APPROACH TO PATIENT FOR

CLINICAL EXAMINATION
IN SURGERY
BY
S
DHILIPKUMAR
PHYSICAL EXAMINATION:
General survey
Local examination
General examination
GENERAL SURVEY:
 Under this heading comes general assessment of
illness, mental state, intelligence, build, state of
nutrition, the attitude, the decubitus (position in bed),
colour of the skin, skin eruptions if present and pulse,
respiration and temperature.
 Physical examination starts when the patient enters
the clinic. It requires daylight and of course a co-
operative patient. In artificial light, one may miss the
faint yellow tinge of slight jaundice. For complete
examination, the patient should be asked to take off
all his clothes and covered by only a dressing gown.
For examining a female patient there must be an
attendant nurse.
MENTAL STATE AND INTELLIGENCE:
 Mental State ( Level of consciousness) is of particular
importance in a head injury patient. There are 5
stages of level of consciousness :
 1.Fully conscious with perfect orientation of time,
space and person
 2.Fully conscious with lack of orientation of time and
space
 3.Semiconsciousness (drowsy) but can be awakened
 4.Unconscious (stupor), but responding to painful
stimuli
 5.Unconscious (coma) and not responding to painful
stimuli. In all cases clinician must be well aware of the
mental state of his patient.
BUILD AND STATE OF NUTRITION:

 Besides the fact that a few endocrine

abnormalities become obvious from the build
of the patient, a hint to clinical diagnosis may
be achieved from a look on the build of the
patient. As for example, a cachectic patient
suffering from an abdominal discomfort with a
lump, is probably suffering from carcinoma of
some part of the G.I. tract
ATTITUDE:
 This is very important and gives valuable information to arrive at a
diagnosis.

 Patients with pain due to peritonitis lie still, whereas patients with
colicky pain become restless and toss on the bed. Meningitis of the
neck will show neck retraction and rigidity.

 An old patient after a fall, when lies helplessly with an everted leg,
possibility of fracture of the neck of the femur becomes obvious
GAIT:
 This means the way the patient walks. Abnormal gait occurs due
to various reasons:
 (a) Pain
 (b) Bone and joint abnormalities
 (c) Muscle and neurological diseases
 (d) Structural abnormalities and
 (e) Psychiatric diseases.
 'Waddling gait' is typical in bilateral congenital dislocation of hip
and bilateral coxa vara.
 'Trendelenburg gait' is typically seen in muscle dystrophies,
poliomyelitis, unilateral coxa vara , Perthes disease and different
arthritis of the hip.
FACIES:
 The face is the 'mirror of the mind' and the eyes are
the 'windows of the mind'.
 Just looking at the face good clinician can assess the
depth of the disease and effect of his treatment. The
general diagnostic importance of the facies is
enormous.
 Typical FADES HIPPOCRATICA In generalized
peritonitis
 “RISUS SARDONICUS” in tetanus
 “MASK FACE” in Parkinsonism
 “MOON FACE” in Cushing's syndrome and
 “ADENOID FACIES” in hypertrophied adenoids
DECUBITUS:
 This means the position of the patient in bed. This is
sometime informatory, e.g. in cerebral irritation the patient
lies curled upon his side away from light.

