Physical Examination | Clinical Assessment Guide

The Art of General Physical Examination

Why GPE Matters

The General Physical Examination begins the moment the patient walks in. Before any lab test or imaging, your clinical eye can detect anemia, jaundice, cyanosis, thyroid disease, heart failure, and more — often within 30 seconds of observation.

Systematic Approach

Always follow a head-to-toe systematic approach. This prevents missed findings. In emergency settings, use the ABCDE approach first (Airway, Breathing, Circulation, Disability, Exposure), then proceed to complete GPE once stabilized.

Components of GPE — The Clinical Framework

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General Survey

Built, posture, gait, decubitus

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Vital Signs

Pulse, BP, RR, Temp, SpO₂

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Peripheral Signs

Hands, nails, pallor, cyanosis

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Head & Neck

Eyes, JVP, lymph nodes, thyroid

🎓 Clinical Pearl — From the ICU

In my experience as an ICU intensivist, I've seen countless cases where a missed GPE finding led to delayed diagnosis. A cold, mottled periphery in a "stable" patient with normal BP can signal early distributive shock — the BP is maintained by compensatory tachycardia. Always correlate GPE with hemodynamics.

General Survey & First Impression

What to Observe in the First 30 Seconds

1. Level of Consciousness (LOC)

AVPU Scale (Quick): Alert → Voice responsive → Pain responsive → Unresponsive

GCS (Glasgow Coma Scale): E (Eye 1-4) + V (Verbal 1-5) + M (Motor 1-6) = 3-15

⚡ Emergency Pearl:

GCS ≤ 8 → Intubation required (cannot protect airway). In my ER experience, always reassess GCS every 15 minutes in deteriorating patients — a drop of 2 points demands immediate CT brain.

Clinical Example: A 65-year-old male brought to ER after collapse. Found to be E2V3M5 (GCS 10) — localizing pain but confused. This localizing pattern with preserved motor suggests hemispheric lesion rather than brainstem.

2. Body Built & Habitus

Ectomorph / Lean

Think: Marfan syndrome (tall, arm span > height, arachnodactyly), Hyperthyroidism, TB, Malignancy

Endomorph / Obese

Think: Cushing's (central obesity + thin limbs), Hypothyroid, Metabolic syndrome, PCOS

Short Stature

Think: Turner syndrome (45,XO), Achondroplasia, GH deficiency, Rickets, Chronic childhood disease

Tall Stature

Think: Marfan, Klinefelter (47,XXY), Gigantism (before epiphyseal closure), Homocystinuria

🎓 Cardiology Correlation: In my cardiology practice, Marfan patients need echocardiography for aortic root dilation (risk of dissection). Any tall patient with chest pain → think aortic dissection until proven otherwise.

3. Posture & Decubitus

Position	Clinical Significance
Orthopnea (propped up)	LVF, Severe asthma, COPD exacerbation, Pericardial effusion
Left lateral (Trepopnea)	Large right pleural effusion (lies on affected side)
Knee-chest position	Pericarditis (reduces pain), Tetralogy of Fallot (squatting ↑SVR)
Opisthotonus	Meningitis, Tetanus, Strychnine poisoning
Fetal position	Acute pancreatitis, Peritonitis

⚡ ICU Insight: A patient who cannot lie flat (PND + orthopnea) with pink frothy sputum = Acute pulmonary edema. Immediate action: Sit up, O₂, IV Furosemide, Nitroglycerine, Morphine (if no hypotension). This is a clinical diagnosis — don't wait for CXR!

4. Gait Assessment

Hemiplegic Gait

Circumduction of affected leg, arm in flexion. Cause: Stroke (UMN lesion)

Parkinsonian Gait

Shuffling, festination, reduced arm swing, stooped. Cause: Parkinson's disease

Ataxic / Cerebellar

Wide-based, staggering, cannot tandem walk. Cause: Cerebellar lesion, Alcohol

Waddling Gait

Trunk sways side-to-side. Cause: Proximal myopathy (DMD, Polymyositis)

High-Stepping (Foot Drop)

Exaggerated hip flexion to clear foot. Cause: Common peroneal nerve palsy, L5 radiculopathy

Scissor Gait

Legs cross midline, stiff. Cause: Bilateral UMN (Cerebral palsy, Spinal cord compression)

