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Introduction on Clinical Examination
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Introduction on
1
1
Clinical Examination
Introduction
Clinical examination is an art. It is an important basic
essential part in surgical learning. Surgery is categorized as clinical surgery; surgical principles and
operative surgery. So surgery is not just cutting. It
involves proper clinical analysis; and application of
principles in treating surgically related patients. All
patients in the surgical ward need not undergo or need
surgery. Conditions like cellulitis, amebic colitis or
acute pancreatitis commonly does not require surgery
but treated by surgeons. A surgeon should be a good
clinician and physician all together to impart proper
treatment to his (surgical) patients. Even though there
are many sub-specialties in surgery now , basic clinical
surgery remains the same. It is the pillar of surgical
basis.
T wo important parts in clinical methods are symp-
toms and signs. Symptom is the one patient complains
of. It is the subjective sensation of the patient. Sign
is the one which clinician elicits. It is an indication
of existence of an objective evidence of a disease.
Clinician is the one who listens patiently; who sees
carefully; who feels evidentially; who hears silently.
Clinical methods are schematically divided as:
History taking which is very important part. Careful
detail history taking many times gives clue about the
exact disease.
Case taking or Case analysis includes:
• Clinical methods.
• Clinical diagnosis.
Investigations are done to come into final conclusion
by various methods like X-ray, CT scan, ultrasound,
blood tests and so on. Types of investigations are
decided based on the clinical suspicion of the disease.
Final diagnosis is to plan the therapy, predict the
outcome.
Treatment plan or protocol often differs for
individual patient.
Postoperative/post therapy management.
Progress of the patient.
Follow-up after discharge and further treatment which
is often needed after initial management.
History Taking
Clinician should spend adequate time for detailed
history taking from the patient. If the patient is a child
or patient is dumb, then history is given by the mother
or close relative who takes care of the individual.
Name and relation of the person who is giving history
should be noted down. Patient should be made
comfortable while taking history.
Physical examination includes general examination;
inspection of the part (diseased or suspected) which
is proper observation prior to palpation for specific
findings; palpation is done once inspection is completed in detail; followed by percussion done in specific areas like abdomen and chest; later auscultation
for altered or specific sounds in particular region.
General History
Name
Correct name of the patient should be asked and
noted down. It is better to remember the patients
name while doing rounds at least up to the discharge
of the patient. This helps to build a zone of comfort
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with the patient. It may be helpful to keep a pocket
note book to write down in short about details of the
patient.
Age
Noting the age of the patient is important. Congenital
anomalies occur in young age group. Cleft lip and
palate; phimosis exists since birth. Branchial cyst even
though of congenital origin occurs in later age group
in 2nd or 3rd decade. Certain tumors like W ilm’s tumor
(kidney) and neuroblastoma occur in early childhood.
Sarcomas develop in adolescents. Usually carcinomas
occur after middle age. But malignancies can occur
at any age group. Benign prostatic hyperplasia occurs
in old age often causing retention of urine.
Sex
Certain diseases occur only in particular sex other
than gender specific diseases. Hemophilia occurs
only in males but females can be carriers. Thyroid
diseases are more common in females. Carcinoma
lung, stomach, kidney are more common in males but
can occur in females.
Religion
Carcinoma penis is not seen in Muslims and Jews due
to their religious practice of early circumcision in
childhood. Duodenal ulcer perforation is common in
Muslims during fasting month of Ramzan.
Residence, complete postal address and method
of communication must be taken down: Many
diseases have got geographical distribution. Hydatid
disease is common in Australia, Iran, Greece, etc;
Schistosomiasis is common in Egypt; Trypanosomiasis is common in Africa; amebiasis is common
in tropical countries; filariasis is common in Orissa;
leprosy in West Bengal; gallstones in Bihar and north
east India; peptic ulcer in South India.
Occupation
Some diseases are common in people with certain
occupations. Varicose veins are common in people
who stand for long hours like bus conductors, garden
workers, watchmen, traffic policemen, surgeons, and
nurses, etc. Carcinoma urinary bladder is more com-
mon in workers in aniline dye factories. Sportsmen
are more prone for injuries to ankle, knee and elbow.
