The general examination starts with the hands. The initial handshake may identify an abnormality, such as the large hand of acromegaly or a deformed hand due to abnormal development or previous injury. There may be excessive sweating, due to anxiety, hyperhidrosis or thyrotoxicosis. Skin color changes are more easily seen in white skinned individuals, but they are usually visible in all races and must be searched for.

The palm gives some indication of the type of work undertaken (figure 7). Note pallor, cyanosis and pigmentation; stretch the skin of the palm to examine the colour in the skin creases, as this provides a better indication than the more exposed areas. Erythema of the palmer skin is most marked over the thenar and hypothenar eminences. It is an important finding in liver disease, but may also occur in pregnancy, thyrotoxicosis, polycythemia, leukemia, chronic febrile illnesses and rheumatoid arthritis. examination of the first dorsal interosseous muscles (figure 8a,b).

The back of the hand is best to assess skin turgidity and look for generalised pigmentation, bruises, rashes and spider nevi. Skin laxity is seen in older subjects, but it may indicate dehydration at all ages (figure 9). Similarly, areas of bruising and senile keratosis (figure 10) are normal features of aging, but may also indicate nonmalignant and malignant disease (tables 1 & 2) and there may be local or generalised skin discoloration (tables 3 & 4). Skin thickness is a useful measure of nutritional status, particularly in children (figure 11). Skin nodules, moles and red, Campbell de Morgan spots (figure 12) are common; skin abnormalities may be encountered anywhere on the body and the general examination must scan all areas (figure 13a–c).

Table 1 Skin Manifestations of nonmalignant systemic disease

Table 2 Cutaneous manifestations of malignancy

Table 3 Skin discolouration – Local

Table 4 Skin discolouration – Generalised

In the fingers, note nicotine staining, and the nutrition of the skin in scleroderma, rheumatoid arthritis, other collagen disorders and ischemic conditions. There may be loss of pulp and small areas of ulceration  around the fingertips. Painful nodules around the fingertips are seen in infective endocarditis (Osler’s nodes) and deformity in rheumatoid arthritis and osteoarthritis (Heberden’s nodes). Warts (figure14) are common findings in children. Thickening of the palmar fascia (Dupuytren’s contracturefigure 15) may be idiopathic, hereditary, or associated with cirrhosis, and various gut and pulmonary disorders.

Skin rashes may be discreet or continuous (confluent) and the lesions may be primary or secondary. Primary lesions have specific features:

Macules are flat circumscribed areas of abnormal skin colour. They may also have characteristic texture or markings

Papules are circumscribed raised areas of abnormal skin. Larger papules are termed nodules or tumors; if greater than 1cm across, raised abnormal areas may be referred to as plaques. They may be due to increased cellular content or edema

Vesicles are raised papules containing clear fluid. Larger collections are termed blisters or bullae

Pustules are raised papules containing pus

Wheals are raised papules with pale centres

Purpura indicates hemorrhage within the skin

Annular lesions may indicate spreading and infiltration or may have a healing centre

Secondary lesions develop from the expansion or decline of primary lesions, or may be related to their mechanical effect. Examples are desquamation or crusting, infiltration, ulceration and scarring. Ichthyosis is thickening of the skin, lichenification is depigmentation and there may be atrophy. Scratching produces specific longitudinal, reddened areas and there may be some associated skin thickening. Although there are very many and diverse cutaneous lesions, only a few are commonly seen. These include acne, dermatitis, psoriasis, urticaria, warts, skin cancers and leg ulcers. In your general survey, also examine the hair distribution (table 5).

Table 5 Hair changes