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General Examination - Macleod's Clinical Examination (Chapter 3)

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General Principles of Physical Examination

Preparing for the Examination

• Wash hands before and after every examination.
• Explain what you are going to do and obtain consent.
• Ensure adequate privacy and good lighting.
• A chaperone is always appropriate for intimate examinations (breast, genital, rectal), when the patient is especially anxious or vulnerable, when there have been past misunderstandings, or when religious/cultural factors apply - regardless of whether the clinician is the same gender as the patient.
• The patient should be appropriately undressed and positioned.

Sequence for Performing a Physical Examination

1. Initial observations (even before touching the patient)
2. Gait and posture
3. Facial expression and speech
4. Hands
5. Skin
6. Tongue
7. Odours
8. Body habitus and nutrition (weight, stature, hydration)
9. Lumps and lymph nodes
10. Spot diagnoses

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1. Initial Observations

• Do they look unwell, frightened or distressed?
• Are there signs of breathlessness or cyanosis?
• Is the patient overweight or cachectic?
• Note mental state: anxious, confused, distressed.
• Note physical appearance: frail, drowsy, in pain.
• Abnormal smells: ketones (diabetic ketoacidosis), alcohol, uraemia (fishy/ammoniacal), fetor hepaticus (sweet/musty - hepatic failure).
• Note skin abnormalities visible at a distance: jaundice, pallor, cyanosis, rashes.

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2. Gait and Posture

• Posture: kyphosis, scoliosis, stooped posture (depression, Parkinson's), rigid upright posture.

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3. Facial Expression and Speech

• The face can reveal physical and psychological wellbeing before any hands-on examination.
• Reluctance to engage may signal depression, anxiety, fear, anger, or grief.
• Some patients conceal depression or anxiety with inappropriate cheerfulness.
• Illness alters demeanour: frontal lobe disease or bipolar disorder may produce animated disinhibition; depression or Parkinson's disease causes poverty of expression (hypomimia).

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4. Hands

"Looking at the hands is a gentle, non-threatening way to begin the examination, which can yield a wealth of diagnostic clues." - Macleod's

• Inspect the dorsal then palmar aspects of both hands.
• Note changes in: skin, nails, soft tissues, tendons, joints.
• Look for evidence of muscle wasting.

Nails

Skin of the Hands

Temperature and Perfusion

• Hands normally feel dry and warm at ambient temperature.
• Normal capillary refill time: 2 seconds or less.
• Cool extremities and prolonged capillary refill time = impaired peripheral perfusion.

Size and Soft Tissue

• Large, broad, fleshy hands = Acromegaly.
• Thickened soft tissues = Myxoedema (hypothyroidism).
• Localised oedema of hand/arm = venous obstruction, lymphatic blockage, or disuse from paresis.

Joints

• Inspect for swelling, deformity, subluxation (rheumatoid arthritis, osteoarthritis, gout).

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5. Skin

• Cyanosis: central (lips/tongue - cardiorespiratory) vs. peripheral (hands/feet - poor perfusion).
• Jaundice: yellow discolouration - sclera first affected (bilirubin > ~35 µmol/L).
• Pallor: anaemia, shock, vasoconstriction.
• Pigmentation: Addison's disease (buccal mucosa, creases, scars), haemochromatosis.
• Purpura/petechiae: thrombocytopenia, vasculitis, meningococcaemia, scurvy.
• Spider naevi: >5 in the distribution of the superior vena cava = chronic liver disease.
• Xanthelasma/xanthomata: hyperlipidaemia.
• Neurofibromatosis: café-au-lait spots, multiple neurofibromas.
• Vitiligo: autoimmune conditions (thyroid disease, Addison's, pernicious anaemia, T1DM).
• Signs of self-harm or intravenous drug use: track marks, scarring.

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6. Tongue

• Dry tongue: dehydration.
• Smooth, red tongue (glossitis): iron, folate, or B12 deficiency.
• Geographic tongue: benign condition, normal variant.
• White patches (leukoplakia): pre-malignant.
• White coating (oral candidiasis/thrush): immunosuppression, antibiotic use, inhaled corticosteroids.
• Macroglossia: hypothyroidism, acromegaly, amyloidosis, Down's syndrome.
• Central cyanosis: assessed on the tongue (not peripheries).