5. Facies (Facial Appearance)

Cushinoid

Moon face, buffalo hump, plethora, hirsutism

Acromegalic

Coarse features, prognathism, frontal bossing, large hands/feet

Myxedematous

Puffy, periorbital edema, dry skin, loss of outer 1/3 eyebrow

Hippocratic

Sunken eyes, pinched nose, hollow temples — peritonitis, moribund

Mitral facies

Malar flush (rosy cheeks + cyanotic tinge) — Mitral stenosis with low CO

Leonine

Thickened skin folds — Lepromatous leprosy

🎓 Cardiology Note: Mitral facies is pathognomonic — the malar flush results from CO₂ retention due to low cardiac output in severe mitral stenosis. This finding alone warrants echocardiography.

Vital Signs — The Fifth Pillar

Pulse Examination

The pulse is examined for: Rate, Rhythm, Volume, Character, Condition of vessel wall, Radio-radial delay, Radio-femoral delay

Pulse Rate & Rhythm

Normal: 60-100 bpm

Athletes: resting 40-60 (physiological sinus bradycardia)

Tachycardia: >100 bpm

Fever (↑10bpm/°F), Pain, Anxiety, Thyrotoxicosis, Anemia, Shock, PE

Bradycardia: <60 bpm

Heart block, β-blockers, ↑ICP (Cushing reflex), Hypothyroid, Jaundice

Irregularly Irregular

Atrial Fibrillation (most common) — pulse deficit present

⚡ ER Tip: Always check pulse deficit in AF (apex rate minus radial rate). A large deficit indicates poor cardiac output from ineffective contractions. In my practice, pulse deficit >20 warrants rate control urgency.

Pulse Character (Named Pulses)

Pulse Type	Character	Condition
Water-hammer (Corrigan's)	Rapid rise & collapse, bounding	Aortic Regurgitation, PDA, AV fistula
Slow-rising (Parvus et Tardus)	Gradual upstroke, low amplitude	Aortic Stenosis (severe)
Bisferiens	Two systolic peaks	Combined AS + AR, HOCM
Pulsus paradoxus	↓SBP >10mmHg on inspiration	Cardiac tamponade, Severe asthma, Constrictive pericarditis
Pulsus alternans	Alternating strong/weak beats	Severe LV failure
Dicrotic	Double beat (systole + diastole)	Low CO states, Dilated cardiomyopathy

🎓 Cardiology Pearl: To elicit water-hammer pulse → raise the patient's arm above heart level and grip the forearm. The collapsing quality becomes dramatically evident. In severe AR, you'll also find: pistol-shot femorals (Traube's sign), capillary pulsation (Quincke's sign), and head-bobbing (de Musset's sign).

Blood Pressure — Technique & Interpretation

Correct Technique: Patient seated 5 min rest, arm at heart level, appropriate cuff size (bladder encircles 80% of arm), 2 readings 1-2 min apart.

Category (JNC-8/ACC 2017)	SBP (mmHg)	DBP (mmHg)
Normal	<120	<80
Elevated	120-129	<80
Stage 1 HTN	130-139	80-89
Stage 2 HTN	≥140	≥90
Hypertensive Crisis	>180	>120

⚡ Critical: Wide pulse pressure (SBP-DBP >60mmHg) → AR, thyrotoxicosis, anemia, PDA, elderly (stiff aorta). Narrow pulse pressure (<25mmHg) → Aortic stenosis, cardiac tamponade, CHF, shock.

Postural Hypotension: ↓SBP ≥20 or ↓DBP ≥10 on standing from supine (after 3 min). Causes: Hypovolemia, autonomic neuropathy (DM), drugs (α-blockers, diuretics), Addison's.

Respiratory Rate & Temperature

Respiratory Rate (Normal: 12-20/min):

Tachypnea (>20): Pneumonia, PE, metabolic acidosis (Kussmaul breathing in DKA), anxiety
Bradypnea (<12): Opioid overdose, ↑ICP, brainstem lesion, hypothyroidism
Cheyne-Stokes: Crescendo-decrescendo pattern with apnea → CHF, stroke, ↑ICP
Biot's breathing: Irregular with sudden apnea → Brainstem damage (pontine)

Temperature (Normal: 36.1–37.2°C / 97–99°F):

Hyperpyrexia (>41.5°C): Heat stroke, Malignant hyperthermia, NMS, Serotonin syndrome
Hypothermia (<35°C): Sepsis (paradoxical), Myxedema coma, Exposure, Hypothalamic lesion

🎓 ICU Pearl: RR is the most sensitive early vital sign for clinical deterioration. In my ICU, a rising RR (even from 16→22) often precedes desaturation and hemodynamic collapse by 6-8 hours. It's the "canary in the coal mine."

