CFB MED02 Clinical Demonstration On General Examination
A clinical demonstration teaching the systematic approach to general examination of a patient, including assessment of general appearance, vital signs, nutritional status, pallor, jaundice, cyanosis, clubbing, lymphadenopathy, and edema as part of the foundational clinical skills in medicine.
This lecture — Clinical Demonstration on General Examination (CFB MED02, Dr Chun-Ka Wong) — is the foundational framework for every physical examination encounter you will ever do [1]. Before you dive into any system-specific exam (CVS, respiratory, neuro, etc.), you must first perform a general examination. This includes:
- Environmental inspection — what surrounds the patient
- Assessing stability — vital signs, GCS, distress
- General appearance — conscious level, body habitus, spot diagnoses
- Head-to-toe peripheral signs — guided by the target system but always done systematically
The lecture fits into the clinical workflow as step 2 of the 4-step approach: History → Physical Examination (General → System-based) → Investigation → Treatment [1].
High Yield: The general examination is not an afterthought. In OSCE/written exams, marks are given for systematic environmental inspection, identifying unstable patients, and recognising classical peripheral signs. The lecture explicitly states: "Practice makes perfect. Open minded inspection. Know the classical faces/signs. Guided by target system." [1]
From the lecture slides and supporting material:
- Understand the systematic approach to physical examination (general before system-specific)
- Know what to do before beginning PE (introduction, consent, curtain, chaperone, position) [1]
- Inspect the environment systematically (sign boards, monitors, devices, drains, medications) [1]
- Assess whether a patient is stable or unstable (vital signs, GCS, distress, breathing patterns) [1]
- Perform a head-to-toe peripheral sign inspection [1]
- Recognise classical faces/signs for spot diagnoses [1]
"Introduce yourself, Consent, Curtain, Chaperone, Position" [1]
| Step | Why It Matters |
|---|---|
| Introduce yourself | Professional courtesy; medicolegal requirement; builds rapport |
| Consent | Ethical obligation — patient must agree to examination |
| Curtain | Privacy and dignity — especially important for intimate examinations |
| Chaperone | Medicolegal protection for both patient and examiner; mandatory for intimate examinations |
| Position | Depends on the target system — e.g., 45° for CVS [2], sitting for respiratory [3], supine for abdomen [4] |
OSCE Exam Tip
In an OSCE, if you forget to introduce yourself, ask for consent, and offer a chaperone, you lose easy marks before you even touch the patient. This is essentially free marks — never skip it.
The lecture dedicates multiple slides (slides 5–13) to environmental inspection because what surrounds the patient tells you about their diagnosis and acuity BEFORE you even examine them. [1]
This is the "end-of-the-bed" assessment taken to its fullest extent.
Categories of Environmental Observations [1]
| Category | What to Look For | Why It Matters |
|---|---|---|
| Sign boards | Bed rest, nil per oral (NPO), warfarin diet, DM diet, fluid restriction | Tells you about mobility status, surgical plans, anticoagulation, metabolic conditions |
| Haemodynamics | Cardiac monitor, cardiac rhythm displayed, blood pressure cuff/readings | Identifies cardiac monitoring needs — arrhythmias, haemodynamic instability |
| Respiratory | SaO₂ reading, O₂ supplementation method (nasal prongs, mask, CPAP/BiPAP, intubation/ventilator) | Tells you about respiratory compromise severity; type of O₂ delivery indicates acuity level |
| Drips | IV fluids, inotrope infusions, medication infusions (pumps) | IV fluids = dehydration/NPO status; inotropes = shock/ICU level care; infusion pumps = precise dosing needed |
| Drains & bedside bags | Foley catheter (+ urine colour/volume), pleural drain, abdominal drain, Tenckhoff catheter & peritoneal fluid | Foley = monitoring urine output or retention; chest drain = pneumothorax/effusion; Tenckhoff = peritoneal dialysis (ESRD) |
| Medications | Inhalers at bedside, oral medications, GTN spray | Inhalers = asthma/COPD; specific meds give diagnostic clues |
| Others | Walking stick, wheelchair, specimen bottles, sputum cup | Walking stick = mobility issues; sputum cup = productive cough being monitored [3] |
Why environmental inspection matters from first principles:
A patient on high-flow oxygen via a non-rebreather mask is very different from one on 2L nasal prongs. The former likely has Type 1 respiratory failure requiring urgent attention; the latter may have chronic mild hypoxia. Similarly, a patient with an inotrope infusion pump (e.g., dopamine, noradrenaline) is in shock — this is an ICU-level patient. The lecture shows images of these devices to train your eye [1].
