GENERAL EXAMINATION
The physical examination starts moment the patient enters the clinic. His orientation, gait,
nutritional status, etc. can be observed. A thorough physical examination is best done with
a cooperative patient, in a well-lit, quiet and warm room. The couch and chairs should be
designed in such a way that even a disabled patient finds them easy to adjust. Utmost
importance should be given to make the patient comfortable and quell his anxiety.
General examination involves observation of the patient from head to toe, for the features
of diagnostic help. Following points should be considered:

Build and Body proportions

Nutrition

Decubitus

Clubbing

Cyanosis

Jaundice

Lymphadenopathy

Pallor

Edema

Skin, Hair and Nails

Vertebral column

Thickened nerves

Joints

Temperature

Pulse

Jugular venous pulse and pressure

Blood pressure

Respiratory Rate
BUILD AND BODY PROPORTIONS
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Build represents the skeletal structure in relation to age and gender of the individual as
compared to normal limits. It is judged from height, weight and chest girth. According to
this, the build of the any patient may be average, sthenic (short and stalky) and asthenic (tall
and thin).
Normally, in adults, the upper segment of the body (from vertex to pubic symphysis) is equal
to the lower segment (pubic symphysis to heel) and the arm span is equal to the height. In
infants, the upper segment is greater than the lower and the height is greater than the arm
span. Certain conditions like cretinism, juvenile myxedema and achondroplasia present
infantile type of body proportion.
NUTRITION
Nutritional state of the patient must be assessed. Certain signs help us to determine
deficiency states.




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Hypoproteinemia causes edema, dry and rough skin, weight loss, brittle hair, etc.
Fat deficiency leads to weight loss, dry skin, loss of shape of hips, etc.
Signs of vitamin deficiency states should be studied thoroughly by all students.
Deficiency of iron (koilonychia) and calcium (tetany) can be diagnosed clinically.
DECUBITUS:
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Note the posture patient adopts in bed. For example, in renal, biliary or intestinal colic, the
patient is restless and turns and tosses about. In acute inflammatory abdominal disease,
patient lies quietly with legs drawn up. In tetanus, opisthotonos may be noted. Meningitis is
characterized by a stiff neck. In cardio-respiratory embarrassment, patient is more
comfortable in sitting-up position.
CLUBBING
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It is bulbous enlargement of soft parts of terminal phalanges with transvers and longitudinal
curving of nails.
Grades:
Grade
Signs
Grade
I
Softening of the nail bed
Grade
II
Obliteration of the angle between base of nails and adjacent skin
Grade
III
Swelling of soft tissues over the base of nail and increased curvature of nail leading
to ‘parrot beak’ appearance or ‘drumstick’ appearance.
Grade
IV
Swelling of the fingers in all dimentions associated with hypertrophic pulmonary
osteoarthropathy. This causes swelling and pain of hand, wrist, etc. In X-ray, there
is evidence of sub-periosteal new bone formation.
Some of the common causes of clubbing are Bronchogenic CA, Lung abscess, Tuberculosis
with secondary infection, Infective carditis, Inflammatory bowel disease, etc.
Normally, when two fingers are held together with nails facing each other, there should be a
space between the nail folds. This space is lost in clubbing. This is Schamroth’s sign.
CYANOSIS
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More than 5 mg% of reduced hemoglobin in capillary blood gives rise to bluish discoloration
of tissues (especially seen in nails, palate, tongue, lips, etc.). This is known as cyanosis.
It can be central, peripheral, mixed or due to abnormal pigments.
Differentiating
points
Central
Peripheral
Seen on
Skin and mucous membranes
(palate, tongue, lips, etc.)
Skin only, nails
Mechanism
Reduced arterial oxygen
saturation
Reduced blood flow to peripheral
tissues or any local part
Temperature of the
part
Warm
Cold
Clubbing and
polycythemia
Usually associated
Not associated
Administration of
oxygen
Cyanosis decreases
Cyanosis persists
Common causes of central cyanosis are congestive cardiac failure, congenital cyanotic heart
disease, chronic obstructive lung disease and fibrosis or collapse of lung. Common causes of
peripheral cyanosis are vasoconstriction due to cold, shock due to any cause and increased
viscosity of blood. Both can occur in acute left ventricular failure and mitral stenosis.
JAUNDICE
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Yellow colouration of tissues (skin, mucous membranes and sclera) and body fluids due to
increase in bile pigments is jaundice.
Normally, total serum bilirubin is 1 mg% and direct serum bilirubin is 0.25 mg%. It appears
in urine if direct serum bilirubin is more than 0.4 mg%.
In haemolytic jaundice, a pale lemon-yellow tint may be present. Orange or dark yellow
colouration is characteristic of obstructive jaundice. Also, in obstructive jaundice, there may
be scratch marks from itching evoked by bile salts. Sometimes, yellowness may appear due to
carotenaemia.
The etiology may be:
1. Congenital (Gilbert’s syndrome, Crigler Najjar syndrome, Dublin Johnson syndrome,
Rotor’s syndrome)
2. Hemolytic (thalassemias, sickle cell disease, infections, drugs, etc.)
3. Hepatocellular (Viral, drugs and chemicals – chloroform, rifampicin, DDT, arsenic,
etc., cirrhosis)
4. Obstructive (cholecystitis, cholelithiasis, CA head of pancreas, biliary atresia, etc.)
PALLOR
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Paleness of the skin and mucous membranes may arise due to diminished circulating RBCs or
diminished blood supply. It also depends on the thickness and quality of the skin. Pallor
occurs in persons with thick or opaque skins, in hypopituitarism, in shock, syncope or left
heart failure. If locally, blood supply is obstructed, pallor may occur in that part (Raynaud's
disease). Generalized pallor occurs in anemia due to any cause.
Lower palpebral conjunctiva, tongue, soft palate, palms and nails are the sites usually
checked for detecting pallor.
LYMPHADENOPATHY
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Enlargement of the lymph nodes should be checked for. The cause may be inflammatory or
non-inflammatory.