Hands & Nails Examination

The hands are a goldmine of clinical information. A systematic hand examination can reveal cardiac, respiratory, hepatic, endocrine, and rheumatological disease.

Nail Changes & Their Significance

Finding	Description	Conditions
Clubbing	Loss of nail-bed angle (>180°), fluctuant nail bed, drumstick appearance	Lung Ca, Bronchiectasis, ILD, IE, Cyanotic CHD, Cirrhosis, IBD
Koilonychia	Spoon-shaped nails (concave)	Iron deficiency anemia (Plummer-Vinson), Hemochromatosis
Leukonychia	White nails	Hypoalbuminemia (cirrhosis, nephrotic syndrome)
Splinter hemorrhages	Linear brown-red lines under nail	Infective Endocarditis, Vasculitis, Trauma
Beau's lines	Transverse grooves	Severe illness, chemotherapy (temporary growth arrest)
Terry's nails	White proximally, pink distally	Cirrhosis, CHF, DM
Half-and-half (Lindsay's)	White proximally, brown distally	Chronic kidney disease / Uremia
Nail pitting	Multiple small depressions	Psoriasis, Alopecia areata, Eczema

⚡ Clubbing Grades (Lovibond): Grade 1: Fluctuation of nail bed | Grade 2: Loss of angle (obliteration of Lovibond angle) | Grade 3: Drumstick swelling | Grade 4: HPOA (periostitis visible on X-ray). In cardiology, clubbing + cyanosis = cyanotic congenital heart disease until proven otherwise.

Palm & Hand Signs

Palmar erythema

Redness of thenar/hypothenar eminences. Causes: Chronic liver disease, Pregnancy, RA, Thyrotoxicosis

Dupuytren's contracture

Thickening of palmar fascia → fixed flexion of 4th/5th finger. Causes: Alcoholic liver disease, DM, Epilepsy (phenytoin)

Osler's nodes

Painful, raised nodules on fingertips (immune complex). Cause: Infective Endocarditis

Janeway lesions

Painless, flat erythematous lesions on palms/soles. Cause: Infective Endocarditis (septic emboli)

Xanthomata (tendon)

Yellow deposits on tendons (especially Achilles, hand extensors). Cause: Familial hypercholesterolemia

Arachnodactyly

Long spider-like fingers. +ve Steinberg sign (thumb beyond palm). Cause: Marfan syndrome

🎓 Cardiology Pearl: In suspected IE, always examine BOTH hands carefully. Osler nodes (painful) = immunological, Janeway lesions (painless) = septic emboli. Combined with splinter hemorrhages + new murmur + fever = Modified Duke's criteria → start empirical antibiotics after 3 sets of blood cultures.

Tremor Assessment

Fine Tremor

Place paper on outstretched hands. Causes: Thyrotoxicosis, Anxiety, β-agonists, Caffeine

Coarse Flapping (Asterixis)

Wrist dorsiflexion with fingers spread → involuntary "flap." Causes: Hepatic encephalopathy, CO₂ narcosis, Uremia

Resting Tremor (Pill-rolling)

4-6 Hz, worse at rest, better with movement. Cause: Parkinson's disease

Intention Tremor

Worsens approaching target (finger-nose test). Cause: Cerebellar disease

⚡ ICU Tip: Asterixis (liver flap) is a NEGATIVE myoclonus (momentary loss of tone). In my ICU, new-onset asterixis in a cirrhotic patient = hepatic encephalopathy → start lactulose immediately. Also check for asterixis in COPD patients (CO₂ retention) and renal failure (uremic encephalopathy).