High Yield Environmental Clues
Key environmental observations and their diagnostic significance:
- Cardiac monitor showing irregular rhythm → atrial fibrillation, other arrhythmia
- Ventilator/intubation → severe respiratory failure, post-surgical, neurological compromise
- Chest drain → pneumothorax, pleural effusion, post-thoracic surgery, empyema, cardiac tamponade (pericardiocentesis)
- Tenckhoff catheter → end-stage renal disease on peritoneal dialysis
- Inotrope infusion → cardiogenic or septic shock
- Sputum cup → chronic respiratory disease with productive cough (colour matters: purulent = infection, haemoptysis = malignancy/TB/PE)
3. General Appearance
"Conscious level, In distress? Septic looking? In pain? Body habitus: obesity, cachexia, etc. Typical 'faces' for spot diagnosis, e.g. acromegaly" [1]
- Is the patient alert, drowsy, confused, or unresponsive?
- Formally assessed using the Glasgow Coma Scale (GCS) — the lecture explicitly shows E4 M6 V5 = 15 (fully conscious) [1]
| Component | Score | Response |
|---|---|---|
| Eye Opening (E) | 4 | Spontaneous |
| 3 | To voice | |
| 2 | To pain | |
| 1 | None | |
| Motor (M) | 6 | Obeys commands |
| 5 | Localises pain | |
| 4 | Withdrawal (flexion) | |
| 3 | Abnormal flexion (decorticate) | |
| 2 | Extension (decerebrate) | |
| 1 | None | |
| Verbal (V) | 5 | Oriented |
| 4 | Confused | |
| 3 | Inappropriate words | |
| 2 | Incomprehensible sounds | |
| 1 | None |
- Minimum GCS = 3 (not zero — each component has a minimum of 1)
- Maximum GCS = 15 (E4 M6 V5)
- GCS ≤ 8 → generally indicates need for airway protection (intubation) [6]
- In distress? — Respiratory distress (accessory muscle use, tachypnoea, tripod position), pain (guarding, grimacing), agitation
- Septic looking? — Flushed, diaphoretic, rigors, altered mental status — these patients are unstable
- In pain? — Assess pain severity, character, impact on examination
| Habitus | Clinical Significance |
|---|---|
| Obesity | Metabolic syndrome, DM, OSA, cardiovascular risk, examination may be technically difficult |
| Cachexia | Malignancy, chronic heart failure (cardiac cachexia), chronic infection (TB), COPD, end-stage liver disease [2] |
| Cushingoid | Central obesity, moon face, buffalo hump, striae — think exogenous steroids or Cushing's syndrome/disease |
| Marfanoid | Tall, thin, long limbs, arachnodactyly — Marfan syndrome (aortic root disease, mitral valve prolapse) |
The lecture explicitly teaches that typical "faces" allow spot diagnosis. Examples include acromegaly, Cushing's, malar rash (SLE), and heliotrope rash (dermatomyositis). [1]
| Face/Sign | Disease | Key Features |
|---|---|---|
| Acromegalic facies | Acromegaly | Coarsened features, prominent supraorbital ridge, prognathism (protruding jaw), macroglossia, widely spaced teeth |
| Cushingoid facies | Cushing's syndrome/disease | Moon face, plethoric appearance, hirsutism, acne |
| Malar rash | Systemic lupus erythematosus (SLE) | Butterfly-shaped erythematous rash over malar eminences, sparing nasolabial folds |
| Heliotrope rash | Dermatomyositis | Violaceous (purple-lilac) discolouration of eyelids |
| Malar flush | Mitral stenosis | Peripheral cyanosis of cheeks due to low cardiac output and pulmonary hypertension [7] |
| Myxoedematous facies | Hypothyroidism | Puffy face, periorbital oedema, coarse dry skin, loss of lateral third of eyebrows, macroglossia |
| Thyrotoxic facies | Hyperthyroidism | Anxious, sweaty, wide-eyed with lid retraction/lag, exophthalmos (Graves') |
| Parkinsonian facies | Parkinson's disease | Mask-like expressionless face, drooling |