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7. Odours

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8. Body Habitus and Nutrition

Weight

• Record height, weight, waist circumference, and BMI at every assessment.
• Serial weight measurements monitor disease progression or response to treatment.

• Note whether obesity is truncal (Cushing's, metabolic syndrome) or generalised.
• Look for abdominal striae or loose skin folds (after weight loss).

Stature

• Short stature: growth hormone deficiency, Turner's syndrome, achondroplasia, childhood illness.
• Tall stature: Marfan's syndrome, Klinefelter's syndrome, acromegaly (in adolescence).
• Disproportionate limb/trunk ratio: achondroplasia, Marfan's.

Hydration

• Assessment is especially important in the acutely unwell patient.
• Signs of dehydration: dry tongue, reduced skin turgor (skin tenting), sunken eyes, low urine output, tachycardia, hypotension.
• Signs of overhydration (oedema): peripheral pitting oedema, pulmonary oedema, ascites.

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9. Lumps and Lymph Nodes

Examining any Lump - The 9 Key Features (Macleod's)

1. Site - anatomical location
2. Size - in two dimensions (cm)
3. Shape - regular, irregular
4. Surface - smooth, nodular, irregular
5. Edge - well or ill defined
6. Consistency - soft, rubbery, firm, hard, fluctuant, cystic
7. Attachment - to skin, underlying muscle or bone
8. Pulsations, thrills, bruits
9. Inflammation - overlying redness, warmth, tenderness
10. Transillumination - cystic (trans-illuminates) vs. solid

Lymph Nodes

• Cervical (anterior and posterior triangles)
• Submandibular and submental
• Occipital and post-auricular
• Supraclavicular (especially left - Virchow's node/Troisier's sign = intra-abdominal malignancy)
• Axillary (5 groups: central, anterior, posterior, medial, lateral)
• Inguinal (horizontal and vertical groups)

• Size (>1 cm = significant)
• Tenderness (tender = reactive/infective; non-tender = lymphoma/malignancy more likely)
• Consistency (soft = reactive; rubbery = lymphoma; hard = metastatic carcinoma)
• Attachment/fixation (mobile vs. matted/fixed - fixation suggests malignancy)
• Overlying skin changes

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10. Spot Diagnoses

• Morbid obesity
• Cushingoid facies
• Hypothyroid facies
• Acromegalic facies
• Down's syndrome (trisomy 21)
• Turner's syndrome (45XO)
• Klinefelter's syndrome (47XXY)
• Achondroplasia
• Marfan's syndrome
• Scleroderma facies

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Summary: What to Record on "General Examination" (OE)

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History Taking - Components and Particulars of the Patient

According to Macleod's Clinical Examination (Chapters 1 & 2)

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Why History Taking Matters

"Understanding the patient's experience of illness by taking a history is central to the practice of all branches of medicine. The process requires patience, empathy and understanding to yield the key information leading to correct diagnosis and treatment."

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Components of History Taking (Macleod's Structure)

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COMPONENT 1: PARTICULARS OF THE PATIENT (Patient Profile)

"After introducing yourself and confirming your patient's name, continue by asking for details of their background including age, date of birth, marital status and current occupation. Then establish the patient's presenting complaint."

1. Name

• What to record: Full name as the patient states it; preferred name or title (Mr, Mrs, Dr, etc.).
• Importance:
  • Correct identification - avoids clinical errors (wrong-patient errors are a major source of harm).
  • Establishes a respectful, personalised relationship from the outset.
  • Legal and medicolegal documentation requires accurate identification.
  • A patient's name can occasionally offer ethnic or cultural clues (e.g. certain surnames suggest South Asian origin, which carries higher cardiovascular and diabetes risk).

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2. Age (and Date of Birth)

• What to record: Exact age in years; date of birth for verification.
• Importance: Age is one of the most powerful determinants of disease probability in clinical medicine.