Social status: Tuberculosis is common in low socioeconomic group; peptic ulcer disease is common in
high socioeconomic group.
Social status is classified as Class I—professionals;
Class II—Executive and higher management; Class
III—Lower management and clerical; Class IV—
Skilled laborers; Class V—Unskilled laborers.
Chief Complaints
Main complaints of the patient are mentioned in the
order of occurrence. Complaints of same duration
should be narrated in the order of severity . Example–
Lump in the breast-6 months.
Ulcer in the swelling of breast-2 months.
Pain in the breast-1 month.
Fever-1 month.
Often proper leading questions are necessary to
elicit clear-cut relevant history. But this should be
used only after proper initial detailed history . History
should be elicited in language which the patient is
comfortable. One should not elicit diagnosis from the
patient. Negative reply of the patient is also very
relevant and so it should not be ignored.
History of Present Illness
It is detailed history in relation to onset of the present
disease until date. It should be in order of occurrence.
Each part of the history should be mentioned in detail
before going to next part of the history.
Mode of onset of symptom: It may be gradual or
sudden or initially slow but later progress rapidly.
History suggestive of whether it is related to any
trauma or any earlier disease should be asked.
Progress of the disease: Whether the symptoms are
decreasing or increasing; gradual or rapid; or waxing
and waning (increase-decrease-increase).
Past History
Earlier diseases should be detailed in order. Often
patient may not know the name of the disease which
he had earlier. History suggestive of specific disease
should be elicited like tuberculosis, syphilis, leprosy,
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bronchial asthma, diabetes mellitus, and tropical
diseases. When such disease has occurred; detailed
history of treatment taken; response to treatment
should be asked for. Often patient might have got
hospitalised for the treatment which should be asked
in detail like place where he was hospitalised;
duration; type of treatment (type of drugs, injections,
etc). Earlier treatment summary/prescriptions if
present should be taken and studied for reference.
History of earlier surgery/trauma; its detail like
duration of hospital stay, recovery period, any postoperative complications, drain placed or not, response of surgery whether patient is relieved of
symptoms completely or partially , any operative notes
available for reference should be asked.
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In females, detailed menstrual history should be
noted. Time of menarche/menopause/regularity/
presence of pain/dysmenorrhoea/white discharge/date
of last menstrual period are noted in detail. Pregnancy
history with number of pregnancies/abortions/normal
delivery or Caesarean/last child birth should be noted.
Family History and Genetic History
Many diseases run in family. Examples are: piles;
breast cancer; diabetes mellitus; tuberculosis, etc. If
any of the family member is suffering from any
disease; its detail, type, therapy for the same, whether
he has underwent any surgery for the same and so
on should be mentioned in detail. Number of siblings
and their health details should also be taken.
Personal History
History of personal habits like smoking beedi or
cigarettes with duration/frequency/number of beedi
or cigarettes per day; history of drinking alcohol
with duration, quantity, whether addicted, whether
associated with alcohol induced problems should be
noted.
Alcohol Intake
A problem drinker is one whose physical, social and
mental well being is harmed by drinking. One unit
of alcohol is 8 grams of alcohol in 290 ml of 4% beer.
Teetotaler is one who has not taken alcohol in last
one year. Occasional drinker is one who has not taken
alcohol in last one month. Light drinker who drinks
alcohol < 25 units per week in males; < 15 units in
females. Moderate drinker who drinks 25-35 units/
week in males; 15-25 units in females. Heavy drinker
who drinks 36-50 units/week in males; 26-35 units
in females. Very heavy drinker is > 50 units/week in
males; > 35 units/week in females.
Smoking
Light smoker smokes one packet of cigarette/day for
2-10 years. Moderate smoker 1-10 packets of
cigarettes/day. Chronic heavy smoker smokes 10-20
packets of cigarettes/day for 2-10 years
Type of diet is also important in relation to many
diseases. It should be mentioned whether patient is
married or not; number of children he/she has.
Other Relevant History
In younger age group history of immunization for different diseases; history suggestive of allergy/reactions
during earlier drug intake; history of long-term drug
therapy like insulin, steroids, antidiabetics, antihypertensives, diuretics, hormones, etc. should be noted.
