General examination for md medicine preparation with detail explanation
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I now have excellent content from Harrison's and Bailey & Love's for a comprehensive General Examination guide. Let me compile the full detailed answer for MD Medicine preparation.
General Examination - MD Medicine Preparation
A Complete Systematic Guide
Overview
The general examination is the first and most important step in the clinical assessment of any patient. It begins the moment you meet the patient - even before formal examination starts. A thorough general examination can reveal the patient's overall health status, nutrition, hydration, signs of systemic disease, and physiological stability.
Step 1 - First Impression / General Appearance
As soon as you see the patient, note:
| Parameter | What to Observe |
|---|---|
| Age | Does apparent age match stated age? Premature aging suggests chronic illness |
| Build | Obese, average, thin, cachectic |
| Posture | Orthopnea (sitting up), tachypnea, guarding |
| Demeanor | Alert, anxious, distressed, confused, unconscious |
| Facies | Moon face (Cushing's), coarse features (hypothyroidism), mask-like (Parkinsonism), malar flush (MS, SLE) |
| Body habitus | Marfanoid, acromegalic, Turner's, Down's syndrome features |
From Harrison's (22E): "The examination begins with an assessment of the general appearance of the patient, with notation of age, posture, demeanor, and overall health status. Is the patient in pain or resting quietly, dyspneic or diaphoretic? Mental status, level of alertness, and mood should be assessed continuously during the interview and examination."
Step 2 - Vital Signs (Must memorize normal ranges)
| Vital Sign | Normal Range | Abnormal Finding |
|---|---|---|
| Temperature | 36.5 - 37.5°C (97.7 - 99.5°F) | Fever (>38°C), Hypothermia (<35°C) |
| Pulse Rate | 60-100 bpm | Tachy/Bradycardia, Irregular rhythm |
| Respiratory Rate | 12-20/min | Tachypnea (>20), Bradypnea (<12) |
| Blood Pressure | <120/80 mmHg | Hypertension (>140/90), Hypotension (<90/60) |
| SpO2 | 95-100% | Hypoxia (<95%) |
Pulse - 7 characteristics to assess: Rate, Rhythm, Volume, Character, Condition of vessel wall, Radio-femoral delay, All peripheral pulses
Key clinical correlations:
- Pulsus paradoxus (drop >10 mmHg on inspiration): Cardiac tamponade, severe asthma
- Pulsus alternans: Severe LV dysfunction
- Collapsing/water hammer pulse: Aortic regurgitation
- Radio-femoral delay: Coarctation of aorta
Step 3 - Anthropometry & Nutritional Status
| Parameter | How to Assess |
|---|---|
| Height & Weight | Measured routinely |
| BMI | Weight(kg)/Height(m²) - Normal: 18.5-24.9 |
| Waist circumference | >102 cm (M), >88 cm (F) = central obesity |
| Waist-to-hip ratio | Cardiovascular risk predictor |
| Nutritional status | Well nourished / Poorly nourished / Malnourished / Cachectic |
Harrison's 22E: "Height and weight should be measured routinely, and both body mass index and body surface area should be calculated. Knowledge of the waist circumference and the waist-to-hip ratio can be used to predict long-term cardiovascular risk."
Step 4 - PALLOR (Anemia Assessment)
Sites to examine:
- Conjunctival pallor (most sensitive)
- Palmar crease pallor
- Tongue and buccal mucosa
- Nail beds
- Skin
Grading of pallor:
- Mild: Conjunctival pallor only
- Moderate: Conjunctival + palmar pallor
- Severe: All sites + signs of high-output state (tachycardia, flow murmur)
Clinical Tip for MD: Pallor in conjunctiva is best assessed by pulling down the lower eyelid - the palpebral conjunctiva should normally be brick-red/pink.