4. Stability Assessment: Is Your Patient Stable or Unstable?
The lecture emphasises three components: (1) Vital signs, (2) GCS, (3) In distress? [1]
The vital signs provide the most objective measure of physiological stability:
| Vital Sign | Normal Range (Adult) | Abnormal and What It Means |
|---|---|---|
| Heart Rate | 60–100 bpm | Tachycardia ( > 100): pain, anxiety, fever, hypovolaemia, sepsis, PE, hyperthyroidism, arrhythmia. Bradycardia ( < 60): β-blockers, hypothyroidism, raised ICP, heart block, athletic heart |
| Blood Pressure | ~120/80 mmHg | Hypotension (systolic < 90): shock (hypovolaemic, cardiogenic, septic, anaphylactic). Hypertension ( > 140/90): essential/secondary HTN, pain, anxiety |
| Respiratory Rate | 12–20/min | Tachypnoea ( > 20): pneumonia, PE, metabolic acidosis (Kussmaul), pain, anxiety. Bradypnoea ( < 12): opioid overdose, raised ICP, fatigue |
| Temperature | 36.5–37.5°C | Fever ( > 38°C): infection, inflammation, malignancy, drug fever. Hypothermia ( < 35°C): sepsis (paradoxically), environmental, hypothyroidism |
| Oxygen Saturation (SpO₂) | 95–100% on room air | < 94%: respiratory failure, need for O₂ supplementation. Be careful in COPD patients — target 88–92% |
The lecture presents a clinical scenario: "Tachypnoea, Room air, SaO₂ 99%. What are the possible causes?" Answer: Kussmaul breathing — rapid/deep breathing due to metabolic acidosis. Point-of-care arterial blood gas shows severe metabolic acidosis. [1]
Why is this important? A patient breathing fast with normal oxygen saturation is NOT necessarily having a respiratory problem. The rapid, deep breathing pattern (Kussmaul) is the body's compensatory response to metabolic acidosis — the lungs are trying to blow off CO₂ to raise pH.
Common causes of metabolic acidosis causing Kussmaul breathing:
- Diabetic ketoacidosis (DKA)
- Uraemia (renal failure)
- Lactic acidosis (shock, sepsis, liver failure)
- Salicylate poisoning
- Ethylene glycol/methanol poisoning
Key Clinical Pearl
Do NOT assume that tachypnoea = respiratory pathology. If SpO₂ is normal but the patient is breathing rapidly and deeply, think metabolic acidosis first. Get a point-of-care ABG immediately. This is a classic exam question trap [1].
| Pattern | Description | Cause |
|---|---|---|
| Kussmaul | Deep, rapid breathing | Metabolic acidosis (DKA, uraemia, lactic acidosis) |
| Cheyne-Stokes | Crescendo-decrescendo with apnoeic pauses | Heart failure, brainstem lesion, raised ICP |
| Biot's | Irregular clusters of breaths with apnoeic pauses | Brainstem damage |
| Apneustic | Prolonged inspiratory gasps with short expiratory periods | Pontine lesion |
| Ataxic | Completely irregular breathing | Medullary lesion (pre-terminal) |
5. Peripheral Signs: Head-to-Toe Systematic Approach
"Inspection > Palpation > Auscultation. Depends on the target system." [1]
The lecture organises peripheral signs by anatomical region: Head → Neck → Upper Limbs → Lower Limbs. The principle is: inspect systematically from head to toe, with findings guided by but not limited to the target system.