In the neck, examine submental, submandibular, tonsillar, cervical, posterior auricular
and occipital groups. They may be enlarged in TB, tonsillitis, dental infections, etc.
The neck should be slightly flexed and examiner should stand behind the patient.

The axillary glands should be checked with patient’s arm slightly abducted and
inserting the finger in the axilla. The apical, anterior, posterior, medial and lateral
groups should be examined. They may be enlarged in mastitis, breast abscess and
upper limb infections.

The inguinal nodes must be examined in supine position with the thigh extended.
Medial and lateral groups must be examined. Infections of the lower limbs, leg ulcers,
genital infections, etc. enlarge them.

Other important groups include para-aortic, femoral and popliteal.

Normally, the lymph nodes are non-tender, firm and smooth. The surface is matted in
TB and irregular in malignancy. The consistency is rubbery in Hodgkin’s disease,
firm and shotty in syphilis and hard in malignancy.
EDEMA
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Collection of excess fluid in interstitial spaces or serous cavities is edema. It may become
evident when 5-6 liters of fluid has accumulated in water depots.
It may be caused due to:
1.
2.
3.
4.
Increased capillary permeability (acute inflammations)
Increased capillary pressure (cardiac failure)
Decreased serum osmotic pressure (hypoproteinemia)
Impaired lymphatic drainage (filariasis, obstruction)
- In congestive cardiac failure and hypoproteinemia, the edema is typically dependent. It first
appears at the ankles and over the dorsum of the foot, and gradually involves the legs, thighs
and trunk. In bed ridden, it first appears over the sacrum.
- The skin over the edematous part is pale and glossy and has a doughy feel. Usually, it pits
on finger pressure. It is important to press firmly and for a sustained period, and the 'pit' can
be seen on removing the finger. The edema of lymphatic obstruction and myxedema do not
pit on pressure.
SKIN, HAIR AND NAILS
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These tell us a lot about the internal processes going on in the body. A magnifying glass
should be kept handy while examining these.
- Colour of the skin should be noted. It may be pale, cyanosed, yellow, red, etc. Depending
on this, underlying cause should be identified.
- Pigmentation – whether hyper (Addison’s and Cushing’s disease, hemochromatosis,
kwashiorkor, lichen planus, malignancy, etc.) or hypo (leprosy, leucoderma, albinism, fungal
infections, etc.) should be carefully noted.
- Various types of eruptions should be identified.
Type of
eruption
Identification
Conditions
Macule
Not raised above skin (less than 1 cm diameter)
Typhoid, syphilis,
purpura
Papule (with Raised tiny nodule (less than 1 cm diameter)
pus – pustule)
Measles, chickenpox,
sulfonamides
administration
Nodules
Large (more than 1 cm diameter) papules as
solitary projection from skin
Erythema nodosum,
leprosy, TB, secondary
syphilis
Vesicles
Small blisters (usually filled with fluid)
Herpes, chickenpox
Patch
Circumscribed skin discolouration (more than 1
cm diameter)
Leprosy, Vitiligo
Plaque
Circumscribed skin elevation (more than 1 cm
diameter), the horizontal dimensions of which
exceed the vertical dimensions.
Psoriasis, lichen planus,
scleroderma
- Hemorrhages under skin should be identified, e.g.: Petechiae are less than 1 cm in
diameter, purpura is 2-5 mm in diameter. These may be seen in scurvy, thrombocytopenia,
HIV, leukemia, etc.
- Type of skin also tells us a lot about many conditions. For e.g.: dry skin may be seen in
myxedema, dehydration. Moist skin may occur in shock due to myocardial infarction,
thyrotoxicosis. Thick skin suggests myxedema, acromegaly, scleroderma.
- HAIR changes should be noted:


Falling of hair – after typhoid, protein deficiency, etc. Patchy hair loss is seen in
alopecia areata, syphilis, etc.
Absence of axillary, pubic and facial hair is seen in hypopituitarism, hypogonadism.
Excessive facial hair may be seen in Cushing’s and adrenocortical syndromes.
- NAILS should be examined for:




Pallor, cyanosis, clubbing
Spoon shaped deformity of the nails may be seen in iron deficiency anemia.
Onychia is deformity of the nails following fungal or tuberculous infection.
Splinter hemorrhages may be seen under the nail beds in SBE and bleeding disorders.
VERTEBRAL COLUMN
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Normally, the vertebral column has two antero-posterior curves – one in upper dorsal region
(concave forwards) and other in dorsolumbar column (convex forwards).
It should be palpated for abnormality, angular deformity, swelling or tenderness. After that,
the mobility should be tested. Normally, it is mobile antero-posteriorly as well as laterally.

Lordosis – abnormal antero-posterior with forward convexity (pregnancy, muscular
dystrophy, large abdominal tumors, etc.)

Kyphosis – abnormal antero-posterior curvature with forward concavity and dorsal
prominence) wedge shaped vertebrae, prolonged carrying of heavy weights, Pott’s
spine, RA, OA, etc.)

Scoliosis – abnormal lateral curvature of the spine (congenital, prolonged carrying
heavy weights in one arm, poliomyelitis, to reduce length of or pain in one of the
limbs, etc.)
THICKENED NERVES
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Nerves may be enlarged in leprosy, neurofibromatosis, diabetes, amyloidosis, sarcoidosis and
few other rare syndromes. Each nerve is a cordlike structure and can be felt like an electric
cable.
Most commonly affected nerves are ulnar and lateral popliteal.
Ulnar nerve:
The forearm of the patient is bent at 90°-110° over the arm. The examiner uses his left hand
to palpate the right ulnar nerve and his left hand to palpate the right ulnar nerve. The nerve
can be palpated first at the elbow in the olecranon groove, between the olecranon and the
medial epicondyle of the humerus. Then it can be felt and evaluated immediately above the
groove.
Lateral popliteal nerve (Common peroneal nerve):
The lateral popliteal nerve can be palpated, with the knee joint semi-flexed, in the popliteal
fossa, just medial to the biceps femoris tendon and as it passes round the neck of the fibula.
Other nerves which should be palpated are – Supraorbital, Great auricular, Radial, Median,
Superficial peroneal, Posterior tibial and Sural.
JOINTS
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Proper history in joint diseases is of utmost importance. It should cover onset, details of pain,
stiffness and swelling, medical history and family history.
Pain and stiffness, leading to loss of function, is a classic feature of joint disease.
Examination of should include:

Inspection – joints affected (whether symmetrical or asymmetrical, large/small, etc.),
swelling, redness, muscular wasting, etc.

Palpation – Local temperature, tenderness, whether swelling is fluctuant or nonfluctuant, etc.

Range of motion – check the range in passive and active motion at the joint, pain on
movement, compensatory muscular spasms, etc.