Step 5 - JAUNDICE
Sites to look:
- Sclerae (earliest sign - jaundice visible when bilirubin >2-3 mg/dL)
- Mucous membranes (sublingual area)
- Skin (best in natural daylight)
- Urine color (tea-colored = conjugated hyperbilirubinemia)
- Stool color (pale = obstructive jaundice)
Types and Differentiation:
| Type | Bilirubin | Urine | Stool | Causes |
|---|---|---|---|---|
| Pre-hepatic | Unconjugated ↑ | Normal | Normal | Hemolysis, G6PD deficiency |
| Hepatic | Both ↑ | Dark (bilirubin +) | Pale | Hepatitis, cirrhosis |
| Post-hepatic | Conjugated ↑↑ | Dark, Pale frothy | Clay-colored | Choledocholithiasis, Ca head of pancreas |
From Harrison's: "Jaundice, which may be visible first in the sclerae, has a broad differential diagnosis but, in the appropriate setting, can be consistent with advanced right heart failure and congestive hepatomegaly."
Step 6 - CYANOSIS
Definition: Bluish discoloration of skin and mucous membranes due to >5 g/dL of deoxygenated Hb in capillaries (NOT a percentage - this is a common exam trap).
| Type | Site | Mechanism | Causes |
|---|---|---|---|
| Central cyanosis | Lips, tongue, oral mucosa | Arterial desaturation | R→L shunt (Fallot's, Eisenmenger's), COPD, pneumonia |
| Peripheral cyanosis | Fingers, toes, earlobes | Reduced peripheral flow | Heart failure, shock, cold exposure, Raynaud's |
| Differential cyanosis | Lower limbs only (not upper) | PDA + pulmonary HTN with R→L shunt | Patent ductus arteriosus + reversal |
Key exam point: In central cyanosis, the tongue is also cyanosed. In peripheral cyanosis, the tongue is spared.
Harrison's 22E: "Central cyanosis occurs with significant right-to-left shunting at the level of the heart or lungs, allowing deoxygenated blood to reach the systemic circulation. Peripheral cyanosis or acrocyanosis, in contrast, is usually related to reduced extremity blood flow due to small vessel constriction."
Step 7 - CLUBBING
Definition: Painless enlargement of the soft tissues of the terminal phalanges, resulting in loss of the normal angle between the nail and the nailbed.
How to detect:
- Schamroth's window test: Place both index fingernails together dorsum to dorsum - normally a diamond-shaped window is visible. In clubbing, this window disappears.
- Profile angle (Lovibond's angle): Normally <160°; in clubbing >160°
Grading (Schamroth):
| Grade | Features |
|---|---|
| Grade 1 | Fluctuation of nail bed (spongy feel) |
| Grade 2 | Loss of angle between nail and nail bed (obliteration of Lovibond's angle) |
| Grade 3 | Drumstick/parrot-beak appearance - increased curvature of nail |
| Grade 4 | Hypertrophic osteoarthropathy (periosteal changes, swelling of wrist/ankle) |
Causes - ABCDE Mnemonic:
| System | Diseases |
|---|---|
| Respiratory | Bronchiectasis, Lung abscess, Empyema, Fibrosing alveolitis, Lung cancer, Cystic fibrosis |
| Cardiac | Cyanotic congenital heart disease, Infective endocarditis |
| GI/Hepatic | Crohn's disease, Ulcerative colitis, Cirrhosis, Malabsorption |
| Endocrine | Thyroid acropachy (Graves' disease) |
| Others | Idiopathic/familial, Mesothelioma |
Does NOT cause clubbing: COPD, asthma (important negative!)
Harrison's 22E: "Clubbing implies the presence of central right-to-left shunting, although it has also been described in patients with endocarditis. Its appearance can range from cyanosis and softening of the root of the nail bed, to the classic loss of the normal angle between the base of the nail and the skin, to the skeletal and periosteal bony changes of hypertrophic osteoarthropathy."
