Directional Terms & Body Planes

Clinical Exam Tests

5 core methods across systems
steps → normal → abnormal → quick examples → pitfalls

🔎 INSPECTION

General Survey & Vitals

Steps

• Observe build, posture, hygiene, hydration, gait/steps, affect/mental state, speech.
• Check vitals: BP, HR, RR, Temp, SpO₂, weight/BMI.
• Expose appropriately; ensure good lighting.

Normal Comfortable, oriented, normal complexion, stable gait.

Abnormal & Examples

• Pallor (anemia), jaundice (hepatobiliary), central cyanosis (hypoxemia).
• Edema (cardiac/renal/hepatic), cachexia (musc wastage-malignancy/CHF), diaphoresis (sweating-ACS, sepsis).
• Abnormal gait (Parkinsonian, hemiplegic, ataxic).

Red flags: altered mentation, SpO₂ ≤ 90%, RR ≥ 30, cyanosis.

Pitfalls: poor lighting, incomplete exposure, ignoring odor/voice clues.

Respiratory (Chest)

• Chest shape (barrel, pectus), symmetry, scars, deformity.
• Work of breathing: accessory muscles, nasal flaring, retractions.
• Pattern: tachypnea(fast shallow), Kussmaul(fast, deep, labored) Cheyne–Stokes (pause in breathing (apnea) or shallow breathing (hypopnea); cyanosis (skin, lips or nails turn blue due to lack of O2 in blood), clubbing (fingertips & nails enlarge, nails curve downwards, appearing swollen & spongy like an upside-down spoon.

Normal Symmetric expansion, quiet effort. Abnormal Tracheal tug (downward movement of trachea during inspiration), paradoxical movement (reversed movement pattern), pursed-lip breathing (COPD).

Raised JVP + peripheral edema + basal crackles → consider heart failure.

Cardiovascular

• Inspect JVP at 45°, precordial (over ❤️) scars/pulsations, peripheral edema, nail changes (clubbing, splinter hemorrhages (under nailbed).

Normal JVP ≤ 3–4 cm above sternal angle, no edema. Abnormal Elevated JVP (RV failure), malar flush (MS), edema (HF/nephrotic).

Prominent v-waves at JVP → tricuspid regurgitation (valve doesn't close properly, allowing some blood to leak backward into right atrium with each ❤️beat)

Abdomen

• Contour (flat/distended), scars/striae(lines), hernias, caput medusae (means "head of Medusa", refers to a visible cluster of swollen veins radiating from umbilicus (belly button), spider nevi, visible pulsations.

Normal Flat/rounded, no scars/masses. Abnormal Generalized distension (obstruction/ascites); Cullen/Grey–Turner (hemorrhage), bluish discoloration (ecchymosis) around umbilicus (belly button)

Visible peristalsis + colicky pain → mechanical obstruction.

Neurological

• Level of consciousness, facial symmetry, tremors, fasciculations (visible, involuntary twitching of an individual musc), involuntary movements.
• Gait (normal, tandem-straight), posture, arm swing.

Rest tremor + shuffling gait + reduced arm swing → Parkinsonism.

Musculoskeletal & Joints

• Alignment, swelling, erythema (redness of skin or mucous membranes resulting from ^blood flow (hyperemia) in superficial capillaries), deformity, scars, muscle bulk, posture; compare sides.

Hot, red, acutely tender monoarthritis → septic arthritis/gout until proven otherwise.

✋ PALPATION

General Survey & Pulses

• Temperature (dorsum of hand), moisture, capillary refill (<2 s), skin turgor.
• Lymph nodes (head/neck/axilla/inguinal): size, tenderness, mobility.
• Pulses: radial → brachial → carotid (one at a time) → femoral → popliteal → posterior tibial → dorsalis pedis (rate, rhythm, volume, symmetry).

Normal Warm, brisk refill, no LAD, equal pulses. Abnormal Cool/clammy (shock), tender nodes (infection), hard fixed nodes (malignancy), pulse deficit (AF).

