Clinical examination common core
Medical assessment unit · Patient encounter
Mr Kareem, a 62-year-old man
Six weeks of progressive breathlessness, ankle swelling, and reported three-pillow orthopnoea.
Estimated lesson time: about 20 minutes, with an optional 8-minute OSCE practice station.
Cardiovascular examination
1. Meet
- Introduce yourself, confirm the patient's identity, explain the encounter, and obtain consent.
- Check comfort, privacy, exposure, positioning, and hand hygiene before examination.
- Look immediately for breathlessness at rest, cyanosis, altered consciousness, or haemodynamic compromise; seek urgent senior or emergency assessment if present.
2. History taking
- Begin with an open invitation, then establish the timing, progression, triggers, and impact of the breathlessness.
- Ask about chest pain, palpitations, syncope, ankle swelling, orthopnoea, and paroxysmal nocturnal breathlessness.
- Review cardiovascular history, medicines, allergies, smoking, family history, and relevant functional baseline; seek urgent senior or emergency assessment for concerning acute symptoms.
3. Examine
- Position the patient at approximately 45 degrees, expose appropriately, and inspect the hands, face, and chest while preserving dignity.
- Assess pulse and blood pressure, estimate the jugular venous pressure, inspect and palpate the precordium, then auscultate systematically.
- Finish with lung bases, sacrum when appropriate, and ankles for peripheral oedema; thank the patient and state that you would complete observations and any indicated examination.
4. Interpret
- Summarize the history and examination pattern before naming possible explanations.
- Explain that no isolated symptom or sign makes a diagnosis; use the whole clinical context and appropriate senior review.
- Recognize that progressive breathlessness, reported orthopnoea, oedema, and raised venous pressure may be consistent with a congestive pattern, while other explanations remain possible and require full clinical assessment.
5. Apply
- Give a brief, ordered summary of Mr Kareem's presenting problem, associated symptoms, relevant background, and examination findings.
- State uncertainty clearly, identify concerning features, and ask for senior review when findings or the patient's condition warrant it.
- Use the checklist to practise a complete, respectful examination rather than memorizing isolated signs.
Respiratory assessment area · Patient encounter
Mr Nasser, a 58-year-old man
Progressive breathlessness and a persistent cough requiring structured supervised assessment.
Estimated lesson time: about 20 minutes, with an optional 8-minute OSCE practice station.
Respiratory examination
1. Meet
- Introduce yourself, confirm Mr Nasser's identity, explain the encounter, obtain consent, and apply appropriate infection precautions before close assessment.
- From the doorway, assess safety and stability through breathing effort, ability to complete speech, cyanosis, consciousness, positioning, and the need for urgent senior or emergency assessment.
- Adjust exposure only as needed, preserve warmth and dignity, and keep the patient in a comfortable position.
2. History taking
- Start with an open invitation, then clarify onset, duration, progression, triggers, variability, breathlessness at rest and on exertion, cough, sputum, haemoptysis, wheeze, pleuritic pain, fever, and sleep symptoms.
- Ask about smoking, occupation, environmental and animal exposures, recent travel, infection contacts, and thromboembolic risks such as immobility, recent surgery, previous thrombosis, or active serious illness.
- Review medication, adherence, recent changes, functional impact, and red flags including severe breathlessness, cyanosis, confusion, syncope, or significant haemoptysis; communicate acute concern promptly.
Fictional staged case disclosure
History disclosed after questioning
- Mr Nasser describes about eight weeks of gradually progressive breathlessness on exertion. He is comfortable at rest but now pauses after one flight of stairs, whereas he previously climbed two flights without stopping.
- His cough occurs daily, is mostly dry, and occasionally produces a small amount of clear sputum. He reports no fever, haemoptysis, pleuritic chest pain, sudden deterioration, orthopnoea, or paroxysmal nocturnal breathlessness.
- He stopped smoking two years ago after an estimated 35 pack-years. He works in building maintenance and recalls regular cement-dust exposure, but no single exposure event clearly preceded the symptoms.
- He reports no recent surgery, prolonged immobility, previous thromboembolism, unilateral leg swelling, recent travel, known infectious contact, unintentional weight loss, reduced appetite, or night sweats.
- He has no established chronic respiratory diagnosis and has not previously used an inhaler.
These are conservative fictional teaching findings for Mr Nasser, not a diagnosis and not a substitute for findings elicited from a real patient.
3. Examine
- Follow this sequence: general inspection; hands; pulse and respiratory rate; face; neck and trachea; chest inspection; expansion; palpation where useful; percussion; auscultation; vocal resonance where useful; completion.