Step 8 - EDEMA
Pitting vs Non-pitting:
| Type | Features | Causes |
|---|---|---|
| Pitting edema | Pit persists on pressure | CCF, nephrotic syndrome, hypoalbuminemia, cirrhosis, pregnancy |
| Non-pitting edema | No pit / woody | Lymphedema, myxedema (hypothyroidism) |
Grading of Pitting Edema:
| Grade | Description |
|---|---|
| +1 | Slight pitting (2 mm), disappears rapidly |
| +2 | Somewhat deeper (4 mm), disappears in 10-15 sec |
| +3 | Deeper (6 mm), disappears in >1 min |
| +4 | Very deep pitting (8 mm), persists >2 min |
Sites to examine: Bilateral ankle, pretibial, presacral (bed-ridden), periorbital (children/nephrotic)
Key clinical correlations:
- Bilateral lower limb edema + elevated JVP = Cardiac cause
- Bilateral lower limb edema + no elevated JVP = Hypoalbuminemia (nephrotic, cirrhosis)
- Unilateral lower limb edema = DVT, lymphedema, cellulitis
Harrison's 22E: "Lower extremity or presacral edema in the setting of an elevated JVP defines volume overload and may be a feature of chronic heart failure or constrictive pericarditis. Lower extremity edema in the absence of jugular venous hypertension may be due to profound hypoalbuminemia as seen in nephrotic syndrome or liver failure."
Step 9 - LYMPHADENOPATHY
Examination of lymph nodes:
- Site: Cervical, axillary, inguinal, supraclavicular, epitrochlear, popliteal
- Size: Normal <1 cm (inguinal can be up to 2 cm)
- Consistency: Soft (reactive), Firm (lymphoma), Hard/stony (carcinoma)
- Tenderness: Tender = infective/inflammatory; Non-tender = malignant
- Matted/discrete: Matted = TB, metastasis
- Fixity: Fixed = malignant; Mobile = reactive
- Overlying skin: Erythema, edema, sinus
High-yield exam facts:
- Left supraclavicular (Virchow's) node enlarged = Troisier's sign - intra-abdominal malignancy (stomach, colon, pancreas)
- Epitrochlear node = secondary syphilis, infectious mononucleosis, non-Hodgkin's lymphoma
- Generalized lymphadenopathy = HIV, EBV, CMV, SLE, lymphoma, leukemia, sarcoidosis
Step 10 - HYDRATION STATUS / DEHYDRATION
Clinical assessment:
| Parameter | Well Hydrated | Mild-Mod Dehydration | Severe Dehydration |
|---|---|---|---|
| Skin turgor | Normal | Reduced | Very poor (tents) |
| Mucous membranes | Moist | Slightly dry | Very dry |
| Eyes | Normal | Slightly sunken | Sunken |
| Capillary refill | <2 sec | 2-3 sec | >3 sec |
| Pulse | Normal | Tachycardia | Thready |
| BP | Normal | Normal/low | Hypotension |
| Urine output | Normal | Slightly low | Oliguria/anuria |
Step 11 - SKIN EXAMINATION (in General Exam)
Key findings to note:
| Finding | Association |
|---|---|
| Spider nevi (>5 = significant) | Chronic liver disease |
| Xanthelasma | Hyperlipidemia, primary biliary cirrhosis |
| Tendon xanthomas | Familial hypercholesterolemia |
| Palmar erythema | Liver disease, pregnancy, RA |
| Acanthosis nigricans | Insulin resistance, GI malignancy |
| Purpura/petechiae | Thrombocytopenia, vasculitis, meningococcemia |
| Bronze discoloration | Hemochromatosis, Addison's |
| Leukonychia (white nails) | Hypoalbuminemia (liver/kidney disease) |
| Muehrcke's lines | Hypoalbuminemia |
| Terry's nails (white + distal red band) | Cirrhosis, CCF, diabetes |
| Mees' lines (transverse white bands) | Arsenic poisoning, renal failure |
Step 12 - ICTERUS vs JAUNDICE vs CAROTENEMIA
| Feature | Jaundice (Icterus) | Carotenemia |
|---|---|---|
| Color | Yellow | Orange-yellow |
| Distribution | Skin + sclera + mucosa | Skin only (NO sclera) |
| Serum bilirubin | Elevated | Normal |
| Cause | Liver/biliary disease | Excess carotene diet |
Step 13 - MISCELLANEOUS GENERAL EXAM FINDINGS (High Yield for MD)
| Sign/Finding | Clinical Significance |
|---|---|
