Clinical Examination I: Principles, general examination, cardiovascular and respiratory

🩺 Clinical examination I: principles, general examination, cardiovascular and respiratory. A slick, systematic and kind examination is the core of clinical practice and of every OSCE and PACES-style station. Examiners look for a consistent routine (introduction, consent, positioning, exposure, inspection, palpation, percussion, auscultation, completion), recognition of key signs, a sensible differential and the ability to present findings concisely. This chapter sets out the principles that apply to every examination, the general (end-of-bed, hands, face and neck) examination, and the cardiovascular and respiratory examinations with the signs you must recognise.
Your four questions at the end of any examination: What are the key positive and negative findings? What is the most likely diagnosis, and what else could it be? What is its cause, severity and complication status? What would you do next (bedside tests, bloods, imaging, management)?

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Before You Start - WIPER and Professionalism

• W - Wash your hands (or use alcohol gel) and be bare below the elbows; I - Introduce yourself (full name and role) and identify the patient (name, date of birth); P - Permission (explain and gain verbal consent; offer a chaperone for intimate examinations - breast, genital, rectal - and document their name or the patient's refusal), P - Pain (ask about any pain before touching), P - Position (45° for cardiovascular and respiratory examinations; flat with one pillow for the abdomen); E - Exposure (expose adequately while preserving dignity - offer a gown or blanket, expose only what is needed at each stage); R - Right side of the patient (examine from the right by convention).
• Throughout: watch the patient's face for discomfort, explain what you are doing, thank them, cover them and help them dress at the end, and wash your hands again.
• The sequence for most systems: inspection → palpation → percussion → auscultation (abdomen: auscultation can come before palpation in some routines), followed by special tests and completion ("to complete my examination I would...").
• Look around the bed - oxygen, inhalers, nebulisers, sputum pot, GTN spray, walking aids, insulin pens, medications, fluid charts, catheter bags, feeding tubes, ECG monitoring, observation chart.
• Communication in OSCEs - open with rapport, avoid jargon, check understanding, respond to cues; examiners mark both technique and professionalism.

General Inspection, Hands, Face and Neck

• End of bed: age, comfort at rest (pain, distress), breathlessness (counting respiratory rate, accessory muscles, pursed lips, inability to complete sentences), colour (pallor, cyanosis, jaundice, plethora, pigmentation), body habitus (cachexia, obesity, Cushingoid, Marfanoid), posture and movement (tremor, involuntary movements, hemiparesis), scars visible, syndromic features (Down's, Turner's).
• Hands:

Sign	Causes
Clubbing (loss of the nail-fold angle, increased curvature, fluctuation of the nail bed, Schamroth's window lost)	Lung - carcinoma (non-small cell), bronchiectasis, CF, empyema, abscess, idiopathic pulmonary fibrosis, asbestosis, mesothelioma; cardiac - cyanotic congenital heart disease, infective endocarditis, atrial myxoma; GI - IBD, cirrhosis, coeliac disease; thyroid acropachy (Graves'); familial. Not COPD - clubbing in COPD suggests lung cancer
Koilonychia (spoon-shaped)	Iron deficiency
Leuconychia (white nails)	Hypoalbuminaemia (liver disease, nephrotic syndrome)
Splinter haemorrhages	Infective endocarditis, trauma (common in manual workers), vasculitis
Nail pitting, onycholysis	Psoriasis (onycholysis also thyrotoxicosis)
Palmar erythema	Liver disease, pregnancy, thyrotoxicosis, rheumatoid arthritis
Dupuytren's contracture	Alcohol, familial, diabetes, epilepsy drugs, manual work
Tar staining	Smoking
Tendon xanthomata	Familial hypercholesterolaemia
Janeway lesions (painless palms), Osler's nodes (painful finger pulps)	Infective endocarditis
Asterixis (flapping tremor)	CO₂ retention, hepatic encephalopathy, uraemia
Fine tremor	β-agonists, thyrotoxicosis, anxiety, caffeine; coarse - lithium toxicity
Small muscle wasting	Ulnar or median nerve lesions, T1 root (Pancoast tumour), MND, rheumatoid arthritis

• Face: conjunctival pallor, scleral icterus, xanthelasma, corneal arcus (under 50 suggests hyperlipidaemia), malar flush (mitral stenosis), central cyanosis (tongue), mouth (dentition - endocarditis source; ulcers; candida - inhaled steroids), Horner's syndrome (ptosis, miosis, anhidrosis - Pancoast), facial asymmetry.
• Neck: JVP, lymph nodes (cervical, supraclavicular - Virchow's), trachea position, thyroid, carotid pulse, scars.

