General Clinical Examination: Revision Notes & Key Signs

General Examination — Revision Notes The Setting Introduce yourself as a "student doctor," explain what you will do, and obtain consent before proceeding Warm, private, quiet room; chaperone required when a male examines a female (especially for breast, rectal, and vaginal examination) Examine from the right side of the bed; patient semi-recumbent at 45 degrees Ask about pain before touching; look at the patient's face throughout for signs of discomfort First assess: how ill is the patient? — well, mildly ill, or severely ill. In a severely ill patient, manage the acute emergency first --- 1. Posture and Gait Start observing from the moment the patient enters the room. Gait / Posture Suggests --- --- Hemiplegic gait Stroke Parkinsonian gait (shuffling, stooped) Parkinson's disease Antalgic gait (limp) Painful joint High-stepping gait Sensory ataxia Veers toward one side Cerebellar lesion — veers toward the side of the lesion Difficulty rising from chair Proximal muscle weakness Propped up in bed Left heart failure (orthopnoea) Lies supine, still, legs drawn up Peritonitis Restless, rolls around Renal colic Neck bent backwards Meningism --- 2. Speech and Interaction Does the patient smile symmetrically? Asymmetry = facial weakness Eye contact, facial animation, emotional expression Expressionless face — Parkinson's disease or severe depression Hoarse voice — laryngeal disease, recurrent laryngeal nerve palsy, myxoedema Pressured speech — thyrotoxicosis or mania Monotonous speech — severe depression Slurred speech — cerebellar disease or previous stroke --- 3. Physique and Nutrition Note if patient is cachectic, slim, plump, or obese Indicators of poor nutrition: temporalis muscle wasting, cracked skin, hair loss, poor wound healing Atrophic glossitis — smooth tongue with loss of papillae; vitamin B12 deficiency Angular stomatitis — cracking at the angles of the mouth; vitamin B or iron deficiency Pellagra — photosensitive dermatitis; niacin (B3) deficiency --- 4. Temperature Diurnal variation: lowest in the morning, highest between 6–10 PM Ovulation causes a 0.5°C rise in women Normal ranges: Oral: 35.8–37°C Axillary: 35.3–36.5°C Rectal: 36.3–37.5°C (highest — closest to core) --- 5. Hands Handshake Weak grip → neurological or musculoskeletal disorder Tremor Type Cause --- --- Fine tremor Thyrotoxicosis, recent beta-agonist use Pill-rolling tremor Parkinsonism Jerky (asterixis/flap) Hepatic or uraemic encephalopathy Intention tremor Cerebellar disease Dupuytren's contracture — thickening of tissue over the flexor tendon of the ring finger at the distal palmar crease → progresses to flexion contracture of MCP and PIP joints. Risk factors: family history, alcoholism, diabetes, liver disease. Clubbing — nails convex both longitudinally and transversely; Lovibond's angle increased. Causes: cyanotic heart disease, bronchiectasis, empyema, bronchial carcinoma, fibrosing alveolitis, IBD, infective endocarditis. Nail signs: Sign Appearance Association --- --- --- Osler's nodes Transient, tender swellings Infective endocarditis (septic emboli) Splinter haemorrhages Tiny subungual blood streaks Trauma or vasculitis Koilonychia Spoon-shaped concave nails Severe iron deficiency Leuconychia Opaque white nails Chronic liver disease, hypoalbuminaemia Beau's lines Horizontal nail depressions Systemic illness, chemotherapy, malnutrition --- 6. Odour Alcohol Organophosphate (pesticide poisoning) Halitosis — suppurative lung disease, gingivitis --- 7. Face and Neck 3rd nerve palsy — ptosis, eye deviated down and out, dilated pupil 7th nerve palsy — unilateral facial weakness (upper vs lower motor neuron pattern) Parotid swelling — mumps, alcoholism, acute parotitis, tumour Malar flush — mitral stenosis Malar rash (butterfly rash) — SLE JVP — assess for elevated venous pressure Neck swellings — thyroid, thyroglossal cysts, enlarged lymph nodes --- 8. Lymph Nodes Use pulps of index and middle fingers to palpate Assess: size, shape, mobility, position, consistency, tenderness, coalescence Tender/painful nodes → infection Non-tender, firm nodes → malignancy (until proven otherwise) Drainage regions: Upper limb and breast → axillary nodes Lower limb → inguinal nodes (superficial vertical and horizontal groups) Head and neck → cervical nodes --- 9. Axillae Axillary adenopathy — infection, lymphoma, breast cancer spread Absence of axillary hair — chronic liver disease Acanthosis nigricans — dark velvety skin in axillae; associated with insulin resistance and occasionally gastric cancer --- 10. Skin Temperature — hot in thyrotoxicosis, febrile illness; cold and clammy in shock Hydration — assess skin turgor (pinch skin) Pallor — check palms, conjunctiva, tongue Jaundice — check sclera, posterior tongue, skin Cyanosis — bluish discolouration; check hands (peripheral) and tongue (central) --- 11. Pulses Palpate: radial, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis. Always compare both sides. --- 12. Blood Pres