General examination for viva PICCLE
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PICCLE general examination viva pallor icterus cyanosis clubbing lymphadenopathy edema clinical
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General Examination for Viva - PICCLE
PICCLE is a systematic mnemonic for the general physical examination:
P - Pallor | I - Icterus | C - Cyanosis | C - Clubbing | L - Lymphadenopathy | E - Edema
P - Pallor
Definition: Paleness of skin and mucous membranes due to reduced hemoglobin, reduced blood flow, or vasoconstriction.
Sites to examine: Conjunctivae (lower palpebral), palmar creases, nail beds, tongue, buccal mucosa.
Best site: Lower palpebral conjunctiva - pallor here is most reliable.
Grading:
| Grade | Finding |
|---|---|
| + | Mild pallor - conjunctiva only |
| ++ | Moderate - conjunctiva + palmar creases |
| +++ | Severe - conjunctiva + palms + tongue |
Causes:
- Blood loss: GI bleed, trauma, menorrhagia
- Hemolysis: Malaria, sickle cell, autoimmune hemolytic anemia
- Decreased production: Iron deficiency, B12/folate deficiency, aplastic anemia, CKD (reduced erythropoietin), bone marrow infiltration (leukemia, myeloma)
- Hemodilution: Pregnancy, overhydration
Viva tip: Pallor ≠ anemia - pallor is a clinical sign; anemia is confirmed by Hb measurement. A person can look pale without anemia (shock, vasospasm) and can be anemic without visible pallor (dark skin).
I - Icterus (Jaundice)
Definition: Yellow discoloration of sclerae, skin, and mucous membranes due to elevated serum bilirubin (>2.5 mg/dL or >43 µmol/L).
Best site: Sclera under natural daylight. In dark-skinned individuals, examine the mucous membranes under the tongue.
Viva tip from Harrison's: Jaundice is rarely detectable if serum bilirubin is <2.5 mg/dL (43 µmol/L), but may remain detectable below this threshold during recovery due to tissue binding of conjugated bilirubin. - Harrison's Principles of Internal Medicine 22E
Classification:
| Type | Bilirubin | Urine color | Stool color | Causes |
|---|---|---|---|---|
| Pre-hepatic (hemolytic) | Unconjugated ↑ | Normal (pale/dark) | Normal/pale | Malaria, hemolysis, sickle cell |
| Hepatic (hepatocellular) | Both ↑ | Dark (conjugated in urine) | Pale | Hepatitis, cirrhosis, drugs |
| Post-hepatic (obstructive) | Conjugated ↑ | Dark (tea-colored) | Clay/pale | Gallstones, cholangiocarcinoma, pancreatic Ca, CBD stricture |
Signs accompanying jaundice:
- Pruritus (cholestasis - bile salts in skin)
- Pale stools + dark urine = obstructive
- Splenomegaly = hemolytic or hepatic
- Spider angiomata, palmar erythema = hepatocellular
C - Cyanosis
Definition: Bluish discoloration of skin/mucous membranes due to >5 g/dL of deoxyhemoglobin in capillary blood (not applicable in severe anemia - may not be detectable).
Types:
| Feature | Central Cyanosis | Peripheral Cyanosis |
|---|---|---|
| Site | Tongue, lips, buccal mucosa | Fingertips, toes, earlobes |
| Cause | Cardiorespiratory disease | Reduced blood flow/vasoconstriction |
| Tongue | Cyanosed | Normal |
| Oxygen test | Does NOT improve with O2 (if shunt) | Improves with O2 or warming |
| Common causes | CHD (R-to-L shunt), severe pneumonia, ARDS, pulmonary hypertension, high altitude | Heart failure, Raynaud's, shock, cold exposure |
- Barash Clinical Anesthesia: Peripheral cyanosis in fingers/toes should be distinguished from acrocyanosis; central cyanosis in buccal mucosa is usually secondary to arterial hypoxemia.
Special types:
- Differential cyanosis (cyanosis of feet but not hands): patent ductus arteriosus with pulmonary hypertension
- Reverse differential cyanosis (hands cyanosed, feet pink): transposition of great arteries with PDA
C - Clubbing
Definition: Bulbous enlargement of the terminal phalanges due to proliferation of connective tissue, associated with increased vascularity and edema.