Pain
Pain is a commonest symptom which patient
complains to a clinician. Latin word ‘poena’ means
penalty/punishment. Pain is the one patient feels;
tenderness (sign) is the one surgeon/clinician elicits.
Types of pain:
Superficial pain: It is sharp usually localised pain,
due to irritation of peripheral nerve endings in
superficial tissues by chemical/mechanical/thermal/
electrical injury.
Segmental pain: It occurs due to irritation of particular nerve trunk/root; located in particular dermatome of the body supplied by the sensory nerve trunk
or root.
Deep pain: It is due to irritation of deeper structures
like muscles/tendons/bones/joints/viscera. It is vague
and diffuse when compared to superficial pain. It is
often referred to common segmental areas of representation. Often spasm of skeletal muscle of same spinal
cord segment can occur.
Psychogenic pain: It may be functional/emotional/
hysterical.
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Other types of pain: Like due to thalamic/spinothalamic diseases/causalgia [intense burning pain
along the distribution of the partially injured (and
healed) nerve].
Specific points in history in relation to pain to be
asked are: original site of pain is very important. In
acute appendicitis original site of pain is in umbilicus;
but later it shifts to right iliac fossa, i.e. shift of pain
towards other site.
Time and mode of onset of pain: It is in sudden
onset, rapidly progressive in acute appendicitis; it is
of insidious onset and of long duration with episodic
nature in chronic peptic ulcer; pain after trauma
means very important and may be an emergency like
internal organ injuries (liver, spleen, and kidney) or
due to fracture bone.
Type/nature of pain: It may be superficial/deep; dull
ache or sharp severe/pricking/bursting/vague aching
(continuous mild pain), throbbing, scalding (burning
sensation particularly felt during urination in cystitis,
pyelonephritis, urethritis), pins and needles pricking
sensation in peripheral nerve injury or irritation,
shooting pain (seen in intervertebral disc prolapse and
sciatica-pain shoots along the course of nerve),
stabbing (sudden, severe, sharp, episodic—seen in
perforated duodenal ulcer), distension pain (a feeling
of restricted or distended like in paralytic ileus or
intestinal obstruction), colicky pain is due to muscular
contraction in a hollow tube in an attempt to obviate
the obstruction by forcing the content out—griping,
episodic pain with vomiting and sweating (seen in
intestinal colic, ureteric colic of stone, biliary colic
of stone), twisting pain of bowel volvulus/twisted
ovarian cyst/torsion testis, constricting pain around
the chest by angina, etc.
Severity of the pain: Severe pain is common in acute
appendicitis, acute pancreatitis, ureteric colic, perforation of bowel, acute peritonitis, intestinal obstruction, acute abscess.
Progression of pain: It may be persistent and
progressive; or initially mild gradually increases, later
subsides gradually; or fluctuates in intensity, i.e.
increases and decreases in intensity at regular
intervals or quickly reaches maximum and remains
like that.
SRB’s Clinical Surgery
Duration of pain: Colicky pain lasts usually for a
minute in each episode; anginal pain lasts for 3-5
minutes; an acute pain like of pancreatitis persists.
Periodicity of pain: Pain appears, persists for few
weeks and then disappears for few weeks; again
reappears. Such periodicity is often observed in
chronic peptic ulcer; trigeminal neuralgia.
Precipitating/aggravating factors: Abdominal pain
may get worsened by taking food like in gastric ulcer.
Pain due to appendicitis, ureteric stone aggravates in
change of position, walking, jolting. Pain of urinary
bladder stone aggravates in standing position. In
reflux oesophagitis pain increases while scooping.
Pain in pancreatitis increases on lying down. Pain in
intervertebral disc prolapse aggravates by lifting the
weight.
Relieving factors of pain: Pain reduces by certain
method and patient uses that method to relieve the
pain. Hunger pain of early morning in duodenal ulcer
is relieved by taking food. Pain of pancreatitis is
relieved by sitting and bending forward. Propped up
position relieves pain of reflux oesophagitis. In acute
peritonitis, pain reduces temporarily by lying still.