Presenting Your Findings

• Structure: "I examined Mr X, a 65-year-old man. On general inspection he was comfortable at rest... The positive findings were... Relevant negatives were... These findings are consistent with... The most likely cause is... My differential includes... To complete my examination I would... I would investigate with... and manage by..."
• Lead with the diagnosis if you are confident ("This patient has signs of aortic stenosis...") - examiners reward clear clinical reasoning.
• Comment on: cause (e.g. rheumatic, degenerative), severity (e.g. slow-rising pulse, narrow pulse pressure, soft S2 in aortic stenosis), complications (heart failure, endocarditis), and treatment (scars, sternotomy, metallic valve clicks, inhalers, oxygen).
• Be honest - if unsure of a sign, say so and say how you would confirm it (e.g. echocardiography).

Cardiovascular Examination - Routine

• Position at 45°, exposed to the waist (offer a sheet or gown for women).
• General inspection - breathlessness, cyanosis, pallor, Marfanoid habitus, Down's syndrome (AVSD), Turner's (coarctation, bicuspid valve), scars (median sternotomy - CABG or valve; left thoracotomy - mitral valvotomy, coarctation repair, PDA ligation; leg - saphenous vein harvest), pacemaker or ICD (left infraclavicular), GTN spray, oxygen.
• Hands - clubbing, splinters, Janeway and Osler, tar staining, xanthomata, capillary refill (<2 seconds), temperature, radial pulse (rate, rhythm), radio-radial delay (coarctation proximal to left subclavian, aortic dissection, subclavian stenosis), radio-femoral delay (coarctation), collapsing pulse (raise the arm with the palm on the forearm - aortic regurgitation; ask about shoulder pain first), blood pressure both arms.
• Face and neck - eyes (pallor, xanthelasma, arcus), malar flush, mouth (central cyanosis, dentition, high-arched palate - Marfan), JVP (height and waveform; hepatojugular reflux), carotid pulse (character and volume - auscultate for bruits before palpating; never palpate both carotids together).
• Praecordium:
  • Inspect - scars, deformity (pectus excavatum), visible pulsations, pacemaker.
  • Palpate - apex beat (normally 5th intercostal space, mid-clavicular line; displaced - LV dilatation; heaving - pressure overload - AS, hypertension; thrusting - volume overload - MR, AR; tapping - palpable S1 in mitral stenosis), heaves (left parasternal - RV hypertrophy or LA enlargement) and thrills (palpable murmurs - grade 4 or above) in each area.
  • Auscultate - with the diaphragm and bell in the four areas: mitral (apex), tricuspid (left lower sternal edge), pulmonary (left 2nd intercostal space), aortic (right 2nd intercostal space), while palpating the carotid to time S1 and systole; carotids and axilla (radiation of MR). Manoeuvres: left lateral position with bell at the apex in expiration (mitral stenosis); sitting forward in end-expiration with diaphragm at the left lower sternal edge (aortic regurgitation).
• Back - lung bases (crackles, effusions), sacral oedema.
• Legs - peripheral oedema (pitting - how high), saphenous vein harvest scars, peripheral pulses, signs of PAD.
• Completion: "To complete I would check the peripheral pulses, measure blood pressure and observations, perform fundoscopy (hypertensive retinopathy, Roth spots), dip the urine (haematuria in endocarditis), and review an ECG, CXR and echocardiogram."

