Clinical Examination Fundamentals

A systematic approach to clinical examination is essential for generating reliable findings that can be communicated clearly to colleagues. Before examining any patient, introduce yourself, obtain verbal consent, ensure the environment is appropriate (adequate lighting, privacy, appropriate chaperone if needed), and position the patient correctly — most examinations begin with the patient at 45 degrees.

The GALS screen (Gait, Arms, Legs, Spine) is a rapid three-minute musculoskeletal screening examination that identifies significant locomotor abnormality in general practice and hospital settings. Gait is observed for symmetry, arm swing, and heel strike. Arms are assessed for shoulder abduction, elbow extension, wrist and finger movements, and a hand grip. Legs are examined for knee flexion, hip internal rotation in flexion, and foot inspection. The spine is examined for lateral flexion and thoracic kyphosis. A normal GALS screen makes significant inflammatory or mechanical musculoskeletal disease unlikely.

The cardiovascular examination follows a structured sequence. General inspection identifies dyspnoea, cyanosis, or pallor at rest. Hand and pulse examination assesses rate, rhythm, character, and radio-radial/radio-femoral delay. The jugular venous pressure (JVP) is assessed with the patient at 45 degrees — the JVP gives an indirect measure of right atrial pressure and is elevated in right heart failure, cardiac tamponade, and superior vena cava obstruction. Precordial inspection identifies scars and visible pulsations; palpation locates the apex beat (normally fifth intercostal space, mid-clavicular line) and detects heaves and thrills. Auscultation identifies S1 and S2, extra sounds (S3 gallop in heart failure, S4 in hypertensive heart disease), and murmurs characterised by timing, location, radiation, and quality.

The respiratory examination incorporates inspection (respiratory rate, pattern, chest wall deformity, use of accessory muscles), tracheal position, chest expansion, percussion (dull over consolidation/effusion, hyperresonant in pneumothorax), and auscultation of breath sounds (vesicular vs bronchial, crackles, wheeze, pleural rub).

The abdominal examination assesses nine regions systematically. Hepatomegaly is percussed from the right iliac fossa moving superiorly until dullness is detected, then confirmed by feeling the liver edge descend on inspiration. Splenomegaly is approached from the right iliac fossa diagonally toward the left upper quadrant — the spleen is dull to percussion, has a notch, and cannot be balloted. Shifting dullness detects ascites: percuss from central tympany toward the flank until dull, keep the finger in place and roll the patient — if the dullness shifts, free fluid is likely present.