Associated symptoms: Acute pain may be associated
with pallor, sweating and vomiting. Migraine pain
with vomiting and visual disturbances; intestinal/
ureteric colic with sweating, vomiting and cold
periphery; acute pyelonephritis and urinary infections
with chills/rigors and fever; ureteric colic with
haematuria; biliary colic with jaundice and pale stool
are other examples of such association.
Time of occurrence of pain is often important in
diagnosing the condition. In duodenal ulcer, hunger
pain occurring in early morning or later evening is
typical. Migraine occurs in early morning; frontal
sinusitis induced headache occurs few hours after
getting up.
Pain may move from one place to other.
Radiation of pain: It is extension of pain from
original site to another site with persisting of pain
at original site. This radiating pain is of same
character of original site. Penetration of duodenal
ulcer posteriorly causes pain both in epigastrium and
back—is an example. Pain of pancreatitis radiates to
back.
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Referred pain: Pain is not felt at the site of the disease
but felt at distant site. Diaphragmatic irritation causes
referred pain at the tip of shoulder through same
segmental supply of diaphragm (phrenic nerve C4, C5)
and shoulder (cutaneous supply C4, C5). Hip joint
pathology may cause referred pain in knee joint—
through articular branches of femoral, obturator and
sciatic nerves. Other examples—referred pain in ear
from carcinoma tongue through lingual and auriculotemporal nerve; referred pain in the epigastrium from
the heart; referred pain in the abdomen from pleura;
referred pain over the testis from the ureter.
Shifting/migration of pain: Origin of pain is in one
site; later pain shifts to another site and pain at
original site disappears. Pain when begins in viscera,
is felt at the same somatic segmental area in the body;
but once parietal layer is involved by inflammation/
pathology pain is felt at the anatomical site. Example
is pain of acute appendicitis, where the original
visceral pain is at the umbilicus (T9 and T10
segments supply both umbilicus and appendix) which
later shifts to right iliac fossa when once the parietal
peritoneum of that area is inflamed.
Grading of pain is done using pain scale. It is compared to a 10 cm line numbered 0 to 10. This is called
as visual analogue scale (V AS). Minimum is 0 means
no pain. 10 is the worst excruciating pain. 2 is mild;
4 is discomforting; 6 is distressing; 8 is intense.
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Bilious vomiting occurs in small bowel obstruction;
which may be either yellow or green coloured. Faecal
content in the vomitus suggests ileal/large bowel
obstruction. Faeculent vomiting is also seen in
gastrocolic fistula. Content is brown in colour with
faecal odour. Haematemesis should be distinguished
from haemoptysis. Vomiting is graded as follows—
None (0); one episode of vomiting in 24 hours (1);
2-5 episodes/24 hours (2); > 6 episodes/24 hours (3);
needs parenteral fluid/nutrition (4).
Nausea
It is sense (feel) of vomiting. It may or may not end
up with vomiting. It can be none (0); nausea present
but able to eat (1); oral intake is reduced (2); No oral
intake, on IV fluids (3).
Itching (Pruritus)
It is due to local or general causes. Multiple scratch
marks are often obvious. It may be due—Skin diseases:
urticaria, eczema, scabies (Psoriasis will not cause
itching). Local causes contact dermatitis due to
clothing, washing soap, washing powder infection
from fungal, parasites like fleas, scabies; vaginal and
rectal discharge. Systemic causes are obstructive
jaundice due to bile acid irritation, Hodgkin’s disease,
leukaemia, uraemia, allergy/hypersensitivity, drug
reactions, diabetes mellitus, etc.
Vomiting
Vomiting is a common symptom heard in clinical
practice. It may be due to—pregnancy , travelling sickness, labyrinthitis, gastritis, peptic ulcer, migraine,
meningitis, intracranial tumour, ureteric colic, pyloric
stenosis, carcinoma stomach (pylorus), intestinal
obstruction, intracranial space occupying diseases,
acute peritonitis, cholecystitis, pancreatitis, metabolic
causes like diabetic ketosis, drug induced. Colour,
quantity , smell of the vomitus should be found. Coffee
ground coloured vomitus is seen in upper GI bleed.