Pulse, Blood Pressure and JVP

Pulse character	Cause
Slow-rising, low volume	Aortic stenosis
Collapsing (water-hammer, Corrigan's)	Aortic regurgitation, PDA, high-output states (anaemia, thyrotoxicosis, pregnancy, AV fistula)
Bisferiens (two peaks)	Mixed aortic valve disease, HOCM
Jerky	HOCM
Pulsus paradoxus (fall in systolic BP >10 mmHg on inspiration)	Cardiac tamponade, severe asthma, constrictive pericarditis
Pulsus alternans (alternating strong and weak)	Severe LV failure
Irregularly irregular	Atrial fibrillation (also multiple ectopics, atrial flutter with variable block)

• Blood pressure - correct cuff size (bladder encircling 80% of the arm), arm supported at heart level, seated for 5 minutes; postural BP (lying and standing at 1 and 3 minutes - drop ≥20 systolic or ≥10 diastolic, or symptoms - orthostatic hypotension); difference >15–20 mmHg between arms → dissection, subclavian stenosis, coarctation. Wide pulse pressure - AR, ageing arteries; narrow - AS, tamponade, shock.
• JVP - patient at 45°, head turned slightly left; look for a double-waveform, non-palpable pulsation between the heads of sternocleidomastoid that rises with abdominal pressure (hepatojugular reflux), falls on inspiration and is occludable; measure vertical height above the sternal angle (normal <3–4 cm).

JVP finding	Cause
Raised, normal waveform	Right heart failure, fluid overload, tricuspid regurgitation
Raised, non-pulsatile	SVC obstruction (lung cancer, lymphoma) - facial plethora, dilated chest wall veins
Large v waves (cv waves)	Tricuspid regurgitation (pulsatile liver)
Large a waves	Pulmonary hypertension, pulmonary or tricuspid stenosis, RV hypertrophy
Cannon a waves (irregular)	Complete heart block (atrium contracting against closed tricuspid valve), VT
Absent a waves	Atrial fibrillation
Rises on inspiration (Kussmaul's sign)	Constrictive pericarditis, tamponade (less so), restrictive cardiomyopathy, RV infarction
Steep y descent	Constrictive pericarditis

Heart Sounds and Added Sounds

• S1 - closure of mitral and tricuspid valves (start of systole); loud in mitral stenosis, tachycardia, short PR; soft in severe MR, long PR, poor LV function; variable in AF and complete heart block.
• S2 - closure of aortic (A2) then pulmonary (P2) valves; physiological splitting on inspiration. Loud P2 - pulmonary hypertension; soft or absent A2 - severe aortic stenosis; wide fixed splitting - atrial septal defect; wide split - RBBB, pulmonary stenosis; reversed (paradoxical) splitting - LBBB, severe AS, RV pacing.
• S3 - early diastolic, low-pitched (rapid ventricular filling) - "Ken-tuc-ky"; normal in young people, athletes and pregnancy; pathological after 40 - heart failure, MR, constrictive pericarditis (pericardial knock).
• S4 - late diastolic (atrial contraction into a stiff ventricle) - "Ten-nes-see"; LV hypertrophy (hypertension, AS, HCM), acute MI; never in AF.
• Opening snap - after S2 in mitral stenosis (pliable valve); ejection click - bicuspid aortic valve, pulmonary stenosis; mid-systolic click - mitral valve prolapse; metallic clicks - mechanical prosthetic valves (loss of a crisp click suggests thrombosis or malfunction).
• Pericardial friction rub - scratchy, three components, best heard sitting forward - pericarditis (after MI, Dressler's, uraemia, viral).

Murmurs

• Describe a murmur by: timing (systolic or diastolic, ejection or pansystolic), site of maximal intensity, radiation, grade (systolic 1–6: 1 - very faint; 3 - loud without thrill; 4 - with thrill; 6 - audible without stethoscope), pitch and character, and dynamic manoeuvres (louder on inspiration - right-sided lesions; louder on expiration - left-sided).