- Compare corresponding areas side to side, examine anterior and posterior chest as the patient's condition permits, and preserve comfort, exposure, and dignity throughout.
- At completion, thank Mr Nasser, help him reposition, and state that you would complete measured observations and any relevant examination under supervision.
Fictional staged case disclosure
Examination findings disclosed after the sequence
- Mr Nasser is alert, comfortable at rest, and able to speak in full sentences. His respiratory rate is mildly increased, with no visible cyanosis or marked accessory-muscle use.
- The trachea is central and chest expansion is mildly reduced but symmetrical.
- Percussion is resonant across corresponding areas, without focal dullness or unilateral hyperresonance.
- Breath sounds are diffusely reduced in intensity with a prolonged expiratory phase and scattered bilateral expiratory wheeze. There is no focal bronchial breathing or focal crackles.
- Vocal resonance has no focal asymmetry, and there is no peripheral oedema or unilateral calf swelling on the limited completion examination.
These are conservative fictional teaching observations for Mr Nasser, not a diagnosis and not findings to assume in an OSCE or a real patient.
4. Interpret
- Report observation before inference: state what was seen, felt, percussed, or heard, then explain which pattern the combination may support.
- Consolidation, effusion, pneumothorax, airflow obstruction, and interstitial patterns are clusters of findings with overlap; each has limitations and requires the wider clinical context.
- A single sign is not diagnostic, and an absent textbook feature does not exclude an important condition.
5. Apply
- Summarize Mr Nasser's presenting symptoms, chronology, associated features, risks, background, function, and only the examination observations actually available.
- Organize the presentation as problem representation, key positive and negative evidence, cautious pattern-level interpretation, alternatives, limitations, and safety concerns.
Gastrointestinal assessment area · Patient encounter
Mr Khalid, a 54-year-old man
Progressive abdominal swelling and fatigue requiring structured supervised assessment.
Estimated lesson time: about 25 minutes, with an optional 8-minute OSCE practice station.
Gastrointestinal examination
1. Meet
- Introduce yourself, confirm Mr Khalid's identity, explain the abdominal encounter, obtain verbal consent, and sanitize hands.
- Position the patient flat (supine) with one pillow to relax the abdominal wall musculature, and keep arms relaxed at the sides.
- Check from the foot of the bed and doorway for respiratory distress, cachexia, jaundice, severe pain, or vomiting.
2. History taking
- Begin with an open invitation, then clarify the abdominal swelling (onset, tempo, progression, discomfort, and impact on daily activity).
- Ask about core gastrointestinal symptoms: abdominal pain, appetite loss, unintentional weight loss, dysphagia, nausea, vomiting, bowel habit changes, and jaundice.
- Screen for red flags including haematemesis, melaena, dark tarry stools, persistent vomiting, severe pain, or rapid weight loss.
Fictional staged case disclosure
History disclosed after questioning
- Mr Khalid describes about two months of progressive abdominal swelling. He is comfortable at rest but feels abdominal fullness and mild exertional breathlessness due to distension.
- His fatigue has worsened over several weeks. He reports mild yellowing of his eyes, first noticed by a family member a week ago.
- He reports no abdominal pain, fever, nausea, vomiting, dysphagia, or change in bowel frequency. However, he notes that his stools have been somewhat darker recently, but denies frank haematemesis or red blood in stools.
- His background history includes osteoarthritis, for which he takes ibuprofen (NSAID) regularly. He has a 20-year history of alcohol consumption, averaging 30 units per week.
- He reports no recent travel, no history of blood transfusions, no known liver disease in his family, and no prior abdominal surgeries.
These are conservative fictional teaching findings for Mr Khalid, not a diagnosis and not a substitute for findings elicited from a real patient.
3. Examine
- Follow the standard sequence: general inspection; hands (palmar erythema, Dupuytren's, asterixis); face/eyes (icterus, pallor, glossitis); chest (spider naevi, gynaecomastia); abdominal inspection (distension, scars, caput medusae); palpation (light, deep, liver, spleen, kidneys, aorta); percussion (liver span, shifting dullness); auscultation (bowel sounds, bruits); completion (hernial orifices, DRE).
- Explain each step to Mr Khalid, examine from his right side, warm your hands, and watch his face for pain throughout palpation.
- Ensure the patient lies flat with one pillow, or flex the knees slightly if needed to relax the abdominal wall musculature.
Fictional staged case disclosure
Examination findings disclosed after the sequence
- Mr Khalid is alert, comfortable at rest, and oriented. There is mild scleral icterus and conjunctival pallor.