"Pallor, Jaundice, Xanthelasma, Ptosis, Proptosis, Gaze deviation, Cyanosis, Cushing's, Acromegaly, Rash: malar, heliotrope, etc." [1]
| Sign | What to Look For | Clinical Significance |
|---|---|---|
| Pallor | Conjunctival pallor (pull down lower eyelid), palmar pallor | Anaemia — check Hb. Causes: iron deficiency, chronic disease, haemolysis, bone marrow failure [8] |
| Jaundice | Yellow discolouration of sclera (best seen in natural light) | Bilirubin > 34 μmol/L (2 mg/dL). Pre-hepatic (haemolysis), hepatic (hepatitis, cirrhosis), post-hepatic (obstruction) |
| Xanthelasma | Yellowish plaques on/around eyelids | Hyperlipidaemia (but can be normolipidaemic). Associated with cardiovascular risk |
| Ptosis | Drooping of upper eyelid | Horner's syndrome (miosis + ptosis + anhidrosis), myasthenia gravis (fatigable), CN III palsy (complete ptosis + dilated pupil), senile |
| Proptosis/Exophthalmos | Forward protrusion of eyeball | Graves' disease (bilateral), orbital tumour (unilateral), cavernous sinus thrombosis |
| Gaze deviation | Eyes deviated to one side | Frontal lobe stroke (eyes look towards lesion), pontine stroke (eyes look away from lesion) |
| Central cyanosis | Blue discolouration of tongue, lips | Severe hypoxia (deoxyHb ≥ 50 g/L, SpO₂ ≤ 90%). Always check tongue — lips can be misleading in cold weather [3] |
| Malar rash | Butterfly rash over cheeks | SLE [1] |
| Heliotrope rash | Violaceous periorbital discolouration | Dermatomyositis [1] |
| Cushingoid features | Moon face, plethora, hirsutism | Cushing's syndrome/disease, exogenous steroids [1] |
| Acromegalic features | Coarsened features, prominent jaw, large hands/feet | Acromegaly (GH-secreting pituitary adenoma) [1] |
Why we check the head first: The face is the most information-dense area of the body. In seconds, you can identify anaemia, liver disease, endocrine conditions, and neurological lesions. The lecture explicitly teaches this as the starting point of peripheral sign examination.
"Cervical lymph nodes, Scar, Mass, Goitre, Catheters, Jugular venous pressure, Carotid pulse, Distended neck veins" [1]
| Sign | What to Look For | Clinical Significance |
|---|---|---|
| Cervical lymphadenopathy | Palpate systematically: submental → submandibular → pre-auricular → post-auricular → anterior cervical → posterior cervical → supraclavicular | Infection (tender, mobile), malignancy (hard, fixed, non-tender), lymphoma (rubbery) |
| Scars | Thyroidectomy (Kocher's incision), cervical lymph node biopsy, tracheostomy, central line scars | Previous surgical history — tells you the diagnosis before you ask [5] |
| Neck mass | Midline vs lateral, moves with swallowing (thyroid), moves with tongue protrusion (thyroglossal cyst) [5] | Systematic approach to differential diagnosis of neck lumps |
| Goitre | Diffuse (Graves', Hashimoto's, iodine deficiency) vs nodular (MNG, thyroid cancer) | Always check thyroid status (hyper/hypo/euthyroid) |
| Catheters | Central venous catheter (internal jugular, subclavian), Hickman line | Indicates need for IV access (chemo, TPN, haemodialysis) |
| JVP | Internal jugular vein pulsation, measured as height above sternal angle (normal < 3 cm above sternal angle at 45°) | Elevated JVP: right heart failure, fluid overload, PE, tamponade, SVC obstruction (fixed, non-pulsatile) [2] |
| Carotid pulse | Palpate medial to SCM | Character: slow-rising (aortic stenosis), collapsing (aortic regurgitation), bisferiens (mixed aortic valve disease) |
| Distended neck veins | Non-pulsatile, fixed | SVC obstruction (SVCO) — e.g., lung cancer, lymphoma, mediastinal mass [1][3] |
Supraclavicular Lymphadenopathy
Left supraclavicular lymphadenopathy (Virchow's node/Troisier's sign) is a classic sign of abdominal malignancy, particularly gastric cancer, draining via the thoracic duct. This is an exam favourite. Right supraclavicular nodes suggest intrathoracic malignancy (lung, oesophageal) draining via the right lymphatic duct.