Face & Eye Examination

Pallor (Anemia Assessment)

Sites to check: Lower palpebral conjunctiva (most reliable), Nail beds, Palmar creases, Tongue, Lips

Grading:

Mild: Only conjunctival pallor (Hb 8-10 g/dL)
Moderate: Conjunctival + palmar pallor (Hb 6-8 g/dL)
Severe: Generalized pallor + palmar crease pallor (Hb <6 g/dL)

⚡ ER Pearl: Pallor in palmar creases (when hand is open and stretched) correlates with Hb <7 g/dL. In my ER experience, if palmar crease pallor + tachycardia + orthostatic symptoms → consider blood transfusion regardless of lab availability. Clinical assessment saves lives when lab results are delayed.

Jaundice (Icterus)

Definition: Yellow discoloration due to elevated bilirubin (>2-3 mg/dL clinically visible)

Best detected: Sclera (earliest site — bilirubin has affinity for elastin), sublingual area, skin in natural light

Lemon Yellow

Hemolytic jaundice (Pre-hepatic). Unconjugated ↑. Think: Hemolysis, Gilbert's

Orange-Yellow

Hepatocellular (Hepatic). Mixed. Think: Hepatitis, Cirrhosis

Greenish-Yellow

Obstructive (Post-hepatic). Conjugated ↑. Think: CBD stone, Pancreatic head Ca

🎓 Clinical Pearl: Painless progressive jaundice + palpable gallbladder (Courvoisier's law) = Periampullary carcinoma until proven otherwise. Painful jaundice + fever + rigors = Charcot's triad (Cholangitis) → Urgent ERCP. Add confusion + hypotension = Reynold's pentad → ICU admission.

Cyanosis

Definition: Blue discoloration due to >5g/dL of deoxygenated hemoglobin in capillary blood

Central Cyanosis

Sites: Tongue (most reliable), Lips, Oral mucosa

Causes: Lung disease (COPD, pneumonia, PE), R→L cardiac shunt (Eisenmenger, TOF), High altitude

Peripheral Cyanosis

Sites: Fingertips, Nail beds, Ear lobes, Nose tip

Causes: All causes of central + Cold exposure, Peripheral vasoconstriction, Shock, Raynaud's, PVD

⚡ Critical Point: Cyanosis is NOT visible in severe anemia (Hb <5g/dL) because you need >5g/dL of DEOXYHEMOGLOBIN. An anemic patient can be severely hypoxic without appearing cyanotic! Always use pulse oximetry. Also: Methemoglobinemia causes "chocolate-colored" cyanosis that doesn't respond to O₂.

Eye Signs in Systemic Disease

Xanthelasma

Yellow plaques around eyes → Hyperlipidemia (but can be normal)

Arcus senilis (before 40)

White ring around cornea → Familial hypercholesterolemia

Kayser-Fleischer ring

Golden-brown ring (Descemet's membrane) → Wilson's disease

Band keratopathy

Calcium deposits in cornea → Hypercalcemia, Sarcoidosis

Exophthalmos (Proptosis)

Protruding eyes → Graves' disease (bilateral), Retro-orbital tumor (unilateral)

Ptosis

Drooping eyelid → Myasthenia gravis (fatigable), Horner's, CN III palsy

Argyll Robertson pupil

Accommodates but doesn't react to light → Neurosyphilis ("prostitute's pupil")

Roth spots (fundoscopy)

White-centered retinal hemorrhages → IE, Leukemia, DM

Neck Examination — JVP, Lymph Nodes & Thyroid

JVP (Jugular Venous Pressure) — The Bedside CVP

Technique: Patient at 45°, head turned slightly left. Observe RIGHT internal jugular vein (direct connection to RA). Measure vertical height above sternal angle + 5cm = RA pressure. Normal JVP = <3cm above sternal angle.

JVP Waveform Components:

Wave	Event	Abnormality
'a' wave	Atrial contraction	Giant 'a': Tricuspid stenosis, Pulmonary HTN, Pulmonary stenosis. Absent in AF. Cannon 'a': Complete heart block, VT
'c' wave	Tricuspid closure (isovolumetric contraction)	Rarely clinically significant
'v' wave	Venous filling (TV closed)	Giant 'v' (cv wave): Tricuspid Regurgitation
'x' descent	Atrial relaxation	Prominent in cardiac tamponade. Absent in TR
'y' descent	TV opens, rapid ventricular filling	Steep: Constrictive pericarditis, TR. Slow: Tricuspid stenosis, RA myxoma

🎓 Cardiology Pearl: Kussmaul's sign = JVP RISES on inspiration (paradoxical). Normal JVP falls on inspiration. Causes: Constrictive pericarditis (classic), Restrictive cardiomyopathy, Massive PE, RV infarct. This sign alone in a post-MI patient → suspect RV infarct → give IV fluids (NOT diuretics!).

