Every clinical examination begins the same way: you meet the patient, you look, and you record the general survey. It is the cheapest, fastest source of diagnostic information in the entire exam — and examiners notice immediately whether you do it systematically.
This is the general survey sequence I use, with the findings that matter and how to present them.
Position and approach
- Ensure privacy, adequate lighting and a comfortable position.
- Examine from the right side, with the patient’s consent and covered appropriately.
- Observe before you touch — lots of information is visible before the first question.
The sequence
1. General appearance and build
Note the patient’s general condition, whether they look ill or well, body build (ectomorph, mesomorph, endomorph), nutrition (normal, thin, obese), and any obvious abnormal posture or distress. In children, assess growth and development.
2. Vital signs
| Parameter | Typical adult range |
|---|---|
| Pulse | 60–100/min |
| Blood pressure | <120/80 mmHg (ideal) |
| Respiratory rate | 12–20/min |
| Temperature | ~37 °C |
| SpO₂ | >94% on room air |
Record each with its character: pulse rate, rhythm, volume and condition of the vessel wall; temperature as measured at a standard site.
3. Pallor
Look at conjunctivae, mucosae, palms, nail beds, tongue and skin. Grade it and always correlate with haemoglobin.
4. Icterus
Look at the sclera in natural light, then the palate and skin. Distinguish from carotenaemia (yellow palms, normal sclera).
5. Cyanosis
Central (tongue, lips, mucosae — indicates low arterial oxygen) versus peripheral (tips, caused by poor perfusion). Look and then confirm.
6. Clubbing
Examine the nail beds and the angle of the nail. Grade from early loss of the angle to drumstick fingers. Ask about the common causes on the ward.
7. Oedema
Site, symmetry, pitting, tenderness, from below upwards (or periorbital). Grade it.
8. Lymphadenopathy
Examine lymph node groups — cervical, axillary, inguinal, epitrochlear. Note size, consistency, mobility, tenderness and matting.
9. Skin, hair and nails
Look for rashes, pigmentation, purpura, hair changes and any obvious cutaneous clue to systemic disease.
10. Other quick checks
Jugular venous pressure, hydration status, and an overall check for any obvious deformity or external device (catheters, dialysis access).
Findings and their common causes
| Finding | Common associations |
|---|---|
| Pallor | Anemia (nutritional, chronic disease, blood loss) |
| Icterus | Hemolysis, hepatitis, biliary obstruction |
| Central cyanosis | Hypoxia – respiratory or cardiac cause |
| Clubbing | Lung disease, cyanotic heart disease, chronic liver disease, IBD |
| Pitting oedema | Cardiac failure, nephrotic syndrome, liver disease, malnutrition |
| Lymphadenopathy | Infection (including tuberculosis), malignancy, lymphoma |
How to present the general survey
“Patient is an adult male of average build and nutrition, conscious and cooperative, with no pallor, icterus, cyanosis, clubbing, lymphadenopathy or pedal oedema. Pulse 78/min, regular, normal volume; BP 120/76 mmHg; RR 16/min; temperature 37 °C.”
Examiner traps
- Missing the general survey entirely and jumping to the system — instant red flag.
- Saying “no abnormality” without actually having looked at each item.
- Forgetting vitals, or recording them without commenting on character.
- Confusing central and peripheral cyanosis.
Frequently asked questions
What is included in a general survey in clinical examination?
General appearance and build, vital signs, pallor, icterus, cyanosis, clubbing, oedema, lymphadenopathy, skin, hair and nails, and a quick assessment of JVP and hydration.
What is the difference between central and peripheral cyanosis?
Central cyanosis affects the tongue, lips and mucosae and reflects low arterial oxygen saturation. Peripheral cyanosis affects fingertips and extremities and reflects poor local perfusion.
Why is the general survey important?
It is quick and can reveal major systemic clues such as anemia, jaundice or hypoxia before you examine any system, guiding your entire approach to the patient.
Take the history first with my history taking format for medicine, then move into systemic examination — start with the CNS examination steps.
Written by Shrikant Bhosale
Final Year MBBS Student at Government Medical College, Chhatrapati Sambhajinagar (Aurangabad), Maharashtra. I write the study, ward and career guides I wish existed when I started MBBS — grounded in the real NMC curriculum, real university exams and real ward experience. More about me →
Educational use only. This guide is written for medical students and is not medical advice. Clinical protocols, drug doses and guidelines change — always verify against the latest standard textbooks and official NMC / institutional guidance before applying anything in practice. Read the full disclaimer.
📌 Executive Summary & High-Yield Takeaways
- The PICCLE mnemonic: Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema.
- Check vitals first: Temperature, Pulse rate & rhythm, Blood pressure (both arms if indicated), Respiratory rate, and SpO2.
- Pallor examination sites: Lower palpebral conjunctiva, dorsum of tongue, soft palate, nail beds, palmar creases.
- Clubbing grades (1 to 5): Fluctuation of nail bed -> Obliteration of Lovibond angle -> Parrot beak curvature -> Drumstick appearance -> Hypertrophic osteoarthropathy.
Frequently Asked Questions (FAQ)
Common questions asked by medical students regarding this topic:
Q: What is the difference between central and peripheral cyanosis?
Central cyanosis is caused by arterial desaturation (cardiac or respiratory shunt) and is seen on warm mucosal surfaces (tongue, inner lips, buccal mucosa). Peripheral cyanosis is caused by reduced peripheral circulation/vasoconstriction and is seen on cold extremities (fingertips, toes, earlobes).
Q: How do you test for pedal edema in bedside medicine?
Press firmly with your thumb over the bony surface of the medial malleolus or lower third of the anterior tibia for at least 15–30 seconds. Look and feel for a persistent indentation (pitting edema).
Q: What is the clinical significance of generalized lymphadenopathy?
Generalized lymphadenopathy (enlargement of two or more non-contiguous lymph node groups) warrants immediate investigation for systemic infections (HIV, tuberculosis, mononucleosis), autoimmune disorders (SLE), or hematological malignancies (lymphoma, leukemia).
Written by Shrikant Bhosale
Final-Year MBBS Student at Government Medical College, Chhatrapati Sambhajinagar (Aurangabad), Maharashtra. Affiliated with Maharashtra University of Health Sciences (MUHS). Written to provide unbloated, peer-tested medical education resources grounded in real hospital ward practice and NMC CBME university examinations.
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