5C. Upper Limbs [1]
"Clubbing, Muscle wasting/deformity, Nail changes, Rash/skin lesions, AV fistula, Scars" [1]
Clubbing is loss of the normal angle between the nail bed and the nail fold (Lovibond angle > 180°), with increased sponginess of the nail bed.
| Category | Causes |
|---|---|
| Respiratory | Lung cancer (most common malignant cause), bronchiectasis, empyema, lung abscess, idiopathic pulmonary fibrosis, cystic fibrosis |
| Cardiovascular | Infective endocarditis (IE), cyanotic congenital heart disease |
| GI | Cirrhosis, inflammatory bowel disease (Crohn's > UC), coeliac disease |
| Others | Thyroid acropachy (Graves'), familial/idiopathic |
Why does clubbing occur? The exact mechanism is debated, but the leading theory involves megakaryocyte fragments and platelet clumps bypassing the pulmonary capillary bed (which normally filters them) and lodging in the digital vasculature. There, they release PDGF and VEGF, causing soft tissue proliferation. This explains why conditions that cause right-to-left shunts (cyanotic CHD) or that destroy the pulmonary capillary bed (lung cancer, ILD) cause clubbing.
| Nail Change | Condition |
|---|---|
| Koilonychia (spoon-shaped nails) | Iron deficiency anaemia |
| Leukonychia (white nails) | Hypoalbuminaemia (cirrhosis, nephrotic syndrome) |
| Muehrcke's lines (paired white transverse bands) | Hypoalbuminaemia (transient) [9] |
| Beau's lines (transverse grooves) | Severe systemic illness causing temporary nail growth arrest |
| Splinter haemorrhages | Infective endocarditis (but also trauma — most common cause) [1] |
| Onycholysis (nail separation from bed) | Hyperthyroidism, psoriasis, fungal infection |
| Pitting | Psoriasis |
| Terry's nails (white nails with distal brown band) | Cirrhosis, heart failure, DM |
The lecture specifically shows images of these signs:
| Sign | Description | Pathophysiology |
|---|---|---|
| Splinter haemorrhages | Linear red-brown streaks under nails | Microemboli or vasculitis affecting nail bed capillaries |
| Osler's nodes | Painful, red, raised nodules on finger/toe pulps | Immune complex deposition (not embolic — this is why they are PAINFUL and tender) |
| Janeway lesions | Painless, erythematous, flat lesions on palms/soles | Septic microemboli (not immune — this is why they are PAINLESS) |
Osler vs Janeway — Exam Discriminator
- Osler's = painful (O for Ouch!)
- Janeway = painless, on palms/soles (J for Just flat)
- Osler's = immune complex deposition; Janeway = septic emboli
- Both are peripheral signs of IE but differ in mechanism and clinical feel
| Sign | Significance |
|---|---|
| Muscle wasting | Disuse, denervation (e.g., C8-T1 wasting in Pancoast tumour), rheumatoid arthritis (small hand muscle wasting) |
| Joint deformity | Rheumatoid arthritis (swan neck, boutonnière, ulnar deviation, Z-thumb), osteoarthritis (Heberden's DIP, Bouchard's PIP nodes) |
| Rash/skin lesions | Gottron's papules (dermatomyositis — papules over knuckles), psoriatic plaques, vasculitic lesions |
| AV fistula | Haemodialysis access (feel for thrill, listen for bruit) — indicates end-stage renal disease on HD [1] |
| Scars | Carpal tunnel release, tendon repair, previous cannulation, AV fistula creation |
| Palmar erythema | Chronic liver disease, pregnancy, thyrotoxicosis, RA |
| Dupuytren's contracture | Chronic liver disease (alcohol), familial, manual labour |
| Asterixis (liver flap) | Hepatic encephalopathy, CO₂ narcosis, uraemia — a negative myoclonus (transient loss of postural tone) |
| Tar staining | Smoking — relevant for respiratory and CVS disease |
Although not individually highlighted on the lecture slides, pulse assessment is integral to general examination:
- Rate: tachycardia/bradycardia
- Rhythm: regular vs irregularly irregular (AF)
- Character: best assessed at carotid — collapsing (AR), slow-rising (AS), bisferiens (mixed aortic)
- Radio-radial delay: coarctation of aorta, subclavian stenosis