Lymph Node Examination

Palpation order: Submental → Submandibular → Pre-auricular → Post-auricular → Occipital → Anterior cervical → Posterior cervical → Supraclavicular → Axillary → Epitrochlear → Inguinal

Characteristics to note: Size, consistency, tenderness, mobility, matting

Tender, soft, mobile

→ Reactive / Infective (most common)

Hard, fixed, non-tender

→ Malignancy (metastatic)

Rubbery, non-tender, matted

→ Lymphoma (Hodgkin's/NHL)

Matted, cold abscess

→ Tuberculosis (scrofula)

⚡ Red Flags: Left supraclavicular (Virchow's node/Troisier's sign) → GI malignancy (especially gastric Ca). Right supraclavicular → Lung/Esophageal Ca. Any supraclavicular node in an adult = malignancy until proven otherwise → urgent biopsy.

Thyroid Examination

Technique: Stand behind patient. Ask to swallow water — thyroid moves UP with deglutition (attached to pretracheal fascia). Ask to protrude tongue — thyroglossal cyst moves UP (unlike thyroid).

Assess: Size, shape, consistency, nodularity, tenderness, bruit, retrosternal extension

Diffuse smooth enlargement

Graves' disease (with bruit), Simple goiter, Hashimoto's (firm, rubbery)

Multinodular

MNG (most common cause of goiter in iodine-sufficient areas)

Solitary nodule

Adenoma, Cyst, Ca (hard, irregular, fixed, cervical LN), Dominant nodule in MNG

Tender thyroid

Subacute thyroiditis (de Quervain's — post-viral), Hemorrhage into cyst, Acute suppurative

🎓 Clinical Pearl: Pemberton's sign — ask patient to raise both arms above head for 1 minute. Facial plethora + distended neck veins + stridor = retrosternal goiter causing thoracic inlet obstruction. This is a surgical emergency if acute.

Skin, Edema & Nutritional Status

Edema Assessment & Grading

Pitting Edema Grading: Press firmly over bony prominence (medial malleolus, tibial shaft, sacrum) for 5 seconds:

2mm pit, immediate rebound

4mm pit, rebounds in 15s

6mm pit, rebounds in 30s

8mm pit, rebounds >30s

Causes by Distribution:

Bilateral dependent (pedal → sacral)

CCF (right-sided), Nephrotic syndrome, Cirrhosis, Drugs (CCB, NSAIDs)

Unilateral

DVT, Cellulitis, Lymphedema, Post-surgical, Venous insufficiency

Facial/periorbital (morning)

Nephrotic/Nephritic syndrome, Angioedema, Hypothyroid, SVC obstruction

Non-pitting (firm)

Myxedema (hypothyroid), Lymphedema (chronic), Pretibial myxedema (Graves')

⚡ ICU/Cardiology: In CCF, edema indicates >3-5L fluid overload. Remember: In bedridden patients, check SACRAL edema (not pedal) as fluid is gravity-dependent. A patient "without edema" on feet examination may have massive sacral edema — always turn them!

Skin Signs in Systemic Disease

Spider naevi (>5)

Distribution: SVC territory. Cause: Chronic liver disease, Pregnancy (↑estrogen)

Purpura (non-blanching)

Thrombocytopenia, Vasculitis (HSP, meningococcemia), DIC, Scurvy

Erythema nodosum

Tender red nodules on shins. Causes: Sarcoid, TB, Strep, IBD, Drugs

Acanthosis nigricans

Velvety hyperpigmented skin folds (neck/axillae). Insulin resistance, GI malignancy

Vitiligo

Depigmented patches. Autoimmune: associated with thyroid disease, DM Type 1, Addison's

Hyperpigmentation (generalized)

Addison's disease (palmar creases, buccal, scars), Hemochromatosis ("bronze DM")

Hydration & Nutritional Status

Dehydration Assessment:

Sign	Mild (3-5%)	Moderate (6-9%)	Severe (≥10%)
Skin turgor	Slightly ↓	↓ (>2s recoil)	Very poor ("tenting")
Mucous membranes	Slightly dry	Dry	Parched/cracked
Eyes	Normal	Sunken	Deeply sunken
Mental status	Alert	Irritable	Lethargic/obtunded
Urine output	Slightly ↓	Oliguria	Anuria

Nutritional Assessment Signs:

Protein-energy malnutrition: Temporal wasting, loss of buccal fat pad, visible ribs, pedal edema (kwashiorkor)
Vitamin C deficiency: Bleeding gums, perifollicular hemorrhages, poor wound healing
Vitamin D deficiency: Bowing of legs (rickets), bone tenderness, proximal myopathy
B12/Folate: Glossitis (smooth red tongue), angular stomatitis, pallor
Iron deficiency: Koilonychia, angular stomatitis, atrophic glossitis, pallor

Anthropometry & Special Measurements

BMI & Body Composition

BMI = Weight (kg) / Height² (m²)

Category	BMI (WHO)	BMI (Asian)
Underweight	<18.5	<18.5
Normal	18.5-24.9	18.5-22.9
Overweight	25-29.9	23-24.9
Obese I	30-34.9	25-29.9
Obese II	35-39.9	≥30
Morbid Obesity	≥40	—

Waist Circumference (metabolic syndrome indicator): Men >102cm (>90cm Asian) | Women >88cm (>80cm Asian)

Waist-Hip Ratio: Men >0.9, Women >0.85 = Central obesity (cardiovascular risk)

Special Measurements & Proportions

Arm Span > Height

Normal: Arm span ≈ Height. If span > height by >5cm → Marfan syndrome, Homocystinuria, Eunuchoidism

Upper:Lower Segment Ratio

Normal adult: ~1.0. Reduced (<0.9): Marfan (long legs). Increased: Achondroplasia, Hypothyroidism (short limbs)

Mid-Arm Circumference (MUAC)

Nutritional status in children. <11.5cm (6-59mo) = Severe Acute Malnutrition → Therapeutic feeding

Head Circumference

Newborn: 33-35cm. Macrocephaly: Hydrocephalus. Microcephaly: TORCH infections, Genetic

Clinical Documentation Template

GENERAL PHYSICAL EXAMINATION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
General Survey:
  • Consciousness: Alert & oriented (GCS 15/15)
  • Built: Medium | Nourishment: Adequate
  • Posture: Comfortable at rest, propped up on 2 pillows
  • Decubitus: Prefers sitting (orthopnea +ve)

Vital Signs:
  • Pulse: 88/min, regular, normal volume
    Character: Normal | Vessel wall: Not thickened
    All peripheral pulses palpable, No radio-femoral delay
  • BP: 134/82 mmHg (Right arm, sitting)
    Postural drop: Absent
  • RR: 18/min, regular rhythm, no distress
  • Temp: 37.0°C (oral) | SpO₂: 97% on RA

Peripheral Examination:
  • Pallor: Mild (conjunctival) | Icterus: Absent
  • Cyanosis: Absent (central & peripheral)
  • Clubbing: Absent | Koilonychia: Absent
  • Lymphadenopathy: No palpable nodes
  • Edema: Bilateral pedal pitting edema (+2)
  • JVP: Elevated (~7 cm above sternal angle)

Skin: No spider naevi, No purpura
Thyroid: Not visibly enlarged, moves with deglutition
Nutritional markers: No temporal wasting, BMI 26.2

IMPRESSION: Features suggestive of fluid overload
(elevated JVP + pedal edema + orthopnea) — 
likely decompensated heart failure. Proceed to 
cardiovascular system examination.

🎓 Final Teaching Point — The Philosophy of GPE

In 25+ years of clinical practice across cardiology, ICU, and emergency medicine, I've learned that the General Physical Examination is not just a checklist — it's a clinical conversation with the patient's body. Every sign tells a story. A cold extremity whispers "shock." A raised JVP shouts "fluid overload." Clubbing warns of hidden malignancy. The best clinician is not the one who orders the most tests, but the one who sees the diagnosis at the bedside. Master the GPE, and you master medicine.