| Koilonychia (spoon nails) | Iron deficiency anemia |
| Leuconychia | Hypoalbuminemia |
| Splinter hemorrhages | Infective endocarditis (also trauma) |
| Osler's nodes | Infective endocarditis (tender, finger pads) |
| Janeway lesions | Infective endocarditis (non-tender, palms/soles) |
| Palmar crease pallor | Hemoglobin <7 g/dL (severe anemia) |
| Dupuytren's contracture | Alcoholic liver disease, diabetes |
| Asterixis/flapping tremor | Hepatic encephalopathy, uremia, CO2 retention |
| Homans' sign | DVT (low sensitivity and specificity - not reliable) |
| Arcus senilis | Lipid disorder (if age <40 years) |
Step 14 - FACE and FACIES RECOGNITION (MD Exam Favorite)
| Facies | Disease |
|---|---|
| Moon facies | Cushing's syndrome |
| Mask-like facies | Parkinson's disease, scleroderma |
| Coarse features | Acromegaly, hypothyroidism |
| Malar flush | Mitral stenosis, SLE |
| Expressionless, sunken | Hippocratic facies (peritonitis) |
| Frog/toad face | Leprosy |
| Lion face (leonine facies) | Lepromatous leprosy, Paget's disease |
| Elfin facies | William's syndrome |
| Webbed neck | Turner's syndrome |
| Exophthalmos | Hyperthyroidism (Graves') |
Step 15 - BUILT and BODY HABITUS
| Habitus | Features | Association |
|---|---|---|
| Marfanoid | Tall, long limbs, arm span > height, arachnodactyly, high-arched palate | Marfan syndrome, MEN2B |
| Eunuchoid | Long limbs, narrow shoulders, female fat distribution in males | Klinefelter's, hypogonadism |
| Cretinoid | Short, stocky, pot-belly, coarse features | Congenital hypothyroidism |
| Acromegalic | Large hands/feet, prognathism, prominent supraorbital ridges | Acromegaly |
| Dwarfism | Short stature | Achondroplasia, GH deficiency |
Systematic Approach for MD OSCE/Long Case
The mnemonic "PLEASE CHECK VITAL" covers the sequence:
- P - Pallor
- L - Lymphadenopathy
- E - Edema
- A - Appearance (general, facies)
- S - Spider nevi / skin signs
- E - Examination of nails (clubbing, koilonychia, leuconychia)
- C - Cyanosis
- H - Hydration
- E - Eyes (icterus, exophthalmos, arcus, xanthelasma)
- C - Clubbing (confirmed separately)
- K - Koilonychia / other nail signs
- V - Vital signs
- I - Icterus
- T - Temperature
- A - Anthropometry (height, weight, BMI)
- L - Lymphadenopathy (if missed above)
Summary Table - "8 Cardinal Signs of General Examination"
| Sign | Key Site | Key Diseases |
|---|---|---|
| Pallor | Conjunctiva, palms | Anemia (all types) |
| Jaundice | Sclerae, skin | Hepatic, hemolytic, obstructive |
| Cyanosis | Lips, tongue, fingertips | R→L shunts, COPD, shock |
| Clubbing | Fingernails (Lovibond's angle) | Respiratory, cardiac, GI |
| Edema | Ankles, sacrum | CCF, nephrotic, cirrhosis |
| Lymphadenopathy | Cervical, axillary | Infection, lymphoma, metastasis |
| Dehydration | Skin turgor, mucosa | Diarrhea, fever, vomiting |
| Fever/temperature | Core temperature | Infection, malignancy, collagen |
Sources: Harrison's Principles of Internal Medicine 22E (2025); Bailey & Love's Short Practice of Surgery 28th Ed; Goldman-Cecil Medicine International Edition
Tips for MD Medicine Viva/OSCE:
- Always examine vital signs first before proceeding to systems
- Mention "patient is conscious, cooperative, oriented to time, place, and person" early
- Comment on built, nutrition, and hydration in every case
- Never miss icterus in the sclerae - always examine in good light
- For clubbing, always demonstrate Schamroth's test - examiners love it
- For edema, always check if pitting or non-pitting and quantify the grade
- Correlate general exam findings to form a differential - e.g., jaundice + spider nevi + palmar erythema = liver disease
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