When bled blood comes in contact with gastric juice,
hemoglobin forms acid haematin colouring contents
blackish or dark brown. Vomitus may contain frank
blood/clots. Presence of undigested material should be
asked for. Oesophageal obstruction by achalasia cardia
or stricture causes regurgitation. Nonbilious vomiting
means obstruction proximal to sphincter of Oddi.
Fatigue
It is subjective sensation of weakness (asthenia/
lethargy). It is graded as none (0); fatigue over baseline (1); moderate fatigue (2); severe (3); bedridden (4).
Anorexia
Anorexia is loss of appetite. It is seen in anorexia
nervosa, gastrointestinal cancers, tuberculosis, debilitating illness like sepsis. Anorexia is graded as none (0);
loss of appetite (1); significant reduction in oral intake
(3); unable to take orally requiring IV fluids (3). Satiety
is sense of fullness after completion of meals. It is
normal. Early satiety is a feature of GI malignancy.
Flatulence
Flatulence is frequent belching more than normal.
Regurgitation is effortless return of food into the
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mouth. It is associated with powerful involuntary
contractions of abdominal muscles. It is seen
oesophageal/OG junction obstructions like carcinoma
and achalasia cardia. Heartburn is burning sensation
behind the sternum due to acid reflux into the
oesophagus.
Constipation
Constipation is defined as having bowel movement
fewer than three times per week; with hard, dry, small
sized stool; difficult to evacuate. It is graded as
none(0); needs diet modification (1); needs laxatives
(2); needs manual evacuation or enema (3); due to
obstruction (4). Constipation can be relative wherein
patient can pass flatus but not faeces; or absolute
wherein patient neither can pass faeces nor flatus.
Diarrhea
Diarrhea is defined as more than 3 stools per day . It is
usually soft, often foul smelling. Often it may be associated with incontinence. It is graded as increase
of < 4 times/day (1); increase 4-6/day (2); increase
> 7/day or with incontinence or need parenteral
nutrition (3); needs intensive care with haemodynamic
collapse (4).
Physical Examination
It should be done in privacy. Female patients should
be examined in presence of a female/nurse. Examination should be done with limited clothing to elicit
proper findings. Broad day light is ideal for examination. Usage of other lights may mislead or mimic
some clinical findings like jaundice.
General Examination
This part of the examination is essential preliminary
step in all patients.
Patient’ s intelligence level should be assessed while
taking history. Uneducated people still can be
intelligent.
Mental Status
Mental status and level of consciousness should be
assessed in general but in particular in specific clinical
situations like head injury, hepatic encephalopathy,
septic shock, etc.
Grading of the mental status
Grade I Properly oriented in time, space and person
Grade II Conscious but without orientation of time,
space and person
Grade III Drowsy and semiconscious
Grade IV Unconscious but responding to painful stimuli
Grade V Unconscious and comatose and not
responding to painful stimuli
Built and Nutritional Status
Built and nutritional status of the patient is important
to be assessed. Built is structural organization of
underlying skeleton. It is related to age and sex of the
patient. Gigantism is height to that age is in excess
than normal (in adult more than 6.5 feet). It may be
racial; familial; endocrinal (hyperpituitarism, hypogonadism); genetic (Klinefelter’s syndrome); metabolic
(Marfan’s syndrome, homocystinuria); overeating;
cerebral causes. Dwarfism is height to that age and sex
is far less than normal (below 4.5 feet). It can be
hereditary, chromosomal (T urner’s syndrome, Down’ s
syndrome); delayed growth; nutritional (Rickets);
endocrinal (hypopituitarism, hypothyroidism, excess
androgens, congenital adrenal hyperplasia, insulin
insufficiency); skeletal (achondroplasia, spinal deformities); systemic diseases (uraemia, cyanotic heart
diseases, cirrhosis). In normal adult, height of the
person is equal to length of arm span. Upper segment
from vertex to pubic symphysis is equal to lower
segment from pubic symphysis to heel. In infants
upper segment is more than lower segment and height
is more than arm span. This infantile body frame
persists in achondroplasia, cretinism, and juvenile
myxoedema. Greater arm span than height and greater
lower segment is observed in Marfan’s syndrome,
homocystinuria, Klinefelter’s syndrome, Frohlich’s
syndrome.
