GENERAL EXAMINATION IN SURGERY
Dr. Nitin Baste
I. Introduction
The general examination forms the foundation of every surgical case presentation. While a
detailed local or systemic examination delineates the pathology of the organ or region
involved, it is the general examination that provides insight into the overall health,
nutritional status, and physiological reserve of the patient. In surgical practice, this step is
not merely a ritualistic prelude to the local examination—it is an essential process that
guides diagnosis, operative planning, and postoperative management.
A good surgeon must never view the patient as a collection of symptoms localized to one
anatomical area. Rather, the patient must be evaluated as a whole biological system. Surgical
patients are often older, malnourished, or suffering from multiple comorbidities. The general
examination helps in assessing fitness for anesthesia, detecting contraindications for surgery,
and formulating a perioperative optimization plan.
II. The Examination Approach
A successful examination begins long before the examiner lays hands on the patient. The
attitude, demeanor, and communication of the examiner play an important role in building
confidence and cooperation.
Environmental & Patient Considerations:
• The examination should be conducted in a well-lit, quiet, and private environment.
• Proper exposure of the patient is essential, but modesty must be preserved with the
use of drapes or sheets.
Examiner Conduct:
• Wash hands thoroughly before examination.
• Approach the patient gently, maintaining eye contact, and explain what you intend to
do.
• The patient’s comfort and dignity must be prioritized throughout.
III. The General Survey
A trained observer can glean valuable information from the very first look at the patient—
known as the “general survey.” The patient’s position in bed, facial expression, complexion,
and posture often provide immediate diagnostic clues.
For instance:
• A patient with acute peritonitis may lie motionless, avoiding movement due to pain.
• A patient with intestinal obstruction may appear restless, tossing in bed.
• Severe anemia produces pallor visible even before formal examination.
A. Build and Nutrition
• Body build may be asthenic (slender), athletic, or pyknic (obese).
• Nutritional status is judged by the amount of subcutaneous fat, muscle bulk, and the
presence of muscle wasting.
• Body Mass Index (BMI) offers a quantitative measure:
BMI = Weight (kg) / Height (m)²
o Normal: 18.5 – 24.9
o Underweight: <18.5
o Overweight: 25 – 29.9
o Obese: ≥30
Clinical Implications of Obesity
• Technical difficulty during surgery.
• Wound dehiscence due to poor vascularity of adipose tissue.
• Higher incidence of postoperative respiratory complications.
• Metabolic syndrome—increased risk of diabetes, hypertension, thrombosis.
B. Posture and Gait
• Observe whether the patient is sitting, lying, or standing comfortably.
• Leaning forward may indicate peritonitis or pancreatitis; a bent posture may occur in
spinal disease.
• Gait can be diagnostic:
o Trendelenburg gait indicates hip abductor weakness.
o Spastic gait may follow upper motor neuron lesions.
C. Facial Appearance
The face often reflects the underlying systemic condition:
• Cushingoid face – moon-shaped with plethoric complexion (Cushing’s syndrome).
• Myxedematous face – puffiness with dry skin and loss of eyebrows.
• Facies hepatica – sallow, muddy complexion seen in chronic liver disease.
• Facies parotidica – swelling over the parotid region.
• Anxious face – seen in acute abdomen.
IV. Vital Signs
A. Temperature
• Measured in the axilla, mouth, or rectum.
• Fever patterns may help diagnosis:
o Continuous – typhoid, pneumonia.
o Remittent – infective endocarditis.
o Intermittent – malaria, abscess.
• Hypothermia suggests shock or exposure.
V. Specific Signs of Nutritional Deficiency
Nutrient Deficiency Signs Surgical Implications
Muscle wasting, edema, poor wound Delayed recovery, increased
Protein
healing infection risk
Vitamin A Xerosis, Bitot’s spots Impaired epithelialization
Vitamin B
Glossitis, angular stomatitis Reduced energy metabolism
Complex
Vitamin C Bleeding gums, poor wound healing Collagen deficiency
Vitamin D Bone pain, deformities Osteomalacia
Vitamin K Bleeding tendency Postoperative hemorrhage
Iron Pallor, koilonychia Anemia, poor oxygenation
Zinc Alopecia, dermatitis Impaired wound healing
IV. Vital Signs (Continued)
B. Pulse
Assess rate, rhythm, volume, character, and condition of the vessel wall.
