The nutritional state of a patient may provide an important indicator of disease, and prompt correction of a deficient nutritional state may improve recovery. The more detailed methodologies available for nutritional assessment and management in the context of complex gastrointestinal disease are covered in Chapter 12. In the general survey, note if the patient is cachectic, slim, plump or obese. If obese, is it generalised or centrally distributed? Wasting of the temporalis muscle leads to a gaunt appearance and recent weight loss may result in prominence of the ribs. Other clues to poor nutrition include cracked skin, loss of scalp and body hair and poor wound healing. Malnutrition accompanying illness results in blood albumin being low leading to oedema, making overall body weight an unreliable marker of malnutrition. A smooth, often sore tongue without papillae (atrophic glossitis, Fig. 2.1) suggests important vitamin B deficiencies. Angular stomatitis (cheilosis, a softening of the skin at the angles of the mouth followed by cracking) may occur with a severe deficiency of iron or B vitamins (Fig. 2.1). Niacin deficiency, if profound, may cause the typical skin changes of pellagra (Fig. 2.2).

Figure 2.1 Atrophic glossitis in a patient with severe vitamin B₁₂ deficiency. There is also angular stomatitis from severe iron deficiency.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Figure 2.2 Pellagra as a result of niacin deficiency.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Temperature

Body temperature may be recorded in the mouth, axilla, ear or rectum. A ‘normal’ mouth temperature is 35.8-37°C. Those in the ear and rectum are 0.5°C higher and and in the axilla 0.5°C lower. There is a diurnal variation in temperature; the lowest values are recorded in the early morning with a maximum between 6 and 10 pm. In women, ovulation is associated with a 0.5°C rise in temperature. In hospitalized patients, regular temperature measurements may identify certain characteristic patterns of disturbance. A persistent fever is one that does not fluctuate by more than 1°C during 24 hours; a remittent fever oscillates by 2°C during the course of a day; and an intermittent or spiking fever is present for only several hours at a time before returning to normal. None has great sensitivity or specificity for any particular diagnosis, but changes may provide useful information about the course of a disease.

Hands

Examine the hands carefully as diagnostic information from a variety of pathologies may be evident. The strength of the patient’s grip may be informative with regard to underlying neurological or musculoskeletal disorders. Characteristic patterns of muscular wasting may accompany various neuropathies and radiculopathies (see Ch. 14). Make note of any tremor, taking care to distinguish the fine tremor of thyrotoxicosis or recent beta-adrenergic therapy, from the rhythmical ‘pill rolling’ tremor of parkinsonism (see Ch. 14), and from the coarse jerky tremor of hepatic or uraemic failure (sufficiently slow to be referred to as a metabolic ‘flap’).

Feel for Dupuytren’s contracture in both hands, the first sign of which is usually a thickening of tissue over the flexor tendon of the ring finger at the level of the distal palmar crease. With time, puckering of the skin in this area develops, together with a thick fibrous cord, leading to flexion contracture of the metacarpophalangeal and proximal interphalangeal joints. Flexion contracture of the other fingers may follow (Fig. 2.3).

Figure 2.3 Dupuytren’s contracture.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

In clubbing of the fingers, the tissues at the base of the nail are thickened and the angle between the base of the nail and the adjacent skin of the finger is lost. The nail becomes convex both transversely and longitudinally and, in gross cases (usually due to severe cyanotic heart disease, bronchiectasis or empyema), the volume of the finger pulp increases (Fig. 2.4). Lesser degrees of clubbing may be seen in bronchial carcinoma, fibrosing alveolitis, inflammatory bowel disease and infective endocarditis. The last of these may also be associated with Osler’s nodes – transient, tender swellings due to dermal infarcts from septic cardiac vegetations (Fig. 2.5). Splinter haemorrhages (Fig. 2.6) and nail-fold infarctions (Fig. 2.7) may be signs of a vasculitic process, but may also be the result of trauma in normal individuals and are therefore rather non-specific.

Figure 2.4 Clubbing of the fingers. This case is very marked.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Figure 2.5 Small dermal infarcts in infective endocarditis.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Figure 2.6 Splinter haemorrhages.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Figure 2.7 Nail-fold infarction.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Trophic changes may be evident in the skin in certain neurological diseases and in peripheral circulatory disorders such as Raynaud’s syndrome, in which vasospasm of the digital arterioles causes the fingers to become white and numb, followed by blue/purple cyanosis and then redness due to arteriolar dilatation and reactive hyperaemia (Fig. 2.8).

