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

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

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.

2. Gait and Posture

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

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).

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).

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.

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).

7. Odours

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.

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

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

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