• Tachycardia is common in fever, anemia, thyrotoxicosis, or shock.
• Bradycardia may occur in raised intracranial pressure or heart block.
C. Blood Pressure
• Both arms should be examined.
• Hypertension is relevant to perioperative management and anesthesia.
• Postural hypotension suggests hypovolemia.
D. Respiratory Rate
• Normal: 12–20 breaths/min.
• Tachypnea indicates respiratory distress, fever, or acidosis.
• Observe pattern: Kussmaul’s breathing (metabolic acidosis), Cheyne–Stokes (CNS
lesion).
V. Signs of Anemia, Cyanosis, and Jaundice
A. Pallor
Pallor is the paleness of skin and mucous membranes resulting from reduced oxyhemoglobin
in capillaries, most often due to anemia. It denotes a reduced hemoglobin concentration.
• Best appreciated in: Lower palpebral conjunctiva, nail beds, and palmar creases.
• Causes: Chronic blood loss (e.g., hemorrhoids, peptic ulcer), nutritional deficiency,
malignancy, renal disease.
Common Sites to Look for Pallor
Always examine under natural light or bright white light — never under yellow bulbs.
Site How to Examine Why It’s Reliable
Lower palpebral Pull down lower eyelid and inspect color of Most reliable site (vascular, th
conjunctiva mucosa epithelium)
Tongue and oral mucosa Ask patient to protrude tongue Early indicator in darker skin t
Palm and nail beds Compare with your own Good for quick screening
Face and lips Look for generalized pallor May be subtle in chronic case
Earlobes Observe overall coloration Useful in emergencies
If both are pale → almost always true
Conjunctiva + Tongue Confirms systemic pallor
anemia
Grading of Pallor (Clinical Grading)
Approx.
Grade Clinical Description Remarks
Hb Level
Just perceptible pallor of
Mild Pallor 10–11
conjunctiva and tongue; skin Often asymptomatic
(Grade I) g/dL
appears normal
Moderate May cause easy
Obvious pallor of conjunctiva,
Pallor (Grade 7–9 g/dL fatigability, mild
tongue, and nail beds
II) tachycardia
Marked pallor of skin, lips,
Dyspnea,
Severe Pallor tongue, palms, nail beds;
<7 g/dL tachycardia, heart
(Grade III) sometimes “paper-white”
failure possible
appearance
Importance in Surgical Patients
• Preoperative optimization: Detect anemia before surgery (especially if Hb <10 g/dL).
• Postoperative monitoring: Sudden pallor may indicate internal bleeding.
• Diagnostic guidance:
o Pallor + lymphadenopathy → lymphoma.
o Pallor + ascites → chronic liver disease.
• Prognostic significance: Severe pallor implies poor oxygen-carrying capacity and
delayed wound healing.
B. Cyanosis
Bluish discoloration of skin and mucous membranes due to increased deoxygenated
hemoglobin (>5 g/dL).
• Central cyanosis – Indicates heart or lung disease.
• Peripheral cyanosis – Caused by vasoconstriction or cold exposure.
• Distinguish from pseudo-cyanosis due to drug pigmentation.
C. Jaundice
Yellow discoloration due to bilirubin accumulation (>2 mg/dL). Check sclera and soft palate.
• Types:
o Prehepatic – Hemolytic (mild yellow tint, no bilirubinuria).
o Hepatic – Hepatitis, cirrhosis.
o Posthepatic – Obstructive (e.g., gallstones, malignancy), with deep yellow or
greenish tinge and pruritus.
• Surgical Relevance: Obstructive jaundice due to gallstones or malignancy is of great
relevance.
VI. Lymph Node Examination
A. Areas to Examine
Occipital, posterior auricular, submandibular and submental, cervical (anterior, posterior,
supraclavicular), axillary, inguinal.
B. Characteristics to Note
• Site and number of nodes.
• Size – measured in centimeters.
• Shape – round, ovoid, irregular.
• Surface – smooth or nodular.
• Consistency – soft (infection), firm (lymphoma), hard (metastatic).
• Tenderness – indicates inflammation.
• Fixity – to skin or deeper tissue.
• Matted nodes – typical of tuberculosis.
C. Surgical Importance
• Virchow’s node: Supraclavicular node enlargement on the left (Troisier’s sign) may
indicate abdominal malignancy.