- Radio-femoral delay: coarctation of aorta
"Scar, Varicose veins, Rash/hyperpigmentation, Oedema, Ulcers/gangrene, Muscle wasting" [1]
| Sign | Clinical Significance |
|---|---|
| Scars | Previous vascular surgery (bypass grafts, vein stripping), orthopaedic surgery (joint replacement) |
| Varicose veins | Chronic venous insufficiency; ask about symptoms (heaviness, aching, cramps) and complications (venous eczema, lipodermosclerosis, ulceration) [10] |
| Rash/hyperpigmentation | Venous eczema, haemosiderin deposition (brown discolouration from chronic venous insufficiency), palpable purpura (vasculitis [1]), necrobiosis lipoidica (DM) |
| Oedema | Bilateral: heart failure, nephrotic syndrome, liver disease, chronic venous insufficiency. Unilateral: DVT, lymphoedema, cellulitis. Always assess: pitting vs non-pitting (lymphoedema, myxoedema = non-pitting), extent (ankle, mid-shin, knee, thigh, sacral) |
| Ulcers | Venous (medial malleolus, shallow, irregular edge, surrounding lipodermatosclerosis), arterial (lateral malleolus/pressure points, deep, punched-out, painful), neuropathic (plantar surface, painless — DM) |
| Gangrene | Dry (arterial insufficiency — black, mummified, well-demarcated) vs wet (infected — swollen, malodorous, poorly demarcated — surgical emergency) |
| Muscle wasting | Denervation (L4/5 lesion), disuse, chronic disease |
| Palpable purpura | The lecture shows an image of palpable purpura consistent with leukocytoclastic vasculitis [1]. This is a classic sign of small vessel vasculitis (e.g., IgA vasculitis/Henoch-Schönlein purpura, ANCA-associated vasculitis, cryoglobulinaemia) |
Differentiating Bilateral Lower Limb Oedema by Physical Exam
| Feature | Cardiac | Renal (Nephrotic) | Hepatic |
|---|---|---|---|
| Periorbital oedema | Absent (orthopnoeic → can't lie flat → no periorbital accumulation) | Present (can lie flat → overnight periorbital accumulation) [9] | Variable |
| JVP | Elevated | Normal | Normal (unless tense ascites) |
| Ascites | Late | Can occur | Common |
| Liver | Pulsatile hepatomegaly (TR), tender (congestion) | Normal | Shrunken/hard (cirrhosis) |
| Skin stigmata | — | — | Spider naevi, caput medusae, palmar erythema |
| Proteinuria | Mild | Heavy ( > 3.5 g/day) | Mild-moderate |
The general examination findings guide you towards the appropriate system-specific examination. Here is how the lecture's peripheral signs link to systems:
| General Exam Finding | System to Examine in Detail |
|---|---|
| Clubbing, cyanosis, barrel chest, accessory muscle use | Respiratory [3] |
| Clubbing, splinter haemorrhages, Janeway/Osler, malar flush | Cardiovascular [2] |
| Jaundice, spider naevi, palmar erythema, ascites, caput medusae | GI/Hepatic [4] |
| Pallor, bruising, petechiae, lymphadenopathy, splenomegaly | Haematological [11] |
| Malar rash, Gottron's papules, joint deformity | Rheumatological [12] |
| Exophthalmos, goitre, tremor, pretibial myxoedema | Endocrine (thyroid) [5] |
| Cushingoid, acromegalic features | Endocrine (pituitary/adrenal) [13] |
| Muscle wasting, gaze deviation, ptosis, abnormal posture | Neurological [14] |
7. Key Clinical Approaches by Sign
- Confirm: conjunctival pallor, palmar crease pallor
- Grade severity: is it clinically significant? (Hb typically < 90 g/L to detect clinically)
- Look for causes: koilonychia (iron deficiency), glossitis (B12/folate), jaundice (haemolysis), bone tenderness (marrow infiltration), lymphadenopathy/splenomegaly (haematological malignancy)
- History: menorrhagia, GI bleeding (melena, haematochezia), diet, chronic disease [8]
- Confirm: scleral icterus in natural light
- Classify:
- Pre-hepatic (haemolysis): pallor, splenomegaly, reticulocytosis
- Hepatic (hepatitis/cirrhosis): tender hepatomegaly or shrunken liver, stigmata of CLD
- Post-hepatic (obstruction): dark urine, pale stools, palpable gallbladder (Courvoisier's law), pruritus/scratch marks
- Bilateral or unilateral?
