Clerking Examination

The purpose of the clerking examination is to detect the presence or absence of signs which help narrow down the differential you formulated during the history. All new admissions should have this basic multi-system examination, when it is safe to do so, before focussing on specific relevant systems in more detail. 

If patients are very unwell then a full history and examination are inappropriate and the patient should be diagnosed and treated simultaneously with an ABCDE approach. You may realise patients are unwell from their observations (recorded on the ‘track and trigger’ chart) so look at this before going to see the patient. If they are scoring high you should ask a doctor to see the patient rather than going in yourself. 

TO START

W2I2P4E

  • Wash your hands

  • Wear appropriate PPE

  • Introduce yourself and check patient’s Identity

  • Permission: “Would it be alright if I examined you today?”

  • Privacy: Ensure curtains to the bay are closed

  • Pain: “Are you in any pain at the moment?” 

  • Position: Patient at 45° to start, late lie flat to examine abdomen

  • Exposure: to waist (women can keep bra on)

INSPECTION

Surroundings

  • Monitoring: ECG, pulse oximeter, catheter, drains bag

  • Treatments: O2 (flow rate & method of delivery), IV access and infusions, nebulisers, medications etc

  • Paraphernalia: food and drink, mobility aids, sputum pots, NBM signs etc 

Patient

  • General appearance: well/unwell, comfortable at rest or in pain, 

  • Alertness & conscious level

  • Body habitus: cachectic (malignancy) or obese? 

  • Breathing: cyanosis, shortness of breath, laboured, irregular

  • Colour: cyanosis, pallor (shock, anaemia), plethora, jaundice, flushed

  • Odour: alcohol, cigarette smoke, ketotic

  • Neurology: moving all four limbs, speech, temor, posture, GCS

UPPER LIMB

Hands 

  • Posture, size (oedema), shape (rheumatoid/Dupuytren’s), colour (peripheral cyanosis/tar stains)

  • Temperature and perfusion: check capillary refill time (normally <2 seconds)

  • Tendon xanthomata (hyperlipidaemia)

  • Palmar creases (pale = anaemia, hyperpigmented = Addison’s)

  • Osler’s nodes and Janeway lesions (endocarditis)

  • Skin turgor (dehydration), thinned skin (steroids)

  • Wasting of small muscles (cachexia, Pancoast tumour) 

Nails

  • Clubbing (chronic lung disease not COPD), lung Ca, IBD, cyanotic heart disease, endocarditis

  • Splinter haemorrhages (trauma, vasculitis, endocarditis)

  • Koilonychia: spoon shaped nails (iron deficiency) 

  • Leukonychia: pale nails (hypoalbuminaemia from cirrhosis or nephrotic syndrome)

  • Beau’s lines: transverse deep white grooves due to arrest of nail growth (severe illness, malnutrition, chemotherapy)

  • Pitting/onycholysis: detachment from the nail bed (psoriasis) 

Wrist

  • Radial pulse – Rate, Rhythm (AF), character (weak= shock, collapsing = aortic regurgitation, radio-radial delay = aortic dissection)

  • Respiratory Rate - count over 15s while palpating radial pulse then x4 (12-20 is normal)

  • Asterixis (CO2 retention, hepatic encephalopathy)

Arm

  • Look for bruising (steroids, anticoagulation), excoriations, track marks, tattoos

  • Measure blood pressure (shock, hypertension, abnormal pulse pressure). Consider checking both arms (aortic dissection) 

HEAD

Face

  • Colour: pallor, plethora etc

  • Characteristic facies e.g. cushingoid, hypothyroidism, acromegaly, Parkinsonism etc

Eyes

  • Corneal arcus: normal in elderly, if young suggests hyperlipidaemia

  • Conjunctival pallor (severe anaemia), petechial haemorrhages (endocarditis)

  • Xanthelasma over eyelids (hyperlipidaemia) 

  • Scleral icterus (jaundice)

  • Thyroid eye disease: soft tissue oedema, exophthalmos, lid retraction, lid lag, conjunctival injection and chemosis (conjunctival swelling)

Mouth

  • Hydration status: check mucous membranes are moist

  • Dentition (anaesthetic risk)

  • Central cyanosis: look under tongue

  • Angular stomatitis (low B12/Fe)

  • Tongue: pale/smooth (low Fe), red/swollen (low B12/folate), white (oral candida)

  • Mouth ulcers (Crohn’s) 

Neck

  • Carotid pulse: character (bounding - CO2 retention)) and volume (thready – shock).