Lesion	Murmur	Other signs
Aortic stenosis	Ejection systolic, crescendo–decrescendo, right 2nd ICS, radiates to carotids	Slow-rising pulse, narrow pulse pressure, heaving undisplaced apex, soft A2, S4; severity - soft/absent S2, late-peaking murmur, slow upstroke, LV failure (the murmur may become quieter as severity rises)
Aortic sclerosis	Ejection systolic, no radiation	Normal pulse and S2 (older people)
Mitral regurgitation	Pansystolic, apex, radiates to the axilla	Displaced thrusting apex, soft S1, S3; AF
Mitral valve prolapse	Mid-systolic click then late systolic murmur	Young women, Marfan
Tricuspid regurgitation	Pansystolic, left lower sternal edge, louder on inspiration	Large v waves, pulsatile liver, oedema (IVDU endocarditis, pulmonary hypertension)
VSD	Harsh pansystolic, left lower sternal edge	Thrill; small VSD - loud murmur
Aortic regurgitation	Early diastolic, decrescendo, left lower sternal edge, sitting forward, expiration	Collapsing pulse, wide pulse pressure, displaced apex; eponymous signs (de Musset's head nodding, Quincke's nail bed pulsation, Traube's, Duroziez's); Austin Flint mid-diastolic murmur at apex
Mitral stenosis	Mid-diastolic rumble at apex, left lateral position, bell, expiration; opening snap	Malar flush, AF, tapping apex, loud S1, left parasternal heave (pulmonary hypertension)
Pulmonary stenosis	Ejection systolic, left 2nd ICS, louder on inspiration	Noonan syndrome, carcinoid, tetralogy of Fallot
ASD	Soft pulmonary flow murmur	Fixed splitting of S2
Patent ductus arteriosus	Continuous "machinery" murmur, left infraclavicular	Collapsing pulse
HOCM	Ejection systolic at left sternal edge, louder with Valsalva and standing, quieter with squatting	Jerky pulse, double apex, S4; family history of sudden death
Innocent (flow) murmur	Soft (≤2/6), short, systolic, left sternal edge, varies with posture	No other abnormalities - children, pregnancy, anaemia, fever

• Red flags in a murmur - any diastolic murmur, loud (≥3/6) or with a thrill, symptoms (syncope, chest pain, breathlessness), abnormal pulses or ECG → echocardiography.

Common Cardiovascular Cases

• Aortic stenosis - commonest valve lesion in older people (calcific degeneration; bicuspid in younger). Symptoms - angina, syncope, breathlessness (prognosis poor once symptomatic). Echo for severity (mean gradient >40 mmHg, valve area <1.0 cm², peak velocity >4 m/s). Treatment - surgical AVR or TAVI (older or high surgical risk).
• Mitral regurgitation - degenerative (prolapse), functional (LV dilatation), ischaemic (papillary muscle), rheumatic, endocarditis. Repair preferred over replacement; transcatheter edge-to-edge repair for some.
• Prosthetic valves - sternotomy scar, metallic clicks (mechanical - lifelong warfarin; INR target 2.5–3.5 depending on valve and position; DOACs contraindicated) or no click (bioprosthetic - limited lifespan 10–20 years). Look for complications - endocarditis, haemolysis, valve dysfunction (new regurgitant murmur), bleeding.
• Infective endocarditis - fever plus murmur until proven otherwise; Duke criteria; three sets of blood cultures before antibiotics; echo (TOE).
• Heart failure - tachycardia, raised JVP, displaced apex, S3, bibasal crackles, pleural effusions, pitting oedema, hepatomegaly; NT-proBNP and echo.
• Atrial fibrillation - irregularly irregular pulse with pulse deficit (apex rate > radial rate); assess stroke risk (CHA₂DS₂-VASc) and bleeding risk (ORBIT); rate or rhythm control.