- Examination of the hands reveals palmar erythema and a mild flapping tremor (asterixis) when wrists are hyperextended. There is no Dupuytren's contracture or leuconychia.
- There are 4 distinct spider naevi visible on the upper chest. Gynaecomastia is absent.
- Abdomen is symmetrically distended with an everted umbilicus. There are no visible surgical scars or caput medusae.
- Light and deep palpation reveal a firm, non-tender liver edge palpable 3 cm below the costal margin in the midclavicular line. The spleen tip is palpable on deep inspiration. There are no other palpable masses, guarding, or rigidity.
- Percussion demonstrates shifting dullness in both flanks. The liver span is estimated at 13 cm. Bowel sounds are present and normal on auscultation.
These are conservative fictional teaching observations for Mr Khalid, not a diagnosis and not findings to assume in an OSCE or a real patient.
4. Interpret
- Report physical findings objectively (e.g., firm liver edge, shifting dullness, spider naevi) before offering a clinical synthesis.
- Recognize that a chronic liver disease pattern includes signs of portal hypertension (ascites, splenomegaly) and impaired synthetic function (jaundice, coagulation changes).
- Acknowledge the diagnostic accuracy of signs: shifting dullness has a high sensitivity for ascites (LR+ 2.7, LR- 0.3), but cannot identify the cause by itself.
5. Apply
- Present the patient encounter using SBAR structure: Situation (Mr Khalid, 54, abdominal swelling), Background (alcohol history, ibuprofen use), Assessment (distension, hepatosplenomegaly, ascites, jaundice), Recommendation (workup, senior review).
- Practice the abdominal OSCE station focusing on correct hand placement, safety checks, patient positioning, and concise presentation of findings.
- Reflect on examiner feedback regarding patient safety, comfort, and the clinical reasoning of your differential diagnosis.
Clinical Skills Lab · Teaching encounter
General Foundations, Chapter 1
Learning bedside communication, history-taking structure, and screening physical examination.
Estimated lesson time: about 20 minutes, with an optional 8-minute bedside OSCE practice station.
General Foundations
1. Meet
- Clean hands thoroughly, greet the patient, introduce yourself, and state your clinical role.
- Confirm the patient's identity and obtain verbal consent before any physical contact.
- Position the patient semi-recumbent at about 45 degrees, ensuring warmth and appropriate exposure.
2. History taking
- Establish the chronological order of the presenting illness (HPI).
- Use open-ended questions first to let the patient tell their story without interruption.
- Recognize and acknowledge patient emotions (sadness, anger, fear) using the NURS mnemonic.
3. Examine
- Record past medical/surgical history, current medications, allergies, and social history (CAGE screen).
- Perform a systematic general appraisal (nutritional state, skin color changes, mobility, and bedside environment).
- Inspect the patient's face for classic eponymous or diagnostic facies.
4. Interpret
- Measure the four primary vital signs: pulse, blood pressure, respiratory rate, and temperature.
- Understand that respiratory rate is the most sensitive predictor of acute clinical deterioration.
- Evaluate how clinical findings shift probability using pre-test risk and Likelihood Ratios (LRs).
5. Apply
- Synthesize and present clinical cases in a structured SBAR (Situation, Background, Assessment, Recommendation) format.
- Perform a systematic, rapid bed-side screening physical examination.
- Avoid therapeutic or pharmacological details; escalate acute findings to senior staff.
Rheumatology Outpatient Clinic · Patient encounter
Mrs Farah, a 42-year-old female
Symmetrical hand joint pain, morning stiffness, and fatigue requiring structured supervised assessment.
Estimated lesson time: about 20 minutes, with an optional 8-minute OSCE practice station.
Rheumatological examination
1. Meet
- Clean hands thoroughly, greet the patient, introduce yourself, and state your clinical role.
- Confirm the patient's identity and obtain verbal consent before performing any physical contact.
- Inspect the patient's general standing posture, checking for spinal curvatures (kyphosis, lordosis, scoliosis).
2. History taking
- Elicit a chronological account of joint symptoms, noting symmetry and pattern of joint involvement.
- Clarify joint stiffness, establishing its duration in the morning and whether it improves with activity.
- Screen for systemic autoimmune features including skin rashes, dry eyes/mouth, Raynaud's, and hair loss.
3. Examine
- Perform joint exam in sequence: Look (inspect), Feel (palpate), Move (movement range), Measure, and Compare.
- Compare joints symmetrically on both sides, checking for deformity, swelling, warmth, and tenderness.
- Warm hands before palpating, and watch the patient's face for signs of pain throughout the exam.