Nutrition is the proportion of soft tissue structures
(muscles, soft tissues, fat) in relation to the bony
structure. In gastrointestinal malignancies or in other
malignancies with metastases patient will be
cachexic. Protein deficiency causes rough skin, brittle
hair, and oedema feet. Fat deficiency causes cachexia,
hollow cheeks, and loss of fat in hips, abdomen and
subcutaneous tissues of elbow . Deficiency of minerals
and vitamins has got specific features.
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Weight Gain
Weight gain is increase in weight. It is graded as
increase of < 5% (0); increase of 5-10% (1); 10-20%
(2); > 20% (3). It is seen in obesity, pregnancy,
myxoedema, water retention, Cushing’s syndrome.
Weight Loss
W eight loss is graded as loss of < 5% (0); 5-10 % (1);
10-20% (2); > 20 % (3). But time duration of weight
loss is also important. Definition of significant weight
loss (2009): W eight loss more than 5% (up to 7.5%) in
30 days; weight loss more than 7.5% (up to 10%) in 60
days; weight loss more than 10% in 180 days.
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Malignant Cachexia
Malignant cachexia is emaciated (Fig. 1.2), languid,
shallow, pale face, loose wrinkled dry skin, loss of
fat, lost appetite/weight/energy with oral infection.
Profound loss of weight is typical.
Fig. 1.2: Typical malignant cachexia.
Wasting
It is obvious on the upper half of the body as there
is often oedema due to hypoproteinaemia in lower
half of body. By looking at the shoulder girdle, loose
skin of arms, trunk and buttocks, severity of wasting
can be assessed (Fig. 1.1). It is observed in starvation,
severe gastroenteritis, tuberculosis, anorexia nervosa,
diabetes mellitus, advanced carcinomas, gastrointestinal malignancies, and old age.
Attitude
Attitude of the patient in the bed is good thing to
observe. Comatose patient/paraplegic or quadriplegic
is silent and immobile. Patient in shock or with peritonitis may not move due to pain. Patient with ureteric
stone may be restless and rolling in the bed due to
severe colicky pain. Position of the patient in the bed
is called as decubitus. It is often typical in certain
diseases like cerebral irritation, cerebral palsy, etc.
In hemiplegia patient lies with one side immobile,
with affected arm flexed and legs externally rotated
and extended. In tetanus, patient develops stiff neck.
In ureteric colic, patient is restless with rolling and
tossing over the bed. In acute peritonitis patient lies
in the bed still and motionless. In cardiac diseases,
patient is comfortable in sitting up position. In pneumonia, patient lies on the affected side to make that
side immobile and restricted so as to reduce the pain.
Stature is the total height from vertex to soles.
Posture is positional relationship of dif ferent regions
of the body. Normal posture is—moderate lordosis
of cervical and lumbar spine; kyphosis of thoracic
and sacrococcygeal region; forward pelvic inclination
30°; normal rotation of femur; line from the mastoid
down passes through the middle of the shoulder and
hip, anterior to knee and lateral malleolus.
Fig. 1.1: Ascites with wasting proximal
part probably due to malignancy.
Face Look
Typical face is diagnostic of some diseases. Hippocratic facies is seen in generalised peritonitis. Face
with typical pale look is seen in chronic renal failure,
risus sardonicus in tetanus; mask face in Parkinsonism;
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moon face in Cushing’s syndrome is to be noted.
Acromegaly (due to increased growth hormone in
pituitary acidophilic adenoma) shows large face due
to overgrowth of soft tissues in face, nose, tongue, air
sinuses; large hands (due to enlargement of bones of
distal phalanges)—facies of Punch of ‘Punch and Judy’
or an ‘Ape man’. Skin is greasy; mental acumen is
normal (in myxoedema skin is dry with decreased
mental acumen). In scleroderma, progressively
thickened, pale, waxy skin with reduced facial
expressions, microstomia, telangiectases on cheeks,
mouth and nose, with fine white horizontal scars in the
neck in transverse skin creases (with oesophageal
stenosis and vasculitis) are seen. In Myasthenia gravis
weakness of all muscles is found; in particular of eyelids
showing drooping of eyelids with weakness of face
muscles and jaw (Fig. 1.3). Cretin is a neonate with
deficient thyroid hormone (cured by thyroid hormone
supplement); diagnosed at birth; with broad flat face,
wide apart eyes, protruded tongue. Down’ s syndr ome/
Mongolism is a congenital abnormality with extrachromosome 21 and total chromosomes 47 (instead of
46); males and females and all races are equally
affected. Features are—mental retardation, floppiness,
short stature, outer ends of the palpebral fissures slanted
upwards with prominent epicanthic folds, flat face,
protruded tongue and squint.