Collapsing (water-hammer) pulse → aortic regurgitation.

Respiratory (Chest)

• Tracheal position (suprasternal notch).
• Chest expansion (thumbs at 10th ribs posteriorly).
• Tactile fremitus (patient says “99”).

Normal Midline trachea, equal expansion, normal fremitus. ↑ Fremitus Consolidation. ↓ Fremitus Effusion, pneumothorax, obesity.

Asymmetric expansion → same side pathology (effusion/PTX/consolidation).

Cardiovascular

• Apex beat: site (5th ICS MCL), size, character (tapping/heaving/thrusting), displacement.
• Thrills over valves; parasternal heave (RV hypertrophy).
• Peripheral pulses & radio-femoral delay.

Normal Localized apex, no thrills, regular pulses. Abnormal Heaving apex (AS), thrusting displaced apex (MR/volume overload), collapsing pulse (AR).

Radio-femoral delay → coarctation of aorta.

Abdomen

• Light palpation (tenderness/guarding) → deep palpation (masses, organ edges).
• Liver edge (RUQ on inspiration), spleen (RIF → LUQ diagonal), kidneys (ballottement), aortic width (epigastrium).

Normal Soft, non-tender, no organomegaly. Abnormal RIF tenderness/guarding (appendicitis), smooth tender hepatomegaly (hepatitis), firm nodular liver (cirrhosis), ballotable kidney (hydronephrosis).

Do the painful area last; watch the patient’s face for wincing.

Neurological

• Tone (spastic vs flaccid), pronator drift, muscle bulk.
• Peripheral nerve tenderness (eg, Tinel at carpal tunnel).

Spastic ↑tone with clasp-knife feel → UMN lesion; flaccid ↓tone → LMN.

Musculoskeletal & Joints

• Joint line tenderness, warmth, effusion (patellar tap, bulge sign), crepitus.
• Neurovascular status: distal pulses, cap refill, sensation.

Pain out of proportion + tense compartment → compartment syndrome (emergency).

🎵 PERCUSSION

Respiratory (Chest)

• Percuss interspaces side-to-side anterior, lateral, posterior.
• Compare resonance; map diaphragmatic excursion if needed.

Resonant Normal lung. Dull Consolidation, collapse, effusion. Hyperresonant Pneumothorax, emphysema.

Dullness + ↓fremitus + ↓BS → pleural effusion; dullness + ↑fremitus + bronchial BS → consolidation.

Abdomen

• Liver span (mid-clavicular), spleen (Castell/Nixon), bladder distension (suprapubic dullness).
• Ascites: shifting dullness, fluid thrill (if tense).

Tympany Over bowel. Dullness Organ enlargement or fluid.

Shifting dullness sensitivity increases with >500 mL fluid.

Cardiovascular (limited use)

Old-school cardiac border percussion is largely replaced by palpation/auscultation and imaging.

Neurological & MSK

True tissue percussion is limited; “percussion” with a reflex hammer tests tendon stretch (covered under Function).

• MSK: gentle bony tapping for focal tenderness if fracture suspected.

🎧 AUSCULTATION

Respiratory (Chest)

• Use diaphragm; compare sides; listen to all lung zones.
• Assess vesicular vs bronchial; added sounds: crackles, wheeze, rhonchi, rub.
• Voice tests: egophony, bronchophony, whisper pectoriloquy.

Normal Vesicular breath sounds, no added sounds. Abnormal Fine crackles (edema/fibrosis), polyphonic wheeze (asthma/COPD), bronchial breathing (consolidation), absent (effusion/PTX).

Stridor (inspiratory) = upper airway obstruction → emergency if acute.

Cardiovascular

• APT(M) areas: Aortic (2RICS), Pulmonic (2LICS), Tricuspid (LLSB), Mitral (apex).
• Diaphragm for high-pitch; bell for low-pitch (S3/S4/MS rumble).
• Assess timing, intensity, radiation; use maneuvers (inspiration, squat, handgrip, Valsalva).