4. Interpret
- Classify joint pain by pattern: inflammatory (morning stiffness, improves with use) vs osteoarthritis.
- Synthesize physical findings (synovitis, joint counts, symmetry) with the clinical history.
- Acknowledge that classification criteria support pattern recognition but do not replace clinical judgment.
5. Apply
- Synthesize history and examination observations into a structured SBAR presentation.
- Rank a prioritized differential diagnosis and state clinical uncertainties clearly.
- Avoid therapeutic, pharmacological, or specific management claims; escalate acute concerns.
Endocrine Outpatient Clinic · Patient encounter
Mrs Layla, a 35-year-old female
Weight loss, heat intolerance, palpitations, and neck swelling requiring structured supervised assessment.
Estimated lesson time: about 20 minutes, with an optional 8-minute OSCE practice station.
Endocrine examination
1. Meet
- Clean hands thoroughly, greet the patient, introduce yourself, and state your clinical role.
- Confirm the patient's identity and obtain verbal consent before performing any physical contact.
- Position the patient sitting comfortably, with neck and upper chest fully exposed for thyroid inspection.
2. History taking
- Elicit a chronological account of weight changes, clarifying relation to appetite (e.g. weight loss with increased appetite).
- Clarify thermal intolerance (heat or cold sensitivity) and ask about resting palpitations or tremor.
- Screen for thyroid-associated eye symptoms such as grittiness, redness, pain, or double vision.
3. Examine
- Inspect the hands for tremor, warm/sweaty skin, and check the radial pulse for resting tachycardia or atrial fibrillation.
- Examine the eyes for proptosis, exophthalmos, lid retraction, and lid lag (following finger downwards).
- Inspect the thyroid gland, perform a swallowing test with water, and palpate the lobes from behind.
4. Interpret
- Synthesize physical findings (goitre consistency, eye signs, tremor) with the patient's history.
- Classify the thyroid state: hyperthyroid (active/sweaty) vs hypothyroid (lethargic/dry).
- Acknowledge that physical signs guide diagnostic staging but do not replace biochemical confirmation.
5. Apply
- Synthesize history and examination observations into a structured SBAR presentation.
- Rank a prioritized differential diagnosis and state clinical uncertainties clearly.
- Avoid therapeutic, pharmacological, or specific management claims; escalate acute concerns.
Neurological Step-down Unit · Patient encounter
Mr Daniel, a 54-year-old man
3-week history of progressive right-sided weakness, mild expressive dysphasia, and focal motor seizures.
Estimated lesson time: about 20 minutes, with an optional 8-minute OSCE practice station.
Neurological examination
1. Meet
- Introduce yourself clearly, explain the examination steps, and obtain verbal consent.
- Perform rapid initial appraisal of consciousness, alertness, speech fluency, and posture.
- Ensure patient dignity, adequate exposure of limbs, and position comfortably (sitting for cranial nerves, supine for limb examination).
2. History taking
- Establish the exact onset mode (sudden vascular vs subacute mass/inflammatory vs chronic degenerative).
- Explore focal motor and sensory symptoms, speech disturbance, visual changes, and sphincter function.
- Screen systematically for neurological red flags: morning headache, vomiting, seizures, fever, and papilloedema.
3. Examine
- Perform a systematic examination covering Cranial Nerves (CN I-XII), Upper Limbs, Lower Limbs, and Gait.
- Assess motor system systematically in order: Inspection (wasting/fasciculations), Tone, Power (MRC scale 0-5), Reflexes, and Coordination.
- Map sensory deficits to dermatomal, peripheral nerve, or stocking-glove distributions.
4. Interpret
- Synthesize motor, sensory, and reflex findings to determine the anatomical site of lesion (localisation before etiology).
- Distinguish Upper Motor Neuron (UMN) signs (spasticity, hyperreflexia, Babinski sign) from Lower Motor Neuron (LMN) signs (wasting, hypotonia, hyporeflexia, fasciculations).
- Recognize focal patterns: hemiparesis (brain/cervical cord), paraparesis (thoracic cord), mononeuropathy/polyneuropathy (peripheral nerves).
5. Apply
- Synthesize history and physical findings into a logical, structured oral SBAR handover to senior colleagues.
- Formulate a prioritized differential diagnosis based on anatomical site and temporal mode of onset.
- Rehearse an 8-minute structured neurological examination and presentation under OSCE conditions.
Hematological System — Common Core
Haematology Day Unit · Patient encounter
Mr Tariq, 46 — 4-week history of progressive fatigue, marked conjunctival and palmar pallor, easy mucosal bruising, and painless cervical lymphadenopathy.