Klinefelter’ s syndrome is a congenital abnormality
in a male having XXY chromosomes instead of
normal XY chromosome. Patient is tall, with female
distribution of fat around breast and pelvis but normal
hairs in face and pubis. Patient is having small testis
without sperms. Turner’s syndrome is a congenital
abnormality of female, having only one X chromosome, XO instead of XX. Short, webbed shoulder,
widened neck with prominently running skin fold
from neck to shoulder—are typical.
Pallor
Pallor is checked in lower palpebral conjunctiva,
mucous membrane of lips and cheeks, nailbeds and
palmar creases. Causes for pallor are-anaemia, massive
bleeding, shock and anxiety status (Figs 1.4A
to C).
A
B
Fig. 1.3: Eyes and face should be examined carefully as
part of general examination. Note the visible lower sclera—
could be due to exophthalmos.
C
Figs 1.4A to C: Lower eyelid is retracted to see the
conjunctiva for pallor. Note the normal conjunctiva and
conjunctiva with pallor.
Cyanosis
It is due to rise in level of reduced haemoglobin in the
blood causing blue/purple discolouration in the skin
and mucous membrane. A minimum of 5 gm/dl of redu-
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ced haemoglobin should be present in the circulation
to cause cyanosis. So in severe anaemia (Hb% below
5 gm %), cyanosis is not seen. T wo types of cyanosis
are observed—peripheral and central. Peripheral
cyanosis is due to poor perfusion of peripheral vessels
causing reduction in oxyhaemoglobin in the capillaries.
It is seen in peripheral vasoconstriction due to any cause
like exposure to cold temperature, reduced cardiac
output, profound shock where blood is diverted from
periphery to vital organs like brain, liver , and kidney .
Peripheral cyanosis is checked in nailbed, palm and
toes, tip of the nose. Here limb is cold and inhaling pure
oxygen may not reduce it. Tongue is not involved in
peripheral cyanosis. Central cyanosis occurs due to
reduced oxygen saturation of arterial blood due to poor
oxygenation in the lungs. It may be due to congenital
heart disease with left to right shunt (cyanotic heart
disease), congestive cardiac failure, lung diseases, and
high altitude due to low oxygen partial pressure. Limb
temperature is normal in this type. Clubbing and
polycythaemia is common here. Pure oxygen inhalation
reduces the central cyanosis. It is confirmed by
checking in tongue (Fig. 1.5), nailbed, palms and toes.
Methaemoglobinaemia or sulphaemoglobinaemia
(abnormal pigments) also causes cyanosis but with
Fig. 1.5: Central cyanosis is checked in the tongue-dorsum.
9
normal arterial tension. In carbon monoxide poisoning,
carboxyhaemoglobin prevents reduction of oxyhaemoglobin and so there will not be any cyanosis but cherry
red discoloration develops.
Differential cyanosis: Patent ductus arteriosus (PDA)
with reversal of shunt causes only lower limb
cyanosis. PDA with reversal of shunt with transposition of great vessels causes only upper limb
cyanosis. PDA with reversal of shunt with preductal
coarctation of aorta causes cyanosis of left upper limb
and both lower limbs.
Polycythaemia
Polycythaemia is excess of circulating red blood
cells giving patient a purple-red florid appearance;
it heightens the colour of all the skin, cheeks, neck,
backs of hands and feet whereas cyanosis is limited
to tips of hands, feet and nose.