• Axillary nodes must be examined in breast cases.
• Inguinal nodes in limb or perineal pathology.
VII. Edema
A. Types
• Pitting edema – Leaves an indentation (cardiac, renal, hepatic causes).
• Non-pitting edema – Lymphedema, myxedema.
B. Distribution
• Localized – Limb or periorbital (venous obstruction, lymphedema).
• Generalized (anasarca) – Cardiac failure, nephrotic syndrome.
C. Surgical Relevance
• Chronic lymphedema may predispose to infection or lymphangiosarcoma.
• Peri-operative fluid management must account for edema status.
VIII. Hydration and Dehydration
A. Signs of Dehydration
Sunken eyes, dry tongue, reduced skin turgor, tachycardia, low blood pressure, poor capillary
refill, concentrated urine and reduced output.
B. Surgical Significance
• Correct fluid and electrolyte imbalance before anesthesia.
• Persistent dehydration in vomiting or obstruction must be aggressively managed.
IX. Skin, Hair, and Nails
A. Skin
Observe color, texture, and lesions.
• Pigmentation – Addison’s disease, hemochromatosis.
• Rashes – Secondary syphilis, drug eruptions.
• Ulcers, scars, or sinuses may suggest chronic infection or previous surgery.
• Spider naevi and palmar erythema are indicators of chronic liver disease.
B. Hair
• Loss of body hair indicates endocrine or nutritional disorders.
• Hirsutism may occur in Cushing’s syndrome.
C. Nails
Nail Change Description Common Causes
Koilonychia Spoon-shaped nails Iron deficiency anemia
Leukonychia White nails Chronic liver disease, hypoalbuminemia
Loss of nail-bed angle, spongy Bronchiectasis, lung cancer, congenital heart disease,
Clubbing
base ulcerative colitis
Onycholysis Separation of nail plate Thyrotoxicosis, psoriasis
Beau’s Lines Transverse grooves Severe illness, chemotherapy
Pitting Pinhead depressions Psoriasis
Clubbing – Clinical Grading
1. Stage 1: Fluctuation and softening of nail bed.
2. Stage 2: Loss of the normal nail–bed angle (Lovibond’s angle > 180°).
3. Stage 3: Increased curvature of nails (drumstick appearance).
4. Stage 4: Hypertrophic osteoarthropathy (periosteal new bone formation).
Surgical Relevance: Clubbing is significant in lung carcinoma, empyema, chronic suppurative
lung disease, cyanotic congenital heart disease, ulcerative colitis, or cirrhosis.
X. Endocrine Manifestations in Surgical Patients
Disease Characteristic Features
Thyrotoxicosis Tremor, tachycardia, exophthalmos, warm moist skin
Myxedema Puffy face, dry skin, bradycardia
Cushing's syndrome Central obesity, moon face, striae, hypertension
Disease Characteristic Features
Addison's disease Generalized pigmentation, hypotension
Acromegaly Large hands, jaw prognathism, spade-like fingers
XI. Eyes and Face
The eyes are “the window to systemic disease.”
A. Conjunctiva and Sclera
• Pallor → anemia.
• Jaundice → yellow discoloration of sclera (bilirubin deposition).
• Cyanosis → bluish discoloration (rare).
• Xanthelasma → yellow plaques near medial canthus, associated with
hyperlipidemia.
XII. Oral Cavity and Tongue Examination
A. Lips
Pallor (anemia), cyanosis (hypoxemia), angular stomatitis (riboflavin deficiency),
ulcers/fissures (trauma, herpes, carcinoma).
B. Teeth
Dental caries (chronic sepsis), loose teeth (periodontitis, scurvy). Poor dentition increases
postoperative infection risk.
C. Tongue
• Pale tongue – anemia.
• Beefy red tongue – vitamin B12 deficiency.
• Glossitis – iron deficiency or pellagra.
• Furred tongue – dehydration, poor oral hygiene.
• Macroglossia – amyloidosis, acromegaly, hypothyroidism.
• Leukoplakia – precancerous white patches (requires biopsy).
D. Mucous Membranes
Pigmentation (Addison’s), petechiae (thrombocytopenia), ulcers (malignancy, TB, aphthous
conditions).
