General Examination

A. General Survey

1. General Assessment of Illness

• Assess immediately on first contact
• Is the patient acutely ill, in distress, comfortable, or critically unwell?
• Severely ill patients: rapid survey, minimal delay before treatment

2. Mental State and Level of Consciousness

3. Build and Nutritional State

• Cachexia (marked weight loss with muscle wasting): suggests malignancy, chronic disease, or malabsorption
• Obesity: associated with metabolic syndrome, sleep apnea, cardiovascular risk
• Record height, weight, BMI, waist circumference, and waist-to-hip ratio (the latter predicts long-term cardiovascular risk)
• Signs of malnutrition: loss of subcutaneous fat (orbital/triceps), temporal wasting, proximal muscle weakness, scaling skin, poor wound healing

4. Attitude (Posture)

• Patients with peritonitis lie still
• Patients with colic (renal/biliary) are restless, tossing
• Meningism: neck retraction and rigidity
• Fractured neck of femur: externally rotated, shortened leg
• Acute pericarditis: patient leans forward to reduce pain

5. Gait

• Waddling gait: bilateral congenital dislocation of hip, bilateral coxa vara
• Trendelenburg gait: muscle dystrophies, poliomyelitis, unilateral coxa vara, Perthes disease
• Gait abnormalities arise from pain, bone/joint disease, muscle/neurological disease, structural causes, or psychiatric disorders

6. Facies (Facial Expression)

• Facies hippocratica: sunken face of generalized peritonitis
• Risus sardonicus: tetanus
• Mask face: Parkinsonism
• Moon face: Cushing syndrome
• Adenoid facies: hypertrophied adenoids
• Myxoedematous facies: hypothyroidism
• Facies of Marfan syndrome, trisomy 21 (Down syndrome), Holt-Oram syndrome are easily recognized
• Eyes: ophthalmic signs of hyperthyroidism

7. Decubitus (Position in Bed)

• In cerebral irritation: patient curls on their side, away from light
• Note whether the patient avoids any particular posture to reduce pain

B. Colour of Skin

Pallor

• Seen in: haemorrhage, shock, anaemia, intense emotion
• Where to look: lower palpebral conjunctiva, oral mucous membrane, nail beds, palmar creases

Cyanosis

• Tongue is spared in peripheral cyanosis - a key distinguishing feature
• Carbon monoxide poisoning: cherry-red discolouration
• Methaemoglobinaemia/sulphaemoglobinaemia: cyanosis with normal arterial PO2

Jaundice

• Icteric tint ranging from faint yellow (viral hepatitis) to dark olive-green (obstructive jaundice)
• Best detected in: sclerae (detected earliest here), then skin
• Requires daylight - artificial light may mask faint jaundice
• Other pigmentation: bronze/tan = haemochromatosis; malar telangiectasia = mitral stenosis or scleroderma; xanthomas = hyperlipidaemias

C. Vital Signs

Pulse

• Rate - fast or slow
• Rhythm - regular or irregular
• Volume - reflects pulse pressure
• Tension and force - reflects diastolic and systolic BP
• Character - water-hammer pulse (aortic regurgitation), pulsus paradoxus (pericardial effusion)
• Vessel wall - atherosclerotic thickening

Respiration

• Tachypnoea: fever, shock, hypoxia, metabolic acidosis, cerebral disturbance, hysteria
• Slow deep breathing: cerebral compression (ominous sign)
• Cheyne-Stokes: alternating hyperpnoea and apnoea - indicates severe brain or cardiac dysfunction
• Pursed-lip breathing with barrel chest: COPD

Temperature

• Oral temperature ~1°F higher than axillary
• Continued fever: fluctuation <1°C over 24 hours, never touches normal
• Remittent: daily fluctuation >2°C, never normal
• Intermittent: fever present only a few hours (quotidian = daily; tertian = alternate days; quartan = every 3rd day)

Blood Pressure

• Record bilaterally
• Note hypertension or hypotension

D. Hands and Peripheral Examination

• Clubbing: chronic hypoxia, bronchiectasis, cyanotic heart disease, cirrhosis, IBD
• Koilonychia (spoon nails): iron deficiency anaemia
• Splinter haemorrhages: infective endocarditis
• Signs of chronic liver disease: Dupuytren's contracture, palmar erythema, leuconychia
• Oedema: peripheral pitting oedema - cardiac/hepatic/renal failure, hypoalbuminaemia

E. Head, Face, and Neck

• Dental hygiene: source of infection; index of general health
• Cervical lymphadenopathy: lymphoma, metastatic disease, infections
• Left supraclavicular (Virchow's) node: suggests intra-abdominal malignancy
• Goitre: thyroid disease
• High-arched palate: Marfan syndrome
• Orange tonsils: Tangier disease
• Bifid uvula: Loeys-Dietz syndrome

F. Tongue

• Index of the digestive system and hydration
• Dry tongue: dehydration
• Dry brown tongue: toxaemia
• Coated tongue: early appendicitis or gastrointestinal disease
• Glossitis (smooth tongue): B vitamin deficiency (especially B12, folate, niacin)

G. Lymph Nodes

• Cervical (anterior and posterior chains)
• Axillary
• Inguinal
• Check for: size, consistency, tenderness, fixation, matting

H. Skin

• Jaundice, pallor, cyanosis (as above)
• Spider naevi: chronic liver disease
• Telangiectasias: Osler-Weber-Rendu syndrome
• Xanthomas: hyperlipidaemia
• Eruptive xanthomatosis: severe hypertriglyceridaemia
• Lupus pernio, erythema nodosum: sarcoidosis
• Skin eruptions, vesicles, bullae, purpura, petechiae

I. Oedema

• Pitting oedema is detected by pressing firmly over the dorsum of the foot or pretibial area
• Causes: right heart failure, nephrotic syndrome, liver cirrhosis, DVT, lymphoedema

Summary: Order of General Examination

• S Das: A Manual on Clinical Surgery, 13th Edition, pp. 8-13
• Harrison's Principles of Internal Medicine, 22nd Edition (2025), pp. 1903-1904
• Bailey & Love's Short Practice of Surgery, 28th Edition, p. 1076
• Textbook of Family Medicine, 9th Edition