Clinical tests

 

CE

Master Clinical Exam Guide

System-wise bedside steps for the 5 core methods — Inspection, Palpation, Percussion, Auscultation, Functional Testing — with normal vs abnormal findings & high-yield clinical pearls.

🧭 General Survey & Vitals ▸

🔎 Inspection

Steps

Approach with hand hygiene; observe build, posture, distress, hydration, hygiene, gait, speech, mental status.

Normal

Comfortable, oriented, stable gait, appropriate affect.

Abnormal

Pallor, cyanosis, jaundice, edema, cachexia, diaphoresis, lethargy, anxiety, toxic look.

Examples

Central cyanosis → hypoxemia; generalized edema → nephrotic/cardiac/hepatic causes.

Pitfalls

Poor lighting, partial exposure, ignoring odor/voice clues.

✋ Palpation

Steps

Temperature (dorsum of hand), capillary refill, skin turgor, lymph nodes (head/neck/axilla), pulses (radial → femoral → distal), compare sides.

Normal

Warm, brisk refill (<2 s), no lymphadenopathy, pulses equal and regular.

Abnormal

Cool/clammy (shock), delayed refill, tender nodes, pulse deficit/volume changes.

Examples

Collapsing (water-hammer) pulse → aortic regurgitation; small-volume → shock.

📏 Vitals (Function)

• BP (sitting & standing if dizziness); HR (rate/rhythm); RR; Temp; SpO₂; BMI; pain scale.
• Orthostatics: ↓SBP ≥20 mmHg or ↑HR ≥30 bpm suggests volume depletion/autonomic failure.

Recheck any abnormal vital yourself; correlate with clinical context.

🌬️ Respiratory (Chest) ▸

🔎 Inspection

• Shape (barrel, pectus), scars, asymmetry, intercostal retractions, accessory muscle use, cyanosis, clubbing.
• Respiratory pattern: tachypnea, Kussmaul, Cheyne-Stokes.

Normal Symmetric expansion, quiet effort.

Abnormal Tracheal tug, paradoxical movement, pursed-lip breathing.

✋ Palpation

• Tracheal position; chest expansion (thumbs at 10th rib); tactile fremitus (patient says “99”).

Normal Midline trachea, equal expansion, normal fremitus.

Abnormal ↓Expansion (effusion/pneumothorax), ↑Fremitus (consolidation), ↓Fremitus (effusion/obesity).

🎵 Percussion

• Percuss interspaces side-to-side, anterior → lateral → posterior.

Normal Resonant.

Dull Consolidation/atelectasis/effusion.

Hyperresonant Pneumothorax/emphysema.

🎧 Auscultation

• Vesicular vs bronchial; compare sides; listen for crackles, wheeze, rhonchi; check vocal resonance (egophony, bronchophony, whisper pectoriloquy).

Normal Vesicular breath sounds, no added sounds.

Abnormal Fine crackles (edema/fibrosis), wheeze (asthma/COPD), bronchial breathing (consolidation), absent (effusion/large PTX).

⚡ Function

• Speaking full sentences? 6-minute walk (if appropriate). Peak flow (baseline vs post-bronchodilator).

Red flags: RR ≥30, SpO₂ ≤90%, silent chest, cyanosis, altered sensorium.

❤️ Cardiovascular ▸

🔎 Inspection

• Facies (malar flush), pallor/icy extremities, chest scars, peripheral edema, JVP at 45°.

Normal JVP ≤3–4 cm above sternal angle, no edema.

Abnormal Elevated JVP with prominent v-waves (TR), sacral edema.

✋ Palpation

• Apex beat (site: 5th ICS MCL), character (tapping/heaving/thrusting/displaced), thrills, parasternal heave; peripheral pulses (rate/rhythm/volume, radio-femoral delay).

Normal Apex localised, no thrills, regular pulses.

Abnormal Heaving apex (AS), diffuse thrusting (MR), collapsing pulse (AR), radio-femoral delay (CoA).