Jaundice
Jaundice is yellowish discoloration of skin and
mucous membrane. T issues and body fluids are also
discoloured yellow. Bilirubin has more affinity to
elastic tissue, blood vessels and nervous tissue. So
it is better seen in sclera and skin. During recovery,
bilirubin takes longer time to get cleared from elastic
tissue and so clinical jaundice persists for little longer
time than biochemical disappearance of jaundice.
Initially it is pale lemon yellow colour, later gets
darkened becomes yellow-orange, olive greenish
yellow as seen in obstructive jaundice. Jaundice is
due to deposition of bile pigments with excess of it
in plasma. It is checked in upper sclera (better seen
against white background; by asking the patient to
look at his feet and clinician pulls the upper eyelid
upwards). It also can be checked in nailbed, ear
lobule, nasal tip, and on under surface of tongue.
Greenish colour is due to deposition of biliverdin.
Scratch marks observed on the dorsum of the body
(forearm, neck, back) is due to deposition of bile
acids which releases excess histamine causing itching
(Figs 1.6A to C).
Jaundice may be due to pre-hepatic cause (excess
haemolysis); hepatic (liver dysfunction—hepatitis,
sepsis, drugs, cirrhosis); post-hepatic (CBD stones,
carcinoma pancreas, drugs—obstructive); congenital
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A
SRB’s Clinical Surgery
obstructive and hepatic jaundice bile pigment-bilirubin is seen in the urine). This conjugated bilirubin
is excreted through biliary canaliculi reaching
intestine. In the intestine, it is converted into stercobilinogen and urobilinogen by intestinal bacteria.
70% of this is absorbed in the colon and brought back
to liver as enterohepatic circulation (Fig. 1.7).
Unabsorbed stercobilinogen colours faeces brown.
Circulating urobilinogen is taken up by kidneys for
excretion. If direct bilirubin in the serum is more than
0.4 mg%, then bilirubin is seen in urine. Normal
urinary urobilinogen is 100-200 mg/day. It is absent
in obstructive jaundice. Normal faecal stercobilinogen is 300 mg/day . It is also absent in obstructive
jaundice.
B
C
Figs 1.6A to C: Janudice is checked in sclera by asking
the patient to look down on the feet and examiner pulls
the upper eyelids upwards. It is also checked in nasal tip,
ear lobule, fingertips and under surface of the tongue.
hyperbilirubinaemia (Gilbert’s syndrome causing
altered bilirubin transport and so increase in unconjugated bilirubin; Criggler-Najjar syndrome causing
disturbance in bilirubin conjugation and so increase
in unconjugated bilirubin; Dubin-Johnson syndrome
and Rotor’s syndrome causing disturbance in excre-
tion of bilirubin and so increase in conjugated bilirubin). Aged red cells get lysed in the reticuloendothelial cells and breakdown into haem and globin.
Haem is divided into globin and bilirubin. Bilirubin
is combined with albumin and transported to liver.
In the liver bilirubin get separated from albumin and
is conjugated to bilirubin glucuronide by glucuronyl
transferase. This conjugated bilirubin glucuronide is
water soluble and can be excreted in kidney (So in
Hypercarotinaemia
Hypercarotinaemia mimics jaundice which is due
to increased yellow pigment carotene. It is seen
equally in face, palm, sole and skin but not seen in
sclera. It is common in vegetarians who eat more raw
carrot. Mepacrine therapy also causes yellow
discolouration.
Pigmentation
It is usually an increase in natural brown pigmentation
of the skin. Often pigmentation by other colours like
blue/red also can occur . Pigmentation can be generalised or localised.
Generalised: It occurs in Addison’s disease (seen in
skin and buccal mucosa); arsenic/silver poisoning;
haemochromatosis; Gaucher’s disease.
Localised: It occurs in pregnancy (around areola,
midline abdomen); venous diseases of lower limb
(medial third of leg and ankle); erythema eb agne
(in the exposed part of leg); ultraviolet and high voltage
irradiation; café au lait spots of neurofibromatosis;
naevi; melanomas; pellagra (nicotinic acid deficiency);
hyperthyroidism (bronzing of eyelids); rheumatoid
arthritis.
Examination of Nails
A transverse groove (transverse lines/Bean’s lines)
seen at similar levels of each nails is suggestive of
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