Measurements – length of the limb, circumference of the limb, relation of various
bony points to the joint, etc.
Also conduct a general and systemic examination for clues in relation to the joint
disease (tuberculosis, syphilis, scurvy, other infections, etc.).
TEMPERATURE
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The body and visceral temperature is maintained by hypothalamus. Ideally, a clean, aseptic
mercury thermometer is kept in axilla for a minute. If there is lot of perspiration, it should be
kept in mouth, under the tongue. In collapsed, comatose and elderly patients, rectal
temperature may be recorded.
In children, the thermometer can be placed in the fold of the groin with the thigh flexed on
the abdomen. The temperature of the mouth and rectum is usually at least half a degree
higher than that of the axilla or groin.
Normal body temperature varies from 36oC to 37.5oC. Hypothermia may be caused in
hypopituitarism, hypoglycemia, alcoholic intoxication, ketoacidocis, shock, etc. Fever or
pyrexia may occur due to infections, neoplasm, immunological diseases, endocrine or
metabolic disorders, mechanical or physical causes, etc.
PULSE
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Palpate and count the peripheral pulsations for a minute when the patient is at rest and
composed. The normal pulse has:



Anacrotic wave (a) which is not felt
Tidal or percussion wave (t) which is felt
Dicrotic notch (n) and Dicrotic wave (d), both of which are not felt.
Variations in these waves suggest some abnormalities. For e.g., in aortic stenosis, we feel an
anacrotic pulse, which beats twice and is slowly rising. A dicrotic pulse is when first
percussion wave is felt during systole and second dicrotic wave is felt in diastole. This is seen
when peripheral resistance and diastolic pressures are low.
COMMON SITES TO BE PALPATED FOR PULSES:
UPPER LIMB
Front of right upper extremity
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

Axillary pulse: located inferiorly of the lateral wall of the axilla.
Brachial pulse: anterior aspect of the elbow, medial to the tendon of the biceps.
Radial pulse: palpable in the anatomical snuff box and on the anterior aspect of the
arm over the carpal bones.
Ulnar pulse: located on the medial of the wrist.
LOWER LIMB




Femoral pulse: located in the inner thigh, at the mid-inguinal point, halfway between
the pubic symphysis and anterior superior iliac spine.
Popliteal pulse: Above the knee in the popliteal fossa, found by holding the bent
knee. The patient bends the knee at approximately 125°, and the physician holds it in
both hands to find the popliteal artery in the pit behind the knee.
Dorsalis pedis pulse: located on top of the foot, immediately lateral to the extensor of
hallucis longus.
Tibialis posterior pulse: located on the medial side of the ankle, 2 cm inferior and 2
cm posterior to the medial malleolus.
HEAD AND NECK
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

Carotid pulse: located in the neck between the larynx and the anterior border of the
sternocleidomastoid muscle at the level of the cricoid cartilage. The carotid artery
should be palpated gently as stimulating its baroreceptors with low palpitation can
provoke severe bradycardia or even stop the heart in some sensitive persons. Also, a
person's two carotid arteries should not be palpated at the same time. Doing so may
limit the flow of blood to the head, possibly leading to fainting or brain ischemia.
Facial pulse: located on the mandible (lower jawbone) on a line with the corners of
the mouth (facial artery).
Temporal pulse: located on the temple directly in front of the ear (superficial
temporal artery).
JUGULAR VENOUS PULSE
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The jugular venous pulse has a flickering character caused by 'a' and 'v' waves separated by
'x' and 'y' descents. The 'a' wave produced by atrial systole precedes tricuspid valve closure.
The 'c' wave is caused by closure of the tricuspid valve. It is followed by the 'x' descent
(marking descent of the tricuspid valve ring). Atrial pressure then rises again, producing the
'v' wave as the atrium fills passively during ventricular systole. The 'y' descent is produced
because of decline in atrial pressure as the tricuspid valve opens to allow ventricular filling.
Variations in these waves may be studied in detail and they suggest corresponding
abnormalities.
JUGULAR VENOUS PRESSURE
Patient is laid at 45° angle using a backrest. Normally, the jugular vein is seen just above the
clavicles. A ruler is placed horizontally at the upper level. Another ruler is kept perpendicular
to the first up to the angle of Louis (anterior angle formed by the junction of the manubrium
and the body of the sternum). The distance from angle of Louis to the first ruler gives jugular
pressure. Normally, it should be 3-4 cms. The jugular vein is in direct continuity with the
SVC and right atrium. Therefore, it varies in right ventricular failure, cardiac temponade,
tricuspid stenosis, SVC obstruction, long standing asthma, etc.
Kussmaul's sign: During inspiration, the pressure within the chest falls and there is a fall in
the jugular venous pressure. In constrictive pericarditis, and cardiac tamponade, inspiration
produces a paradoxical rise in the jugular venous pressure (JVP). This is because the
increased venous return cannot be accommodated in the right heart.
BLOOD PRESSURE (BP)
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It is the lateral pressure exerted by column of blood on the vessel wall. It denotes pressure in
systemic arteries.
Explaining the procedure of measuring BP is important to the patient who is checking it for
the first time. Exertion, meals, smoking, stimulants, etc. are avoided for about 30 minutes
before BP is checked. After 5 minutes of rest, check the BP in supine, sitting and standing
position. The arm must be kept at the level of heart in all positions.
APPARATUS