  • Jugular Venous Pressure (JVP): start looking for the JVP at the insertion of sternocleidomastoid at the clavicle and manubrium. Work upwards and look for an upwards biphasic flicker. Elevated in right heart failure, fluid overload, tension pneumothorax, severe asthma, prominent V wave in tricuspid regurgitation

  • Tracheal Deviation: warn patient it may be uncomfortable

  • Goitre (thyroid disease) 

  • Lymphadenopathy: assess with patient sitting forwards and palpating from behind. Can wait until examining the back, but don’t forget!

CHEST

Inspect

  • Scars: midline sternotomy (CABG/valve surgery), posterolateral thoracotomy (mitral valve/pneumonectomy), pacemaker, chest drains (5th intercostal space in mid-axillary line) 

  • Shape: pectus carinatum/excavatum, barrel chest (COPD), scoliosis  

  • Spider naevi/gynaecomastia (chronic liver disease)

  • Radiotherapy stigmata (telangiectasia)

  • Visible apex beat

Palpate

  • Apex beat: normal/displaced (heart failure), forceful (left ventricular hypertrophy), tapping (mitral stenosis)

  • Parasternal heave (right ventricular hypertrophy)

  • Thrills (palpable murmurs)

  • Chest expansion

Percuss

  • Lung fields - upper (above clavicle), middle, lower zones and axillae bilaterally,. Move in ‘S’ shape for comparison.

Auscultate

  • Heart: 

    • Listen at apex, LLSE, ULSE, URSE whilst feeling a central pulse for heart sounds, added sounds and murmurs

    • Dynamic manoeuvres

    • Listen for carotid bruits 

  • Lungs:

    • Breathing normally through mouth, listen at points of percussion and compare both sides

    • Listen for breath sounds: vesicular or bronchial? Reduced or normal? 

    • Listen for added sounds (crackles, wheeze, pleural rub)

    • Vocal resonance (if consolidation  is suspected) 

ABDOMEN

Lie the patient flat at this point. 

Inspect

  • Look for distention, scars, stomas, striae, bruises, caput medusae, Grey-Turner and Cullen signs, pulsations, hernias

  • Ask patient to:

    • Take a deep breath (peritonism)

    • Cough (with your hands on inguinal region to look for hernias)

    • Lift head (divarication of recti, paraumbilical or incisional hernia)

Palpate

  • Ask about pain beforehand, watch patient’s face through out and feel in the 9 areas superficially, the deeply observing for tenderness, guarding and masses

  • Palpate for organomegaly (liver and spleen), kidneys and AAA

Percuss

  • Percuss in each of the 9 areas of the abdomen 

  • Organomegaly: Liver (RIF→ RUQ), spleen (RIF → LUQ) and bladder (suprapubic)

  • Shifting dullness if abdomen distended (percuss from centre of abdomen to one side until you hear a dull tone, then keeping your finger at this point ask the patient to roll on their side so that your hand is on the top. Percussion at this point should now be resonant as the fluid should settle with gravity. To look slick percuss to the side away from you so that when the patient has to roll they roll towards you, minimising the risk they fall off the bed!)

Auscultate

  • Bowel sounds: normal, tinkling (obstruction), absent (ileus)- listen for up to 3 minutes

  • Bruits: renal arteries and aorta (stenosis)

BACK

Inspect

  • Ask the patient to sit forwards (feel for lymphadenopathy if not already done)

  • Scars: thoracotomy, spinal surgery, nephrostomy

Palpate

  • Chest expansion

  • Sacral oedema

Percuss

  • Lung fields: upper, middle and lower (most of lung bases are posterior)

Auscultate

  • Listen to the percussion areas for reduced air entry or respiratory crackles (pulmonary oedema 2° to heart failure, fluid overload or basal consolidation)

LOWER LIMB


Inspect

  • Bruising and ulceration (peripheral vascular disease)

Palpate

  • Pitting oedema over tibia (heart failure, fluid overload). If present find the upper limit

CLOSURE


To complete: Thank the patient and ensure they are comfortable and can re-dress themselves. Clean your equipment, doff your PPE and wash your hands. Document your findings, formulate a differential diagnosis and decide what investigations you wish to request to guide your management.