XIII. Examination of the Neck
Observe for: Swelling/asymmetry (thyroid, lymph nodes, cysts), scars/sinuses (previous
surgery, TB), jugular venous distension (cardiac failure, SVC obstruction).
Surgical Relevance: Crucial for assessing:
• Virchow’s node (left supraclavicular) in GI malignancies.
• Supraclavicular nodes in carcinoma breast.
• Cervical nodes in head and neck malignancies.
XIV. Back and Spine
• Scars or sinuses – suggest previous surgery, tuberculosis, or pilonidal disease.
• Bedsores (decubitus ulcers) – over sacrum, heels, or scapulae in bedridden patients.
• Tenderness – over vertebrae indicates osteomyelitis, metastasis, or trauma.
Surgical Importance:
• Bedsores reflect prolonged immobility and poor nursing care.
• Spinal deformity may influence positioning during anesthesia or surgery.
XV. Signs of Chronic Liver Disease
Jaundice, spider naevi, palmar erythema, gynecomastia, testicular atrophy, ascites, asterixis
(flapping tremor).
XVI. ASA Physical Status Classification
ASA Grade Description Example
I Normal healthy patient Hernia repair in young
ASA Grade Description Example
II Mild systemic disease Controlled hypertensio
III Severe systemic disease COPD, diabetes mellitu
IV Severe disease, constant threat to life Decompensated heart
V Moribund patient not expected to survive without operation Ruptured aneurysm
XVII. Predictors of Poor Postoperative Outcome
• Severe malnutrition or cachexia.
• Anemia and hypoproteinemia.
• Jaundice or hepatic dysfunction.
• Edema and dehydration.
• Uncontrolled diabetes or hypertension.
XVIII. Common Errors in General Examination
• Neglecting the general survey and proceeding directly to local examination.
• Recording findings without actually observing them.
• Ignoring subtle clues (spider naevi, tremor, lymphadenopathy).
• Poor organization of findings.
• Failure to correlate general findings with the surgical problem.
XIX. Practical Pearls for Clinical Examination
• Observe before touching – inspection often gives the most information.
• Always compare bilaterally – asymmetry is a vital clue.
• Examine from head to toe in a logical order.
• Document findings objectively – avoid subjective adjectives.
• Correlate signs with symptoms – integration distinguishes a clinician from a
technician.
• Never rush – a thorough general examination rarely takes more than 5–7 minutes
but reveals a wealth of information.
XX. How to Present Findings in an Exam
Opening Statement:
"The patient is [alert/conscious/drowsy], [cooperative], and [lying
comfortably/uncomfortably] in bed. He/She appears [well nourished/moderately
built/cachectic]."
Systematic Description:
• Posture: [Erect / leaning / lying still].
• Gait: [Normal / antalgic / spastic / ataxic].
• Facial expression: [Anxious / distressed / calm / toxic].
• Vital Signs: "Patient is afebrile. Pulse is 80/min, regular in rhythm, good volume.
Blood pressure is 120/80 mmHg in the right arm in supine position. Respiratory rate
is 15/min, [abdominothoracic/thoracoabdominal]."
• General Survey:
o Build & Nutrition: [Good / average / poor].
o Hydration: [Normal / dehydrated].
o Anemia (pallor): [Present / absent].
o Jaundice: [Present / absent].
o Cyanosis: [Present / absent].
o Clubbing: [Present / absent].
o Lymphadenopathy: [Present / absent – specify site, size, consistency].
o Edema: [Pitting / non-pitting / absent].
• Conclusion: "On further general examination, the skin, nails, hair, eyes, face, oral
cavity, neck, spine, and extremities do not reveal any other abnormalities."
XXI. Summary and Clinical Significance
The general examination serves as the gateway to clinical reasoning in surgery. It establishes
the patient’s baseline physiological status and often provides the first clue to diagnosis. It
bridges the gap between symptomatology and systemic pathophysiology, reminding the
clinician that no local lesion can be interpreted in isolation.
XXII. The Surgeon’s Perspective
General examination represents more than physical assessment—it reflects the art and
philosophy of surgery. To quote Sir William Osler: “The good physician treats the disease; the
great physician treats the patient who has the disease.” In the same spirit, the good surgeon
examines the lesion, but the great surgeon examines the patient. Every tremor,
discoloration, or scar narrates a story. The general examination is your means of listening to
that story.