Mercury sphygmomanometer is most widely used and is more accurate.
Aneroid meter reflects changes in pressure through a needle connected to a spring.
An electronic BP meter may also be employed.
A stethoscope is required in auscultatory method.
TECHNIQUE
- Palpatory method: Feel the radial pulse at wrist and raise the pressure in cuff until the
pulse is no more felt. Reduce the pressure in the cuff now, and note the pressure when the
radial pulse is again felt. This is the systolic pressure.
- Auscultatory method: Raise the pressure in cuff 40 mm above the level obtained in
palpatory method. Place the diaphragm (preferably bell) of the stethoscope over the brachial
artery. No sound is heard. Now, reduce the pressure gradually. Note the pressure at which the
first tapping sound is heard (systolic pressure). The sound now diminishes in quality on
reducing the pressure, and finally disappears (diastolic pressure). These are ‘Korotkoff
sounds’. There are 5 phases in the sounds heard:




Phase 1: First appearance of faint clear tapping sounds (thuds) which gradually
increase in intensity.
Phase 2: Softening of the sounds which may become swishing or blowing.
Phase 3: Return of sharper softer sounds, which become crisper, but never fully
regain the intensity of Phase 1 sounds.
Phase 4: Distinct abrupt muffling of sounds, which become soft and blowing.

Phase 5: Point at which all sounds disappear.
CLASSIFICATION OF BP
Category
Systolic/Diastolic
Optimal
< 120 AND > 80
Normal
< 135 AND > 85
High normal
130-139 OR 85-89
Hypertension (Stage 1)
140-159 OR 90-99
Hypertension (Stage 2)
160-179 OR 100-109
Hypertension (Stage 3)
≥ 180 OR ≥ 110
RESPIRATORY RATE
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Count the patient's respirations for a minute, by diverting their attention elsewhere. This
criterion is especially important because abnormalities in it suggest many pulmonary and
cardiac diseases.
The normal respiratory rate is 16-20/min in adults and may be about 40/min in children. The
pulse-respiration ratio should be about 1:4.
Tachypnea refers to increased respiratory rate. It may occur after exertion or excitement, in
fevers, anemia, acidocis, pain while breathing, etc.
Bradypnea refers to decreased respiratory rate. It occurs during sleep, in narcotic poisoning
e.g. opium, barbiturates, brain tumors, etc.
DYSPNOEA
Breathlessness inappropriate to the level of physical exertion, or even occurring at rest, is
called dyspnoea.
Severity of dyspnoea:
Grade
Degree
Condition
0
None
Not troubled by shortness of breath on level or going uphill
1
Mild
Troubled by shortness of breath on level or going uphill
2
Moderate
Walks slower than people of same age
3
Severe
Has to take a break after walking for about 90-100 meters
4
Very severe
Breathlessness at rest
RHYTHM
Along with rate of respiration, also watch for the rhythm. Normally, the rhythm is regular
with inspiration longer than expiration.
Chyne-Stokes respiration is characterized by rhythmical alteration of apnea and hyperapnea
due to anoxemia. Seen in – Left ventricular failure, increased intracranial pressure, narcotic
poisoning, uraemia, deep sleep, etc.
Kussmaul’s respiration is deep and rapid (air hunger) usually seen in diabetic ketoacidosis,
alcoholic or starvation ketoacidocis and uraemia.
TYPE
Normally, in males abdominal movements are more prominent while breathing
(abdominothoracic). In females, thoracic movements are more prominent while breathing
(thoracoabdominal).
Abdominal breathing is seen in pleurisy, pain in chest, collapse of the lung, etc.
Thoracic breathing may be seen in paralysis of diaphragm, peritonitis and gross ascites.
Top
BY.
DR . AR.WADGAONKAR
PSPMMHMC, SOLAPOUR.