Signs:
- Loss of nail fold angle (Lovibond's angle - normally <165°)
- Fluctuation of nail bed (spongy feel)
- Positive Schamroth's window test (diamond-shaped gap disappears when dorsal surfaces of two thumbs are apposed)
- Drumstick appearance of fingers
Grades (Schamroth / Clubbing Grading):
| Grade | Feature |
|---|---|
| 1 | Softening/fluctuation of nail bed |
| 2 | Obliteration of Lovibond's angle (hyponychial angle >180°) |
| 3 | Beaking/parrot-beak appearance, increased AP diameter of fingertip |
| 4 | Drumstick appearance |
| 5 | Periosteal new bone formation (hypertrophic pulmonary osteoarthropathy - HPOA) |
Causes - Mnemonic "ABCDE":
| System | Causes |
|---|---|
| Respiratory | Lung cancer (most common cause of unilateral), bronchiectasis, empyema, cystic fibrosis, pulmonary fibrosis, mesothelioma |
| Cardiac | Cyanotic congenital heart disease, infective endocarditis |
| GI/Hepatic | Cirrhosis, Crohn's disease, ulcerative colitis, celiac disease |
| Endocrine | Thyroid acropachy (thyrotoxicosis) |
| Congenital | Hereditary/familial (autosomal dominant, benign) |
| Unilateral | Arteriovenous fistula, subclavian artery aneurysm, Pancoast tumor (ipsilateral) |
| Pseudo-clubbing | Pachydermoperiostosis, acromegaly |
NOT a cause of clubbing: TB (uncomplicated), asthma, COPD, simple pneumonia.
L - Lymphadenopathy
Definition: Enlargement of lymph nodes (>1 cm in most regions; >1.5 cm in inguinal).
Examination: Palpate all nodal groups - cervical (anterior + posterior), submandibular, submental, supraclavicular, axillary, epitrochlear, inguinal, popliteal.
Key clinical sign: Virchow's node = left supraclavicular lymphadenopathy - classically suggests intra-abdominal malignancy (Troisier's sign). - Bailey & Love's Surgery, 28e
Character of nodes:
| Feature | Suggests |
|---|---|
| Soft, tender, fluctuant | Acute infection/abscess |
| Firm, rubbery, non-tender | Lymphoma |
| Hard, fixed, matted | Metastatic carcinoma |
| Matted, "bag of worms" | TB lymphadenitis (can suppurate/collar-stud abscess) |
Distribution:
- Localized: Look for a local cause in the drainage area
- Generalized: Lymphoma, leukemia, HIV, infectious mononucleosis, SLE, sarcoidosis, drugs (phenytoin)
Harrison's: Lymph nodes should be evaluated in multiple regions: popliteal, inguinal, epitrochlear, axillary, multiple cervical regions, with notation of size, consistency, mobility, and tenderness. - Harrison's 22E
E - Edema
Definition: Abnormal accumulation of interstitial fluid.
Types:
| Type | Feature | Causes |
|---|---|---|
| Pitting edema | Finger pressure leaves a pit | Cardiac failure, hypoalbuminemia (nephrotic, cirrhosis, malnutrition), CKD, drugs (CCBs) |
| Non-pitting edema | No pitting | Lymphedema, myxedema (hypothyroidism) |
Grading of pitting edema:
| Grade | Pit depth | Recovery time |
|---|---|---|
| 1+ | 2 mm | Rapid (<5 sec) |
| 2+ | 4 mm | <15 sec |
| 3+ | 6 mm | 15-30 sec |
| 4+ | 8 mm | >30 sec |
Examination sequence: Start at ankles/dorsum of foot. If edema present, go up to determine upper limit (tibial, pretibial, up to knee, up to thigh, sacral in bedridden, ascites = anasarca).
Causes by mechanism:
| Mechanism | Cause |
|---|---|
| ↑ Hydrostatic pressure | Right heart failure, venous obstruction, portal hypertension |
| ↓ Oncotic pressure | Nephrotic syndrome, cirrhosis, malnutrition (kwashiorkor), protein-losing enteropathy |
| ↑ Capillary permeability | Sepsis, burns, anaphylaxis, ARDS |
| Lymphatic obstruction | Malignancy, filariasis, post-surgery/radiation |
| Na+/water retention | CKD, Cushing's, drugs (NSAIDs, CCBs, corticosteroids) |
Anasarca: Generalized edema involving subcutaneous tissue throughout the body (face, extremities, trunk). Suggests severe hypoalbuminemia or severe right heart failure.
Quick Viva Summary Table
| Sign | Key Site | Threshold | Best Single Cause to Remember |
|---|---|---|---|
| Pallor | Lower palpebral conjunctiva | Hb <10 g/dL (visible) | Iron deficiency anemia |
| Icterus | Sclera (natural light) | Bilirubin >2.5 mg/dL | Hepatitis / CBD stone |
| Cyanosis | Tongue (central) | >5 g/dL deoxy-Hb | Cyanotic CHD / ARDS |
| Clubbing | Nail bed, Schamroth test | Grade 1 = nail bed spongy | Lung Ca / Bronchiectasis |
| Lymphadenopathy | All nodal groups | >1 cm | Lymphoma / metastasis |
| Edema | Ankles, sacrum | Pitting = fluid | Right heart failure / Nephrotic |
Sources: Harrison's Principles of Internal Medicine 22E; Bailey & Love's Short Practice of Surgery 28e; Barash Clinical Anesthesia 9e; Goldman-Cecil Medicine; Rosen's Emergency Medicine.
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