"Additional factors affecting the pre-test probability of disease in patients with the same presenting symptoms include age, gender, past medical history, family history and lifestyle."

• Chest pain in a 25-year-old woman → musculoskeletal or anxiety more likely.
• Chest pain in a 60-year-old male smoker → ischaemic heart disease until proven otherwise.
• Haematuria in a 70-year-old → bladder cancer must be excluded.
• Haematuria in a 20-year-old → IgA nephropathy, UTI more likely.

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3. Sex / Gender

• What to record: Biological sex and, where relevant, gender identity.
• Importance:

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4. Address / Place of Residence

• What to record: Full address including postcode/area.
• Importance:
  • Geographical disease patterns: Some diseases cluster by geography - e.g. mesothelioma near former shipbuilding/asbestos industries; endemic infections vary by region.
  • Socioeconomic deprivation: Macleod's specifically states "social deprivation is a powerful predictor of many forms of ill health." The patient's area of residence provides an immediate proxy for socioeconomic status.
  • Environmental exposure: Industrial areas, rural farming communities, coastal areas each carry specific risk profiles.
  • Contact tracing and public health: Essential for notifiable disease management.
  • Logistics of care: Determines accessibility to services, home visits, community care planning.
  • Housing conditions: Damp housing → respiratory disease; overcrowding → TB and infections.

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5. Occupation

• What to record: Current occupation AND full occupational history (especially past jobs if currently retired or unemployed).
• Macleod's states: "Ask ALL patients about their occupation. Clarify what the person does at work, especially about any chemical or dust exposure."

• Disease may make a patient unable to continue their work - e.g. a surgeon developing essential tremor, a pilot with epilepsy, a lorry driver with new-onset diabetes.
• Macleod's example: "Arthritis in a manual labourer" is a far more functionally significant problem than the same condition in a sedentary office worker.
• Occupational fitness-to-work assessments, sick certification, and rehabilitation planning all depend on knowing the patient's job.

• Macleod's notes: "Unemployment is also associated with increased morbidity and mortality." - It acts as a marker of social deprivation and is an independent risk factor for poor health outcomes.

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6. Marital Status / Relationship Status

• What to record: Single, married, cohabiting, divorced, widowed, civil partnership.
• Importance:
  • Social support: Married/partnered patients generally have better recovery and adherence to treatment.
  • Bereavement - Macleod's states: "Enquire sensitively if the patient is bereaved, as this can have profound effects on a patient's health and wellbeing."
  • Relevant to sexual history (STIs, contraception, gynaecological history).
  • Relevant to children at home - both as a source of support and as dependants who may be affected if the patient is unwell.

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7. Religion / Ethnicity (where relevant)

• Though not always listed as a separate heading in older editions, Macleod's acknowledges the importance of cultural and religious background in patient care:
  • Blood transfusion refusal: Jehovah's Witnesses.
  • Dietary restrictions: affect nutritional assessment.
  • Drug sensitivities by ethnicity: e.g. G6PD deficiency more common in African and Mediterranean populations.
  • Disease prevalence: Certain conditions (sickle cell disease, thalassaemia, Tay-Sachs) have strong ethnic clustering.
  • Communication and consent: Language barriers, the need for interpreters.

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COMPONENT 2: PRESENTING COMPLAINT (PC)

• The single main problem that brought the patient to seek medical attention.
• Recorded in the patient's own words, not medical terminology.
• Example: "chest tightness for 3 days" not "angina."
• Use open questions: "What brings you here today?" or "Tell me what has been bothering you."
• Do not interrupt the patient's first few sentences - Macleod's emphasises: "Make sure patients tell you what they feel the principal problem is in their own words without pressure or interruption."
• If multiple complaints exist, list all of them.

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COMPONENT 3: HISTORY OF PRESENTING COMPLAINT (HPC)

• Ideas: What does the patient think is causing the problem?
• Concerns: What are they worried it might be?
• Expectations: What do they hope you can do for them?