• AS: Ejection systolic @ aortic → carotids; soft/absent S2.
• MR: Holosystolic @ apex → axilla.
• MS: Low-pitch mid-diastolic rumble @ apex with opening snap.
• AR: Early diastolic decrescendo @ LLSB; wide pulse pressure.

Right-sided murmurs intensify with inspiration; handgrip ↑MR/AR; Valsalva ↑HCM murmur.

Abdomen

• Bowel sounds: normoactive vs hyperactive “tinkling” vs absent.
• Bruits: aorta, renal, iliac; venous hum (portal HTN).

Absent Ileus/peritonitis (if tender/rigid, urgent).

Hyperactive, high-pitched sounds early → mechanical obstruction.

Vascular (Carotids)

• Bell lightly over carotid (one side at a time), ask patient to hold breath briefly.

Carotid bruit → atherosclerosis; correlate with neuro symptoms.

⚡ FUNCTIONAL TESTING

General (Vitals & Orthostatics)

• Measure BP seated, repeat standing at 1 & 3 min for orthostatics.
• HR, RR, Temp, SpO₂, pain scale, BMI.

Orthostatic hypotension ↓SBP ≥20 mmHg or ↓DBP ≥10 mmHg (± symptoms).

Always recheck abnormal vitals yourself; interpret with context.

Respiratory

• Peak expiratory flow (baseline vs post-bronchodilator).
• 6-minute walk test (if appropriate) with SpO₂ monitoring.

Silent chest + hypoxia = impending respiratory failure (urgent).

Cardiovascular

• Exercise tolerance (stairs, 6MWT), NYHA class, orthopnea (pillows), PND history.

Chest pain + diaphoresis + hypotension → activate ACS pathway immediately.

Abdomen — Special Signs

• Murphy (cholecystitis), Rovsing (appendicitis), Psoas/Obturator (appendix/retrocecal), Carnett (abdominal wall pain).

Rebound tenderness + guarding + rigid abdomen → peritonitis (emergency).

Neurological

• Cranial nerves II–XII (visual fields, EOM, facial movements, palate, tongue).
• Motor: bulk, tone, power (MRC 0–5).
• Sensory: light touch, pin, vibration, proprioception; dermatomes.
• Reflexes: biceps (C5–6), triceps (C7–8), patellar (L3–4), ankle (S1–2); plantar (Babinski).
• Coordination: finger–nose, heel–shin; Romberg; gait (tandem/heel/toe).

UMN ↑tone (spastic), hyperreflexia, Babinski upgoing. LMN ↓tone, atrophy, fasciculations, hyporeflexia.

Positive Romberg = sensory/vestibular deficit (not cerebellar).

Musculoskeletal & Joints — ROM & Special Tests

• Shoulder: Active/passive ROM; Neer/Hawkins (impingement), Empty Can (supraspinatus), Apprehension/Relocation (instability).
• Knee: Lachman/Anterior drawer (ACL), Posterior drawer (PCL), McMurray (meniscus), Varus/Valgus (LCL/MCL), Thessaly (meniscus).
• Hip: Trendelenburg (gluteus medius), FABER/FADIR (intra-articular).
• Spine: Straight leg raise (L5–S1 radiculopathy), Schober (lumbar flexion restriction).
• Neurovascular: Distal pulses, sensation, capillary refill after injuries/splints.

Lachman is most sensitive for ACL; McMurray click + joint line tenderness → meniscal tear.

Critical Red Flags (Escalate)

• SpO₂ ≤ 90% at rest, severe respiratory distress, stridor.
• Chest pain with hypotension/diaphoresis/syncope.
• Rigid, tender abdomen with rebound/guarding; GI bleed with shock.
• GCS drop, new focal neuro deficits, status epilepticus.
• Sepsis signs: fever or hypothermia, tachycardia, hypotension, altered mentation.
• Compartment syndrome: pain out of proportion, pain on passive stretch, tense compartment.