Respiratory Examination - Routine

• Position at 45°, exposed to the waist.
• General inspection - respiratory rate (count for 30 seconds), work of breathing (accessory muscles, intercostal recession, tripod position, pursed-lip breathing - COPD), ability to speak in sentences, cough (productive, bovine - recurrent laryngeal nerve palsy), stridor, wheeze, cyanosis, cachexia, chest shape (barrel chest - hyperinflation; pectus; kyphoscoliosis), scars (thoracotomy, lobectomy, pneumonectomy, chest drain sites, sternotomy), radiotherapy tattoos (small blue dots) and skin changes, oxygen, inhalers, sputum pot (colour, blood).
• Hands - clubbing, tar staining, peripheral cyanosis, CO₂ retention flap (asterixis), fine tremor (β-agonists), small muscle wasting (Pancoast tumour - T1), joint changes (rheumatoid - ILD), skin changes (systemic sclerosis - ILD), pulse (bounding in CO₂ retention), respiratory rate.
• Face - Horner's syndrome, central cyanosis, conjunctival pallor, plethora, SVC obstruction, butterfly rash (SLE), heliotrope rash (dermatomyositis), lupus pernio (sarcoidosis).
• Neck - tracheal position (warn the patient; deviated away from tension pneumothorax and large effusion; towards collapse, pneumonectomy, upper lobe fibrosis), cricosternal distance (<3 fingers - hyperinflation), tracheal tug, lymph nodes (sit the patient forward - cervical, supraclavicular, axillary), JVP (cor pulmonale; fixed raised in SVC obstruction).
• Chest - front then back:
  • Inspection - scars, symmetry of expansion, deformity, dilated veins.
  • Palpation - chest expansion (hands on the chest with thumbs meeting in the midline - reduced on the side of pathology; >5 cm normally), apex beat (displaced by mediastinal shift).
  • Percussion - compare side to side, top to bottom (including axillae and supraclavicular fossae/apices); resonant (normal), hyper-resonant (pneumothorax, emphysema), dull (consolidation, collapse, fibrosis), stony dull (pleural effusion); loss of cardiac and liver dullness in hyperinflation.
  • Auscultation - diaphragm, compare both sides at each level; breath sounds (vesicular, bronchial - harsh, gap between inspiration and expiration - consolidation, above an effusion), added sounds (wheeze, crackles, pleural rub, stridor), vocal resonance ("99" - increased in consolidation, decreased in effusion and pneumothorax) or tactile vocal fremitus.
• Completion: "I would examine the legs for oedema and DVT, check observations including oxygen saturations, inspect the sputum, measure peak flow or spirometry, and request a chest X-ray and arterial blood gas if indicated."

Interpreting Respiratory Signs

Condition	Trachea	Expansion	Percussion	Breath sounds	Vocal resonance
Consolidation (pneumonia)	Central	Reduced on affected side	Dull	Bronchial; coarse crackles	Increased
Pleural effusion	Central (away if massive)	Reduced	Stony dull	Reduced or absent (bronchial at the upper border)	Reduced
Pneumothorax	Central (away if tension)	Reduced	Hyper-resonant	Reduced or absent	Reduced
Lobar collapse	Towards the collapse	Reduced	Dull	Reduced	Reduced
Pneumonectomy	Towards the operated side	Reduced	Dull	Absent (or transmitted)	Reduced
Pulmonary fibrosis	Central (towards if upper lobe)	Reduced bilaterally	Normal or dull	Fine end-inspiratory "velcro" crackles (bases - IPF)	Normal or increased
COPD / emphysema	Central; reduced cricosternal distance	Reduced bilaterally (hyperinflated)	Hyper-resonant	Reduced, prolonged expiration, wheeze	Normal or reduced
Bronchiectasis	Central	Normal or reduced	Normal	Coarse crackles that change with coughing; wheeze	Normal

• Wheeze - polyphonic (asthma, COPD - diffuse small airway narrowing), monophonic (fixed single airway obstruction - tumour, foreign body); stridor - inspiratory noise from upper airway obstruction (emergency).
• Crackles - fine late inspiratory (fibrosis, pulmonary oedema early), coarse (bronchiectasis, pneumonia, oedema).

Common Respiratory Cases

• Pleural effusion - describe side and level; look for cause (transudate - heart failure, cirrhosis, nephrotic syndrome; exudate - malignancy (clubbing, cachexia, nodes, breast surgery), parapneumonic, TB, rheumatoid arthritis, PE, mesothelioma - asbestos exposure). Next - CXR, ultrasound-guided diagnostic aspiration (protein, LDH, pH, glucose, cytology, microscopy and culture).
• Interstitial lung disease - clubbing, fine bibasal crackles; look for cause (rheumatoid hands, systemic sclerosis, drugs - methotrexate, amiodarone, nitrofurantoin; occupational exposure, bird keeping); upper lobe fibrosis (TB, sarcoidosis, silicosis, ankylosing spondylitis, ABPA, hypersensitivity pneumonitis) versus lower lobe (IPF, asbestosis, connective tissue disease, drugs). Next - HRCT, spirometry with gas transfer (restrictive, low TLCO).
• COPD - hyperinflation, pursed lips, accessory muscles, wheeze, CO₂ retention flap, cor pulmonale (raised JVP, oedema, loud P2), long-term oxygen. Next - spirometry (FEV₁/FVC <0.7 post-bronchodilator).
• Bronchiectasis - clubbing, coarse crackles, sputum pot full of purulent sputum, finger clubbing; causes - post-infective, CF (young, thin, port-a-cath, pancreatic enzymes), primary ciliary dyskinesia (dextrocardia), immune deficiency, ABPA, rheumatoid arthritis. Next - HRCT.
• Previous lobectomy/pneumonectomy - thoracotomy scar, tracheal deviation towards the side (pneumonectomy), reduced expansion; cause - lung cancer, old TB (thoracoplasty, phrenic nerve crush - older patients), bronchiectasis.
• Lung cancer - clubbing, cachexia, nodes, Horner's, collapse or effusion signs, SVC obstruction, paraneoplastic features.

