INTRODUCTION TO CLINICAL EXAMINATION

 The two broad aims of a patient-doctor interaction are, to understand the patient’s
perception of his/her own problems and to start the process of diagnosis. This requires
knowledge of disease and its presentation, together with the ability to interpret a patient’s
symptom (complaint) and the findings on observation or physical examination (sign).
Appropriate skills are needed to understand the symptom from patient conversations and to
elicit signs during examination

 For the doctor a clinical interaction consists of:

 History taking
 Examination
 Arriving at a differential diagnosis and ordering relevant investigations

History taking: Patient’s complaints and history indicate the system of body which is primarily
involved. The doctor listens to the patient’s complaints and collects relevant points as given
below. It is a good idea to let the patient describe her/his complaints and then ask a few
questions to get any (additional) information that you need and the patient may have missed.
i) Particulars of the patient such as name,age, sex, occupation, ethnicity and
address.
ii) Presenting Complaints e.g. pain, fever, swelling
iii) History of presenting complaints e.g. for pain, the origin, location, duration,
progress and factors that increase or decrease it may be sought
iv) Past history- Specific past medical history e.g. Diabetes, heart disease, high blood
pressure, injury.
v) Personal history-Smoking, alcohol consumption, allergies, menstrual history.
vi) Treatment history- is the patient taking any drugs (medicines) or did she/he take
prolonged treatment
vii) Family history Does/did anyone in the family have similar complaints/Heart
Disease/High BP/Diabetes Mellitus i.e. Disorders with familial predisposition

General examination: It involves examination of the patient as a whole. It should be conducted

in a comfortable, private, quiet area. A chaperone should be present when a doctor examines a
patient of the opposite sex. It should be done before systemic examination.
The intent is to assess the general health status of the patient. It, also, allows us a
quick assessment of the urgency to treat a patient, may indicate the system affected by the
disease process and aids in diagnosis. The general examination begins when we first see the
patient as she/he enters our chambers and continues as we hear/elicit the history. Once history
taking is done we continue with the balance of the general examination. The following points
may be best noted as the patient enters the chamber and gives her/his history.

i) Posture and Gait, tremors. we shall deal with these in detail when
ii) Speech and interaction, we learn to examine the CNS
iii) Mental state
iv) Measurement - height, weight, waist. Measurements are best made with the patient
standing.
After this ask the patient to lie down on an examination couch and start the
examination standing on the right (if you are right handed), otherwise from the left of the
bed/couch with the patient supine/semi recumbent. Proceed to note the following points in an
orderly manner and keep on recording your findings with pen and paper. Do not wait to examine

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 for multiple points and then write down your findings. You are very likely to forget earlier
findings. Allow the patient 5 minutes of rest before you begin the examination.
The major parameters/features, known as vital parameters are
i) Pulse – felt at the radial artery in the wrist
ii) Blood pressure – measured in the right arm
iii) Respiratory rate – counted as breaths per minute
iv) Temperature: is recorded with a thermometer orally/rectally/in the armpit. For oral
temperatures, choose a glass or an electronic thermometer. When using a glass
thermometer, shake the thermometer down to 35°C (96°F) or below, insert it under the
tongue, instruct the patient to close both lips, and wait 3 to 5 minutes. Then read the
thermometer, reinsert it for a minute, and read it again. If the temperature is still rising,
repeat this procedure until the reading remains stable. Note that hot or cold liquids, and
even smoking, can alter the temperature reading. In these situations, it is best to delay
measuring the temperature for 10 to 15 minutes. The normal temperature measured in
the mouth is 35.8-37° C (96.4- 98.6 °F), 0.5°C higher in the rectum and 0.5°C lower in
the axilla.
v) Jugular venous pressure- The pressure in the internal Jugular vein. This shall be
covered in a subsequent practical class.