RESPIRATION:
 Tachypnoea (fast breathing) is seen in fever, shock,
hypoxia, cerebral disturbances, metabolic acidosis,
tetany, hysteria etc. Slow and' deep respiration is an
ominous sign in cerebral compression. Also note if
there is any irregular breathing e.g. Cheyne-Stokes
respiration. In Cheyne-Stokes respiration there is
gradual deepening of respiration or overventilation
alternating with short periods of apnoea
COLOUR OF THE SKIN:
 PALLOR of the skin is seen in massive haemorrhage, shock and
intense emotion. Anaemic patients are also pale. One should look
at the lower palpebral conjunctiva, mucous membrane of the lips
and cheeks, nail beds and palmar creases for pallor.
 CYANOSIS i.e. bluish or purplish tinge of the skin or mucous
membrane which results from the presence of excessive amount
of reduced haemoglobin in the underlying blood vessels. It may
be either due to poor perfusion of these vessels (peripheral
cyanosis) or due to reduction in the oxygen saturation of arterial
blood (central cyanosis). For cyanosis to be observed, there must
be a minimum of 5 g/dl of reduced haemoglobin in the blood
perfusing the skin. So cyanosis is not detectable in presence with
severe anaemia.
 Peripheral cyanosis is due to excessive reduction of oxyhaemoglobin
in the capillaries when the blood flow is slowed down. This may
happen on exposure to cold (cold-induced vasoconstriction). It is also
seen in patients with reduced cardiac output when differential
vasoconstriction diverts blood flow from the skin to other more
important organs e.g. the brain, the kidney etc. Peripheral cyanosis is
looked for in the nail bed, tip of the nose, skin of the palm and toes.
 Central cyanosis occurs from inadequate oxygenation of blood in the
lungs. This may be due to diseases in the lungs or due to some
congenital abnormalities of the heart where venous blood by-passes
the lung and is shunted into the systemic circulation. For central
cyanosis one should look at the tongue and other places as mentioned
above. The tongue remains unaffected in peripheral cyanosis. Very
occasionally cyanosis may be due to the presence of abnormal
pigments e.g. methaemoglobin or sulphaemoglobin in the blood
stream. In these cases arterial oxygen tension is normal. This may
occur due to taking of drugs such as phenacetin. Carbonmonoxide
poisoning produces a generalized cherry-red discolouration.
 JAUNDICE is due to icteric tint of the skin, which varies from faint
yellow of viral hepatitis to dark olive greenish yellow of obstructive
jaundice. This is due to the presence of excess of lipid-soluble
yellow pigments (mostly the bile pjgments) in the plasma. The
places where one should look for jaundice are — (i) sclera of the
eyeball — for this the patient is asked to look at his feet when the
surgeon keeps the palpebral fissure wide open by pulling up the
eyelid, (ii) nail bed, (iii) lobule of the ear, (iv) tip of the nose, (v)
under-surface of the tongue etc. When the jaundice is deep and
long standing, a distinct greenish colour becomes evident in the
sclerae and in the skin due to the development of appreciable
quantities of biliverdin. Scratch marks may be prominent in the
skin in obstructive jaundice as a result of pruritus which is believed
to be due to retention of bile acids.
 Jaundice may be confused with hypercarotinaemia in which yellow
pigment of carotene is inequally distributed and is particularly seen
in the face, palms and soles but not in the sclerae. Such
hypercarotinaemia may occur occasionally in vegetarians and in
those who eat excessive quantities of raw carrot.
SKIN ERUPTIONS:
 Under this heading comes macules, papules, vesicles, pustules, wheals etc.
 Macules — are alterations in the colour of the skin, which are seen but not
felt. They may be due to capillary naevi or erythemas which disappear on
pressure, whereas purpuric macules do not blanch when pressed.
 Papules — are solid projections from the surface of the skin. It may be
epidermal papule, e.g. a wart or a dermal papule, which will become less
prominent if the skin is stretched, e.g. a granuloma of tuberculosis,
reticulosis or sarcoidosis.
 Vesicles — are elevations of horny layer of the epidermis by collection of
transparent or milky fluid within them.
 Pustules — are similar elevations of the skin as vesicles, but these contain
pus instead of fluid within them.
 Wheal — is a flat oedematous elevation of the skin frequently accompanied
by itching. It is the typical lesion of urticaria and may be seen in sensitive
persons provoked by irritation of the skin.
PULSE:
 Pulse gives a good indication as to the severity of acute
appendicitis and thyrotoxicosis. Generally it gives a good
indication of the cardio-vascular condition of the patient.
Abnormalities of the heart and the vascular system, e.g.
hypertension and hypotension are also revealed in pulse. Shock,
fever and thyrotoxicosis are a few conditions, which are well
reflected in pulse.
 Following points are particularly noted in pulse :— (a) Rate —
fast or slow, (b) Rhythm — regular or irregular, (c) Tension and
force which indicate diastolic and systolic blood pressure
respectively, (d) Volume which indicates pulse pressure, (e)
Character e.g. Water-hammer pulse of aortic regurgitation or
thyrotoxicosis, pulsus paradoxus of pericardial effusion etc. and
(f) condition of arterial wall e.g. atherosclerotic thickening etc.
TEMPERATURE:
 This is normally taken in the mouth or in the axilla of the patient.
The temperature of the mouth is about 1°F higher than that of
the axilla..
 There are three types of fever :
 CONTINUED, REMITTENT and INTERMITTENT.
 When the fever does not fluctuate for more than 1°C during 24
hours, but at no time touches the normal, it is described as
continued. When the daily fluctuations exceed 2°C it is
remittent and when the fever is present only for a few hours
during the day, it is called intermittent. When a paroxysm of
intermittent fever occurs daily, it is called quotidian, when on
alternate days it is called tertian and when two days intervene
between the consecutive attacks, it is called quartan.
LOCAL EXAMINATION:
 This is the most important part in the physical examination, as a
careful local examination will give a definite clue to arrive at a
diagnosis. By 'Local examination' we mean examination of the
affected region. This should be done by
 INSPECTION (looking at the affected part of the body)
 PALPATION (feeling of the affected part by the hands of the surgeon)
 PERCUSSION (listening to the tapping note with a finger on a finger
placed on the affected part)
 AUSCULTATION (listening to the sounds produced within the body
with the help of a stethoscope)
 MOVEMENTS (of the joints concerned)
 MEASUREMENTS (of the part of the body concerned)
 Examination of the lymph nodes draining the affected area.
GENERAL EXAMINATION:
 For the diagnosis and differential diagnosis: Cases are on
record when teen-aged boy with the complain of pain in the right
iliac fossa was referred to the hospital by the general physician
as a case of acute appendicitis. Only after examination of the
scrotum, the surgeon found torsion of the testis as the cause of
pain and not appendicitis.
 For selecting the type of anaesthetic.
 To determine the nature of the operation.
 To determine the prognosis.
HEAD AND NECK:
 Cranial nerves — particularly the 3rd, 4th, 5th, 6th, 7th, 9th, 11th
and 12th cranial nerves should be examined.
 Eyes.— Tests are done to know the visual field, condition of the
conjunctiva and pupils (equality, reaction to light and
accommodation reflex), movements of the eye and ophthalmic
examination
 Mouth and pharynx.— Teeth and gum, movement of soft palate,
the tongue and its undersurface, tonsils and lips for colour,
pigmentation (seen in Peutz-Zegher syndrome) and eruptions.
 Movements of the neck, neck veins and lymph nodes of the neck,
carotid pulses and the thyroid gland.
UPPER LIMBS:
 General examination of the arms and hand with
particular reference to their vascular supply and nerve
supply
(Power, tone, reflexes and sensations).
 2) Axillae and lymph nodes.
 3) Joints.
 4) Finger nails — clubbing or koilonychia.
THORAX:
 1) Type of chest.
 2) Breasts.
 3) Presence of any dilated vessels and pulsations.
 4) Position of the trachea.
 5) Apex beat.
 6) Lungs — as a whole, i.e. inspection, palpation, percussion and
auscultation.
 7) The heart should be examined as a whole, i.e. palpation,
percussion and auscultation.
ABDOMEN:
 1) Abdominal wall — position of the umbilicus, presence of scars,
dilated vessels etc.
 2) Abdominal reflexes.
 3) Visible peristalsis or pulsation.
 4) Generalized palpation, percussion and auscultation.
 5) Hernial orifices.
 6) Genitalia.
 7) Inguinal glands.
 8) Rectal examination.
 9) Gynaecological examination, if required
LOWER LIMBS:
 1) General Examination of legs and feet — with
particular reference to the vascular supply and nerve
supply
(Power, tone, reflexes and sensation).
 2) Varicose vein.
 3) Oedema.
 4) Joints.

EXAMINATION OF EXTERNAL GENITALIA

Sputum ,vomit , urine and stool should be
examined by naked eye and under microscope if required
THANK
YOU