Figure 2.8 Raynaud’s syndrome in the acute phase with severe blanching of the tip of one finger.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

In koilonychia the nails are soft, thin, brittle and the normal convexity replaced by a spoon-shaped concavity (Fig. 2.9). It is usually due to longstanding iron-deficient anaemia. Leuconychia (opaque white nails) may occur in chronic liver disease and other conditions associated with hypoalbuminaemia (Fig. 2.10).

Figure 2.9 Koilonychia.

(Reproduced with permission from Mir 2003 Atlas of Clinical Diagnosis, 2nd edn, Saunders, Edinburgh.)

Figure 2.10 Leuconychia in a patient with chronic liver disease.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Odours

Certain odours may provide diagnostic clues. The odour of alcohol on the patient’s breath is easily recognizable, but do not assume that an alcoholic foetor implies alcoholism or that all the patient’s current symptoms and signs are related to alcohol intoxication. Patients with alcohol dependence may have reversible problems such as hypoglycaemia or a subdural haematoma. The odour of diabetic ketoacidosis resembles acetone (‘pear drops’ or nail varnish remover) and those of hepatic failure and uraemia have been described as ‘ammonia-like’ or ‘mousy’ respectively, but such terms are rather subjective and their use is limited. Halitosis (bad breath) is common in patients with suppurative lung diseases and those with gingivitis due to poor dental hygiene. As with all smells, they are difficult to describe but can be characteristic when previously experienced and learnt.

Lymph glands and lymphadenopathy

Details pertaining to the examination of specific lymph node groups may be found in the relevant chapters (e.g. Ch. 20 for cervical lymphadenopathy). Here, the principles of palpating for lymphadenopathy will be covered. Lymph nodes are interposed along the course of lymphatic channels and their enlargement should always be noted. Lymph from the arm drains into the axillary nodes. These should be routinely examined, but particularly in conjunction with examination of the breast (see below). Lymph from the lower limbs drains via deep and superficial inguinal nodes, although only the latter can be palpated and, in turn, comprise a vertical and horizontal group. The vertical inguinal nodes lie close to the upper part of the long saphenous vein and drain the leg. The horizontal group lies above the inguinal ligament and drains the lower abdominal skin, anal canal, external genitalia (excluding the testes), buttocks and lower vagina.

Examination of lymph nodes involves inspection and palpation. Inflammation of the overlying skin and associated pain usually implies an infective aetiology, whereas malignant lymphadenopathy is usually non-tender. To palpate for lymphadenopathy, use the pulps of your fingers (usually the index and middle but, for large nodes, the ring as well) to move the skin overlying the potentially enlarged node(s). Determine the size, position, shape, consistency, mobility, tenderness and whether it is an isolated lymph node or whether several coalesce. For the head and neck nodes, it is often helpful to tilt the head slightly towards the side of examination in order to relax the overlying muscles. Feel for each of the groups shown in Figure 2.11 in whatever order you find most efficient and reliable. Muscles and arteries in the neck and groin may be mistaken for lymph nodes. If in doubt, try to move the structure in question in two directions (laterally and superior to inferior). It should be possible to move a lymph node in two directions, but not an artery or muscle.

Figure 2.11 The cervical lymph node groups.

Determining whether a lymph node is pathological can be difficult and requires practice and experience. In general, small, mobile, discrete lymph nodes are frequently found in normal individuals, particularly those who are slim and have little overlying adipose tissue. The finding of an enlarged lymph node should prompt the question ‘Is this consequent upon local pathology, for example infection or malignancy, or is it part of a more generalized abnormality of the reticuloendothelial system (including other lymph node groups, liver and spleen)?’ (Fig. 2.12).

Figure 2.12 Gross enlargement of supraclavicular and cervical lymph nodes.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Axillae

Most information from examination of the axillae comes from palpation for possible lymphadenopathy (Fig. 2.13), but inspection may reveal an absence/paucity of secondary sexual hair in either gender (most commonly in association with chronic liver disease, but also in certain endocrinopathies), abnormal skin colouring, such as the dark velvety appearance of acanthosis nigricans, or (very rarely and almost always in the presence of café au lait spots elsewhere) the characteristic freckling of von Recklinghausen’s disease.

Figure 2.13 Gross (in this case, painless) axillary lymph node enlargement.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Support the weight of the patient’s arm by holding his arm at the elbow with your non-examining hand, so that the patient’s pectoral muscles are relaxed. With the fingers of your right hand cupped together, probe the apex of the left axilla, then slide them downwards against the chest wall to feel for lymphadenopathy. Next, ‘sweep’ your fingers along the inside of the anterior and posterior axillary folds, feeling for enlargement of the pectoral and subscapular lymph nodes respectively. Use your left hand in the same way to examine the right axilla.