After this proceed to look for the three “colours” and three “swellings”.
The three colours are pallor, cyanosis and icterus. One must examine for these in good
ambient lighting conditions (preferably sunlight/ a well lit room with white light).
i) Pallor (decreased “pinkness” of mucosa/skin). The mucosa i.e. inner lining of the mouth
and lower eyelid (lower palpebral conjunctiva), gums, underside of the tongue looks pink in
healthy people. The palms of the hands and feet and the skin in fair complexioned people,
similarly, look pink, hence the term “in the pink of health” to imply good health. If the mucosa or
palms of hands/feet look pale in a thermally comfortable environment, then the person has
pallor. With greater pallor the mucosa/palmar skin may look almost white and the creases in the
palm will look darker by comparison. In normal people i.e. physiologically, this is seen on a cold
day in the body parts exposed to the cold e.g. people look “fairer” in the cold. The cold causes
decreased blood flow to the exposed parts. Pathologically, this is seen in anaemia (low Hb
content of blood).
ii) Cyanosis: bluish discolouration of the mucosa/skin – seek this in the tongue, palms, nail
beds, tip of the nose etc. This may be seen physiologically when on a very cold day the blood
flow in your fingers or tip of the nose becomes very slow so that large amounts (>5gm/dL) of
reduced Hb are present in this area – the reduced Hb gives a blue colour. Pathologically,
cyanosis is an indicator of very low oxygen content in blood either in a part of or throughout the
body.
iii) Icterus: yellow discolouration of the skin/mucosa/sclera (bulbar conjunctiva) – seek this
by looking at the sclera of the eye and the palms. Icterus is seen in Jaundice, which is due to
inflammation of the liver or excessive formation of bilirubin/failure to remove it.
The three swellings are
i. Clubbing: the finger nail when seen from the side forms an angle with the nail bed.
When this angle is obliterated the terminal part of the finger looks like a club. Some people have
clubbed nails normally i.e. physiological. Most people with clubbing of the nails would have
heart or lung disease that leads to less oxygen in blood.
ii. Edema: this is diffuse swelling due to collection of fluid in the tissues below the skin and
is best seen in dependent (between the heart and the ground, closest to the ground) parts of the
body. Press on the inner side of the lower third of the leg with the pulp of your thumb for 30
seconds. Remove your thumb to see if a pit has formed. Observe the pit for the next 30 seconds
to see if it disappears. It is normal i.e. physiological edema if it disappears in <30 seconds,

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 otherwise it is due to disease i.e. pathological. E.g. physiological – with prolonged standing,
Pathological – with heart failure
iii. Lymphadenopathy – swelling of the lymph nodes. Lymph nodes are present throughout
the body and are a part of the immune system that fights infections. Lymph nodes may be
swollen in local infection or due to malignancy of lymphoid tissue. Some locations where lymph
nodes are commonly sought include the sub-mental, cervical and inguinal areas.

After completing the general examination, you shall know if the patient needs
emergency medical care or she/he can continue on to seek care on an out-patient basis. You
would also have picked up indicators of the system affected by disease, e.g. in a patient with
complaint of fever and anorexia, the finding of icterus would indicate to you that the likely cause
of the complaints is an inflammation of the liver.

The systemic examination gives you further detailed information to aid in the diagnosis and is
always conducted for each system under four major heads,
Inspection – to look
Palpation – to touch
Percussion (drum) – to create sound on the body surface and listen to its quality
Auscultation – to listen to sounds emanating from within the body

Each of the examination modalities is used to varying degrees in the examination of the
four major systems i.e. the Respiratory system, Cardio-Vascular system, Abdomen and Central
Nervous system. Note that the abdomen is a body area and not a system. Various organs within
it are parts of various systems e.g. the liver is a part of the gastro-intestinal system, the kidneys
are a part of the genitor-urinary system etc. However, it makes it easy for us to examine
systems under the four major headings mentioned above. We shall learn the modalities and
details of systemic examination when we learn to examine each system.

Glossary
Symptom: Complaint of the patient.
Sign: Finding on observation or examination by the doctor.
Pulse: The pressure wave in arteries due to injection of blood into the aorta during a cardiac
systole
Blood pressure: The pressure of blood that distends the arteries at all times. It is the result of
the elastic nature of arteries and the fact that they accommodate a volume of blood at all times
which is slightly greater than their empty capacity.
Differential diagnosis: When the clinical picture is diffuse and the doctor is not sure of what
disease the patient is afflicted by, the doctor considers more than one condition as the likely
cause. This list of conditions is known as the differential diagnosis. The doctor then proceeds to
order investigations to establish which of the differential diagnosis, is the true diagnosis.
Diagnosis: is the specific disease/illness the patient is suffering from as inferred by the doctor
from the clinical picture of the patient and results of laboratory investigations.
Anorexia decreased appetite
Inflammation is a reaction of the body to injury or infection and has five cardinal components
i.e., Tumor (Swelling), Rubor (Redness), Calor (Heat), Dolor (Pain) and Functio Laesa
(Loss of function). Think of an abscess on your hand or the effects of an abrasion on your
knee after a bad fall.