🎵 Percussion

Rarely used now for cardiac borders; rely on palpation/auscultation and imaging.

🎧 Auscultation

• Listen at APT(M) — Aortic (2RICS), Pulmonic (2LICS), Tricuspid (LLSB), Mitral (apex). Diaphragm for high-pitch, bell for low (S3/S4/MS murmur).
• Assess S1/S2, extra sounds, murmurs (timing, location, radiation, grade, maneuvers: inspiration, hand-grip, squat, Valsalva).

Finding	Clue
AS	Ejection systolic murmur @ aortic → carotids; soft/absent S2; slow-rising pulse.
MR	Holosystolic @ apex → axilla; displaced thrusting apex.
MS	Low-pitch mid-diastolic rumble @ apex (bell), opening snap; malar flush.
AR	Early diastolic decrescendo @ LLSB; wide pulse pressure; collapsing pulse.

⚡ Function

• Postural BP, exercise tolerance, orthopnea (pillows), NYHA class; 6MWT if indicated.

Emergency: chest pain + diaphoresis + hypotension → activate ACS pathway.

🍽️ Abdomen ▸

🔎 Inspection

• Contour (flat/scaphoid/distended), scars, striae, hernias, visible pulsations/veins, skin changes (caput medusae, spider nevi).

Normal Flat/rounded, no scars, no visible masses.

Abnormal Generalized distension (obstruction/ascites), periumbilical ecchymosis (Cullen), flank ecchymosis (Grey-Turner).

✋ Palpation

• Light palpation → guarding/rebound; deep palpation for masses; liver edge (RUQ, on inspiration), spleen (RIF → LUQ diagonal), kidneys (ballot), aorta width.

Normal Soft, non-tender, no organomegaly.

Abnormal Tender RIF (appendicitis), smooth tender liver (hepatitis), firm nodular liver (cirrhosis), ballotable kidney (hydronephrosis).

🎵 Percussion

• Liver span (mid-clavicular); spleen percussion (Nixon/Castell); shifting dullness & fluid thrill for ascites.

Dullness over enlarged organ or fluid; Tympany over bowel gas.

🎧 Auscultation

• Bowel sounds (normo/hyper/hypo/absent); bruits over aorta/renal/iliac; venous hum (portal HTN).

Hyperactive early obstruction; Absent ileus/peritonitis (emergency if pain + guarding).

⚡ Function

• Murphy sign, Rovsing, Psoas/Obturator tests; stool/urine color inquiry; hydration status.

Do painful area last; watch face for wince/guarding.

🧠 Neurological ▸

🔎 Inspection

• Conscious level (AVPU), speech, facial symmetry, involuntary movements, muscle wasting/fasciculations, gait.

✋ Palpation

• Tone (spastic vs flaccid), tenderness over nerves, temperature asymmetry (CRPS).

🎵 Percussion (Reflexes)

Reflex	Root	Notes
Biceps	C5–C6	Tap on tendon in antecubital fossa.
Triceps	C7–C8	Tap above olecranon.
Knee (patellar)	L3–L4	Leg dangling, brisk tap.
Ankle	S1–S2	Foot slight dorsiflexion.
Plantar	L5–S1	Babinski upgoing = UMN lesion.

🎧 Auscultation

Limited role: carotid bruits (stroke risk), cranial auscultation for AVM in pediatrics (rare).

⚡ Function

• Cranial nerves (II–XII), motor power (MRC grade 0–5), coordination (finger-nose, heel-shin), sensation (light touch, pin, vibration, proprioception), Romberg, gait (normal, tandem, heel-toe).

Abnormal Ataxia (cerebellar), positive Romberg (sensory/vestibular), hemiparesis pattern (UMN).

🦴 Musculoskeletal & Joints ▸

🔎 Inspection

• Alignment, swelling, deformity, erythema, muscle bulk, gait aids; compare sides.

✋ Palpation

• Joint line tenderness, warmth, effusion (patellar tap/balloon), crepitus.