Skin

Examination of the skin with respect to specific dermatological diagnoses is covered in Chapter 15. In the context of the general examination, the most important features relate to temperature, hydration, pallor, colour/pigmentation and cyanosis. Use the back of your fingers to assess the temperature of the skin. This complements rather than replaces the formal measurement with a thermometer. There may be generalized warmth in febrile illness or thyrotoxicosis, or localized warmth if there is regional inflammation. Cold skin may be localized, such as when a limb is deprived of its blood supply, or generalized in states of circulatory failure, when the skin feels clammy and sweaty.

Lift a fold of skin and make note of its thickness, mobility and how easily it returns to its original position (turgor). The skin on the back of the hand is often thin and fragile in elderly patients, may show decreased mobility in scleroderma (Fig. 2.14) or in oedematous states, and have reduced turgor in the presence of dehydration. The skin of acromegalic patients is typically thick and greasy.

Figure 2.14 Advanced scleroderma.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

An important determinant of skin colour is the relative amount of oxyhaemoglobin and deoxyhaemoglobin. Oxyhaemoglobin is a bright red pigment. An increase in its flow beneath thinned facial skin causes the characteristic plethora of Cushing’s syndrome (Fig. 2.15), whereas a decrease in flow causes pallor. As blood passes through the capillary bed, oxygen is given up to metabolizing tissues to produce deoxyhaemoglobin. This has a darker, less red, more bluish pigment and its presence in peripheral blood vessels in increased amounts causes the clinical sign of cyanosis. There are two physiological types of cyanosis: peripheral and central. Peripheral cyanosis is associated with increased extraction of oxygen from capillaries when peripheral blood flow is slowed, often due to vasospasm caused by cold, heart failure or anxiety. The cyanosed extremity is usually cold and the tongue is unaffected. Any condition causing slowing of the peripheral circulation may lead to peripheral cyanosis as there is more time for oxygen extraction. Central cyanosis is caused by inadequate oxygenation of blood, in turn due to heart failure, serious respiratory disease or mixing of venous and arterial blood across a right to left cardiac shunt. In the latter situation, blood passes directly from the right to the left side of the heart, without passing through the pulmonary circulation, thereby failing to become oxygenated. Central cyanosis is generalized and the peripheries are often warm. At least 5 g/dl of reduced haemoglobin is necessary to produce central cyanosis, and it is therefore less marked in anaemic patients. The cyanosis of heart failure is often due to both peripheral and central causes. The presence of central cyanosis is best appreciated at the lips, mucous membranes and conjunctivae, where the keratinized skin is thinnest (Fig. 2.16).

Figure 2.15 The characteristic plethoric appearance of a patient with Cushing’s syndrome.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Figure 2.16 Central cyanosis in a patient with severe respiratory disease (left) compared to the tongue of a normal person.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Pulses

Arterial pulses are detected by compressing the relevant vessel against a firm underlying structure, usually a bone. Details of the characteristic pulse abnormalities that help in the diagnosis of various cardiac disorders are described in Chapter 11, but palpation of all the peripheral pulses should form part of the general examination of all patients. Some may be difficult to feel and you may need to vary the degree of pressure in order to pick up the relevant pulsation. On occasion, you may confuse the patient’s pulse with your own. Count your own heart rate and compare it with the patient’s as they will usually be different.

The radial pulse is palpated by gentle pressure of the artery against the distal shaft of the radius, using the tips of the index and middle fingers. It provides information about rate and rhythm, although significant abnormalities in character may also be detected. If the rhythm is regular, it is safe to count the number of beats for 15 seconds and multiply by 4 for the rate. Irregular and very slow pulses require palpation for a full minute.

To palpate the femoral pulse, press deeply below the inguinal ligament, midway between the anterior superior iliac spine and the symphysis pubis. The pulse is usually easily felt against the underlying femur. In obese patients it may be useful to use two hands, one on top of the other.

The popliteal pulse is the most difficult to palpate. Flex the knee to approximately 120° and, with your thumbs on the patella, place your fingers in the popliteal fossa such that they meet in the midline. Occasionally, it may be necessary to lie the patient prone and, with the knee flexed to 90° and the leg resting against the shoulder or upper arm, press the thumbs deep into the popliteal fossa.

The dorsalis paedis (DP) pulse is palpated by pressing against the tarsal bones just lateral to the extensor tendon of the great toe although, in some patients, it may be necessary to explore the dorsum of the foot more widely. In general, it is most convenient to use the right hand to examine the left DP pulse; the right is often best felt with the right hand from the left side of the patient.