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COMPONENT 4: PAST MEDICAL HISTORY (PMH)

• All previous illnesses, operations, hospital admissions, accidents and injuries.
• Specifically ask about:
  • Childhood illnesses (rheumatic fever, TB, measles, jaundice).
  • Previous hospital admissions - dates, hospitals, reasons.
  • Operations and procedures - type, date, complications.
  • Obstetric history in women (pregnancies, deliveries, miscarriages, complications).
  • Blood transfusions - when, why, any reactions.
  • Allergies (covered also under drug history).
  • Vaccinations and immunisation status.
• Macleod's documentation format: record the condition, date, treatment received.

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COMPONENT 5: DRUG HISTORY (DH)

• All medications currently taken: name, dose, frequency, route, duration.
• Non-prescribed medications: over-the-counter drugs, herbal remedies, supplements.
• Recreational/illicit drug use (approach non-judgementally).
• Drug allergies and reactions: record the drug AND the nature of the reaction (rash, anaphylaxis, GI intolerance - true allergy vs. side effect distinction matters).
• Concordance and adherence: Do they actually take the medications as prescribed?

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COMPONENT 6: FAMILY HISTORY (FH)

• Record age and current health, or age at and cause of death, of:
  • Parents, siblings, children (first-degree relatives).
  • Grandparents (second-degree) if relevant.
• Use a pedigree chart (Macleod's provides symbols) for families with genetic conditions.
• Specifically note conditions with a hereditary component: IHD, diabetes, hypertension, cancers (breast, bowel, ovarian), epilepsy, mental illness, bleeding disorders, congenital anomalies.
• Macleod's: "Include family history in the HPC if relevant - e.g. family history in disorders with a possible genetic trait such as hypercholesterolaemia or diabetes."

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COMPONENT 7: SOCIAL HISTORY AND LIFESTYLE (SH)

Smoking

• Current/ex-smoker/never-smoker.
• Pack-year history: number of packs/day × number of years smoking.
• Pipe, cigar, e-cigarette use.

Alcohol

• Calculate intake in units per week.
• UK low-risk guidelines: <14 units/week for both sexes.
• Use CAGE questionnaire for screening alcohol problems:
  • C - Have you felt you should Cut down?
  • A - Have people Annoyed you by criticising your drinking?
  • G - Have you felt Guilty about your drinking?
  • E - Do you need a drink first thing in the morning (Eye-opener)?
  • Score ≥ 2 = likely alcohol dependence.

Housing and Home Circumstances

• "Establish who is there to support the patient by asking 'Who is at home with you, or do you live alone?'" (Macleod's 15th ed.)
• Type of housing: house, flat, bungalow; stairs; accessibility.
• Any carers; activities of daily living (ADLs).
• Is the patient themselves a carer for someone vulnerable?

Occupational History

Travel History

• Recent travel abroad - essential for infectious disease history.
• Malaria prophylaxis, vaccinations before travel.

Sexual History

• Approached sensitively; relevant for STIs, contraceptive history, gynaecological and obstetric history.

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COMPONENT 8: SYSTEMATIC ENQUIRY (Review of Systems)

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Closing the Interview

• Summarise what you have heard back to the patient.
• Ask: "Is there anything else you'd like to tell me or ask me about?"
• Explain what will happen next.
• Thank the patient.

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How to Document the History (Macleod's Format)

Name:          [Full name, preferred name]
Age/DOB:       [Age], [Date of birth]
Sex:           [Male/Female/Other]
Address:       [Full address]
Occupation:    [Current and relevant past]
Marital Status:[Status]
Date of Clerking: [Date]

PC:   [One-line presenting complaint in patient's own words]

HPC:  [Detailed narrative of presenting symptoms with all cardinal features]

PMH:  [Previous illnesses, operations, admissions]

DH:   [Drugs with doses; allergies and reactions]

FH:   [Parents/siblings/children - health or cause/age of death]

SH:   [Smoking, alcohol, occupation, home circumstances, carers]

SE:   [Positive and relevant negative findings across systems]

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Summary: Why Particulars of the Patient Are Indispensable

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