)
- Splinter haemorrhages - Infective endocarditis
5. OTHER SYSTEMS OVERVIEW (Quick Scan)
| System | Quick Check |
|---|---|
| Head & Neck | Thyroid, JVP, carotid bruits, trachea position |
| Hands | Clubbing, tremor, signs of liver disease (palmar erythema, leuconychia, Dupuytren's) |
| Eyes | Icterus (sclera), anaemia (conjunctiva), exophthalmos, Horner's |
| Mouth | Dentition, pyorrhoea, glossitis, angular stomatitis |
Summary Mnemonic Card
General Examination = "G-PICCLE VTS"
G = General appearance (built, nutrition, attitude, facies, gait, consciousness)
P = Pallor
I = Icterus
C = Cyanosis
C = Clubbing
L = Lymphadenopathy
E = Edema
V = Vital signs (T, P, R, BP, SpO2)
T = Temperature
S = Skin / special signs (koilonychia, dehydration, pigmentation)
Key Examination Tips (from S Das, Bailey & Love)
- Always examine in daylight - artificial light masks faint jaundice - S Das, Manual on Clinical Surgery
- Ask the patient to undress fully (gown covering only) for complete examination
- Start observation the moment the patient enters the room (gait, distress, dyspnoea)
- In severely ill patients, rapidly focus on key findings that guide immediate treatment rather than a complete survey
- Record weight and BMI in all elective patients - Bailey & Love's, p. 1076
Sources: S Das - A Manual on Clinical Surgery (13th Ed.) | Bailey & Love's Short Practice of Surgery (28th Ed.) | PICCLE clinical framework (standard undergraduate teaching)
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