To feel the posterior tibial (PT) pulse, with the patient’s foot relaxed between plantar- and dorsiflexion, press your curved fingers against the distal part of the tibia, approximately 1 cm behind and below the medial malleolus. The PT pulse may be difficult to feel and require extra patience and pressure in obese or oedematous patients.

Legs and feet

Examination of the legs requires adequate exposure from the groins and buttocks to the toes. Note the colour and texture of the skin. Peripheral vascular disease often makes the skin shiny and hair does not grow on ischaemic legs or feet (Fig. 2.17). Pressure on the toes of ischaemic feet will cause blanching of the characteristic purple colour with subsequent slow return. Passive elevation of an ischaemic leg leads to marked pallor of the foot as perfusion against gravity falls. Painless trophic lesions, often with deep ulceration, may be seen in diabetic peripheral neuropathy. The posterior aspect of the heels is a particularly important area to inspect in elderly, emaciated or neurologically impaired patients, all of whom are vulnerable to pressure sores caused by obliteration of arteriolar and capillary blood flow to the skin.

Figure 2.17 Peripheral vascular disease. There is pallor, loss of hair and early ulceration on the dorsum of three toes.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Inspect the legs for obvious oedema and examine for pitting oedema. Press firmly but gently for around 5 seconds behind the medial malleolus, over the dorsum of the foot and on the shin. If oedema is present, a depression/concavity will form (Fig. 2.18).

Figure 2.18 Pitting oedema in a patient with cardiac failure. A depression remains in the oedema for several minutes after firm fingertip pressure is applied.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Varicose veins should be examined for with the patient standing (Fig. 2.19). Superficial varicosities are generally obvious in this position, whereas the efficiency of the valves of the long saphenous vein should be assessed by Trendelenburg’s test. With the patient lying, the saphenous vein is emptied by elevating the leg. Occlude the upper end of the vein by finger pressure on the saphenous vein opening (alternatively use a tourniquet) and ask the patient to stand while maintaining this pressure. If the valves are incompetent, the veins will rapidly fill from above when the pressure is released.

Figure 2.19 Varicose veins.

(From Forbes and Jackson 2002 Color Atlas and Text of Clinical Medicine, 3rd edn, Mosby, Edinburgh. Reproduced by kind permission.)

Venous thrombosis is rare in healthy mobile subjects, but frequently complicates enforced bed rest, particularly after surgery. The affected limb will be swollen. The circumference of the calf should be measured and compared with the unaffected leg, at the same distance below the tibial tuberosity. A discrepancy of more than 1 cm is significant. The affected leg is also tender and warmer than normal, with dilated superficial veins which do not collapse when the leg is elevated. Forceful dorsiflexion of the foot may cause pain in the calf (Homan’s sign). Sometimes extension of a deep vein thrombosis may extend up the thigh leading to a tender, hard, palpable femoral vein.

Breasts

Examination of the breasts should form part of the routine clinical assessment, usually at the time of examination of the chest. It requires tact and sensitivity and should be conducted with a chaperone. With the patient disrobed to the waist, the arms should be in a relaxed position by the sides. By inspection, make note of the size, symmetry, contour (e.g. any dimpling) and colour of the breasts. Inflammatory breast cancer with oedema of the overlying skin may produce a characteristic look and texture termed peau d’orange (orange peel skin). Note any asymmetry or inversion of the nipples. Simple longstanding inversion is often a normal phenomenon, but associated retraction of the areola or recent nipple inversion are more sinister. Ask the patient to raise her arms above her head. This manoeuvre allows inspection of the inframammary fold and may expose subtle contour abnormalities. Now, with the patient supine, ask the patient to rest one arm above her head. This helps spread the breast tissue more evenly across the chest and makes palpation of any nodules easier. For ease of annotation, the breast is usually divided into four quadrants, with the upper outer quadrant extending into an axillary tail. Use the pads of your middle three fingers to palpate the breast, using rotatory movements gently to compress the tissue against the chest wall. Proceed systematically to examine all quadrants, the tail and areola. Sometimes it is useful to support the breast with the other hand in order to aid examination, especially when the breasts are large.

Breast tissue is variable between patients, ranging from smooth to granular, and may change in a given individual with the menstrual cycle. For any nodule, note its size, shape, consistency, tenderness, mobility and the presence of any tethering or skin ulceration. Ask the patient to press her hands against her hips. If the lump becomes less mobile, it is likely to be attached to the pectoral muscles. Fixation to skin may be assessed by moving the skin overlying the lump independently. If this is not possible then skin involvement is likely.

Swelling of male breast tissue is usually easily apparent (Fig. 2.20). Distinguishing true glandular enlargement from pectoral fat may be facilitated with the patient’s arms above his head. At some stage of puberty, most boys will have a palpable disc of tissue.