🎵 Percussion

Percussion has minimal routine role; tap for bony tenderness (fracture suspicion).

🎧 Auscultation

Not standard; occasionally listen for crepitus/snaps over tendons (rare).

⚡ Function (ROM & Special Tests)

• Shoulder: active/passive ROM; special tests — Neer/Hawkins (impingement), Empty can (SS), Apprehension (instability).
• Knee: Lachman/Anterior drawer (ACL), Posterior drawer (PCL), McMurray (meniscus), Varus/Valgus (LCL/MCL).
• Hip: Trendelenburg (gluteus medius), FABER/FADIR (intra-articular pathology).
• Spine: SLR for radiculopathy; Schober for lumbar flexion (spondyloarthritis).

🗂️ One-Glance Summary Table ▸

Technique	Normal	Abnormal	High-Yield Examples
Inspection	Symmetry, no distress, appropriate color	Pallor, cyanosis, jaundice, edema, scars, deformity	Central cyanosis → hypoxemia; JVP rise → right heart failure
Palpation	Warm, non-tender, normal pulses, no organomegaly	Tenderness, guarding, masses, altered pulses	Heaving apex → AS; tender RUQ + Murphy → cholecystitis
Percussion	Resonant chest, tympanic bowel, normal liver span	Dullness (fluid/solid), hyperresonance (air)	Dull base + ↓fremitus → pleural effusion
Auscultation	Vesicular BS, normal S1/S2, bowel gurgles	Crackles/wheeze, murmurs/rubs, absent BS	Holosystolic @ apex → MR; early diastolic @ LLSB → AR
Function	Full power, intact reflexes, steady gait	Weakness, hyper/hyporeflexia, ataxia, limited ROM	Positive Romberg → sensory ataxia; Lachman → ACL tear

💡 USMLE-Style Clinical Pearls ▸

Always inspect before you touch. Palpation can abolish subtle visible signs (e.g., small hernias, fine venous pulsations).

Dull percussion + ↓ breath sounds + ↓ tactile fremitus = pleural effusion. Dull percussion + bronchial breath sounds + ↑ fremitus = consolidation.

Wheeze is predominantly expiratory (airflow obstruction). Stridor is predominantly inspiratory (upper airway obstruction) — emergency if acute.

Apex beat that is lateral and diffuse suggests LV dilation (e.g., MR, cardiomyopathy). Localised, heaving = pressure overload (AS).

Early diastolic decrescendo murmur at LLSB = aortic regurgitation; low-pitched mid-diastolic rumble with opening snap at apex = mitral stenosis.

Right-sided murmurs intensify with inspiration (↑ venous return). Hand-grip augments MR/AR; Valsalva accentuates HCM murmur.

Rovsing + Psoas + localized rebound in RIF → classic appendicitis cluster (especially with anorexia and migration of pain).

Hyperactive, high-pitched “tinkling” bowel sounds suggest mechanical obstruction; absent sounds in a tender, rigid abdomen → consider peritonitis/ischemia.

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

Positive Romberg = impaired proprioception/vestibular, not cerebellar (cerebellar ataxia persists even with eyes open).

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

Orthostatic hypotension: ↓SBP ≥20 mmHg or ↓DBP ≥10 mmHg within 3 min of standing, with symptoms → evaluate volume status and meds.

Capillary refill >2 s with cool peripheries can indicate shock (check pulse, BP, mental status, lactate).

Always examine the painful area last (abdomen, joint) to avoid reflex guarding and to preserve cooperation.

Safety Red flags requiring urgent escalation: resting hypoxia (SpO₂ ≤ 90%), severe respiratory distress or stridor, chest pain with hemodynamic instability, rigid/tender abdomen with peritonism, GCS fall/new focal neuro deficits, septic appearance with hypotension.

Quick Map: Inspection = look; Palpation = feel; Percussion = tap for density; Auscultation = listen; Function = test performance. Correlate with history and investigations.