1. Meet
- Perform thorough hand hygiene and put on personal protective equipment where neutropenic precautions are indicated.
- Introduce yourself clearly, confirm Mr Tariq's identity, explain the haematological examination, and obtain informed consent.
- Position the patient comfortably seated or semi-recumbent at 45 degrees under bright natural light.
- Perform an immediate general inspection for acute distress, severe pallor, active mucosal bleeding, or high fever signaling febrile neutropenia.
2. History taking
- Inquire systematically about anaemia symptoms: exertional dyspnoea, fatigue, palpitations, postural dizziness, and headache.
- Ask about bleeding and bruising history: spontaneous epistaxis, gingival bleeding, prolonged cut oozing, hematuria, or melena.
- Screen for infective and neutropenic symptoms: recurrent sore throats, slow-healing skin infections, or unprovoked fevers.
- Check for lymphoproliferative symptoms (B-symptoms): unexplained fever (> 38°C), drenching night sweats, and unintentional weight loss (> 10% in 6 months).
Fictional staged case disclosure — History disclosed after questioning
- Mr Tariq reports a 4-week history of progressive lethargy, shortness of breath on climbing one flight of stairs, and lightheadedness when standing.
- He notes frequent epistaxis, spontaneous gum bleeding when brushing teeth, and new painless lumps in his left neck.
- He endorses B-symptoms: drenching night sweats requiring clothes changes, intermittent fever up to 38.2°C, and an unrecorded weight loss of ~5 kg.
These are conservative fictional teaching observations for Mr Tariq, not a diagnosis and not findings to assume in an OSCE or a real patient.
3. Examine
- Inspect the hands and nails: observe for palmar crease pallor, leukonychia, koilonychia (spoon nails in chronic iron deficiency), and peripheral petechiae.
- Examine the eyes and face: gently invert lower palpebral conjunctivae for pallor and inspect sclerae under direct light for icterus (haemolysis).
- Inspect the oral cavity: evaluate tongue papillae (atrophic glossitis), angular stomatitis, buccal petechiae, gingival hypertrophy (monocytic leukaemia), and oral ulceration.
- Palpate all superficial lymph node groups systematically: submental, submandibular, cervical chains, supraclavicular, axillary, and epitrochlear nodes.
Fictional staged case disclosure — Examination findings disclosed after the sequence
- Hands & Eyes: Marked palmar crease pallor, pale palpebral conjunctivae, non-icteric sclerae, no koilonychia.
- Oral Cavity: Multiple small non-blanching petechiae over the soft palate and gingival margins; no overt ulceration or gingival hyperplasia.
- Lymph Nodes: Firm, non-tender, mobile 2.5 cm lymph nodes in the left anterior cervical chain and left axilla; no supraclavicular enlargement.
- Abdomen: Spleen palpable 4 cm below the left costal margin, firm, non-tender, with a distinct splenic notch; liver non-palpable.
These are conservative fictional teaching observations for Mr Tariq, not a diagnosis and not findings to assume in an OSCE or a real patient.
4. Interpret
- Interpret Full Blood Count parameters: Haemoglobin (Hb), Mean Corpuscular Volume (MCV), White Cell Count (WCC) with differential, and Platelet count.
- Classify anaemia morphologically by MCV: Microcytic (< 80 fL), Normocytic (80-100 fL), or Macrocytic (> 100 fL).
- Correlate bicytopenia or pancytopenia (reduction in >= 2 haematopoietic cell lines) with bone marrow production failure or peripheral destruction/sequestration.
5. Apply
- Synthesize history and physical findings into a structured problem list: B-symptoms, generalised lymphadenopathy, splenomegaly, and mucosal bleeding signs.
- Formulate a prioritized differential diagnosis: Lymphoproliferative disorder (Lymphoma), Acute Leukaemia, Chronic Lymphocytic Leukaemia, or Disseminated Granulomatous Infection.
- Rehearse an 8-minute structured haematological examination and presentation under OSCE conditions.
Sources and further reading: Talley and O'Connor, Clinical Examination, General principles, cardiovascular, respiratory, and gastrointestinal system chapters, pp. 23-146, 238-295, and 461-463; DeGowin's Diagnostic Examination, screening, symptom, cardiovascular examination, abdomen, and oral presentation chapters, pp. 30-69, 320-360, 450-530, and 742-743; The Rational Clinical Examination, clinical examination accuracy, central venous pressure, ascites, and splenomegaly chapters, pp. 1-16, 125-136, and 175-204.
For supervised education only. This portal does not replace clinical assessment, local guidance, or senior review. Use both linear encounters with a clinical teacher; they do not provide treatment advice.