At a Glance

Sign	Think
Slow-rising pulse + ejection systolic murmur to carotids	Aortic stenosis
Collapsing pulse + early diastolic murmur	Aortic regurgitation
Pansystolic murmur to axilla + displaced apex	Mitral regurgitation
Mid-diastolic rumble + malar flush + AF	Mitral stenosis
Fixed split S2	ASD
Cannon a waves	Complete heart block
Kussmaul's sign	Constrictive pericarditis
Stony dull + reduced vocal resonance	Pleural effusion
Bronchial breathing + increased vocal resonance	Consolidation
Trachea towards dull side	Collapse or pneumonectomy
Clubbing + fine bibasal crackles	Idiopathic pulmonary fibrosis

Spot the Sign

• Clubbing in a long-standing COPD patient. → Not due to COPD - look for lung cancer, bronchiectasis or fibrosis.
• A tall young man with a high-arched palate and an early diastolic murmur. → Marfan syndrome with aortic regurgitation.
• A soft ejection systolic murmur that disappears when a pregnant woman sits up. → Innocent flow murmur.
• Raised non-pulsatile JVP, facial plethora and dilated chest veins. → SVC obstruction.
• Small blue dots on the chest wall and a dull hemithorax. → Radiotherapy tattoos - previous cancer treatment; effusion or collapse.

Exam-style Scenarios

• Scenario. Present this patient: 78-year-old woman, breathless on exertion, slow-rising pulse, BP 110/90, heaving non-displaced apex, ejection systolic murmur grade 3 radiating to carotids, soft S2.
  Answer: "This patient has signs of severe aortic stenosis - a slow-rising pulse with narrow pulse pressure, a heaving apex suggesting LV hypertrophy, and an ejection systolic murmur radiating to the carotids with a soft second heart sound. There are no signs of heart failure or endocarditis. The likely cause at her age is calcific degeneration. I would arrange an ECG and echocardiography (valve area, gradient, LV function) and refer to cardiology - with exertional symptoms she should be assessed for valve replacement (surgical AVR or TAVI)."
• Scenario. A patient has reduced expansion on the right, a stony dull right base, absent breath sounds and reduced vocal resonance. He has clubbing and lost weight; he worked as a pipe-fitter.
  Answer: Right pleural effusion, likely an exudate from malignancy - mesothelioma (asbestos exposure) or lung cancer. Next: CXR, ultrasound-guided pleural aspiration (cytology, protein, LDH, pH), CT chest with contrast, and pleural biopsy if cytology is negative; respiratory MDT. Mention industrial disease compensation.
• Scenario. How do you tell the JVP from the carotid pulse?
  Answer: The JVP is not palpable, has a double waveform (a and v), is occluded by gentle pressure at the root of the neck, rises with hepatojugular pressure, falls on inspiration, and changes with posture; the carotid is palpable, single, and unaffected by these manoeuvres.

Key Points

• WIPER, chaperones, dignity and an explained, systematic routine earn marks before any sign is found.
• Inspect, palpate, percuss, auscultate - then special manoeuvres and completion.
• Time murmurs against the carotid pulse; use positioning to bring out MS and AR.
• Learn the signs table for consolidation, effusion, pneumothorax, collapse and fibrosis.
• Present: diagnosis, cause, severity, complications, next steps.

Further Reading

• Macleod's Clinical Examination
• Talley NJ, O'Connor S. Clinical Examination
• Epstein O et al. Clinical Examination
• Geeky Medics: OSCE examination guides
• 2020 ACC/AHA and 2021 ESC/EACTS guidelines for valvular heart disease