- Pitting or non-pitting?
- Distribution: dependent (ankles if ambulant, sacral if bed-bound)
- Associated signs: JVP (cardiac), periorbital (renal), ascites (liver/renal), skin changes (venous)
8. Exam Intelligence
Based on past papers and the lecture emphasis:
| Question Type | How This Lecture Is Tested |
|---|---|
| SAQ | "Name five physical signs you would look for on general examination of a patient with [condition]" — you need to list systematically from head-to-toe [15] |
| MCQ | "Which of the following is the most specific sign for heart failure?" — answer: elevated JVP, S3 gallop, basal crepitations [16] |
| OSCE | "Perform a general examination of this patient and describe your findings" — need structured approach: environment → general appearance → stability → head-to-toe |
| Minicase | Given a clinical photo, identify the sign (xanthelasma, malar rash, clubbing, palpable purpura, etc.) |
This question asked about a 60-year-old smoker with haemoptysis and a left apical lung mass:
- (b) Name five possible physical signs you would look for in general and respiratory system examination (5 marks)
- Expected answers include: clubbing, tar staining, lymphadenopathy (supraclavicular/cervical), Horner's syndrome signs (miosis, ptosis, anhidrosis), small hand muscle wasting (Pancoast), cachexia, chest wall signs
This directly tests the general examination framework from this lecture!
| Trap | Correct Approach |
|---|---|
| Forgetting environmental inspection | Always start with bedside observations — easy marks |
| Assuming tachypnoea = respiratory disease | Normal SpO₂ + tachypnoea = think metabolic acidosis (Kussmaul) [1] |
| Confusing Osler's nodes and Janeway lesions | Osler's = painful (immune complex); Janeway = painless (septic emboli) |
| Peripheral cyanosis vs central cyanosis | Central = tongue/lips (severe hypoxia); Peripheral = hands/feet (vasoconstriction, can be normal in cold) |
| Non-pitting oedema vs pitting oedema | Non-pitting: lymphoedema, myxoedema. Pitting: cardiac, renal, hepatic |
| Forgetting to mention chaperone | Especially important for breast, abdominal, and genital examinations |
| Step | Components | Key Points |
|---|---|---|
| Before PE | Introduce, consent, curtain, chaperone, position | Free marks in OSCE |
| Environment | Sign boards, monitors, drips, drains, meds, others | Tells you diagnosis and acuity |
| General Appearance | Conscious level, distress, body habitus, spot faces | GCS, cachexia/obesity, acromegaly/Cushing's |
| Stability | Vital signs, GCS, distress, breathing pattern | Kussmaul = metabolic acidosis |
| Head | Pallor, jaundice, xanthelasma, ptosis, proptosis, cyanosis, rashes | Conjunctival pallor, scleral icterus |
| Neck | LN, scars, mass, goitre, catheters, JVP, carotid, veins | Virchow's node, JVP height, SVCO |
| Upper Limbs | Clubbing, wasting, nails, rash, AV fistula, scars | IE signs (splinter, Osler, Janeway) |
| Lower Limbs | Scars, varicose veins, rash, oedema, ulcers, gangrene, wasting | Differentiate venous/arterial/neuropathic ulcers |
High Yield Summary
-
General Examination = the foundation of every clinical encounter.
-
Summary
- 1.
- Before PE: Introduce, consent, curtain, chaperone, position (system-dependent) 2.
- Environment: Sign boards, monitors, O₂/ventilators, drips/infusions, drains/catheters, medications, walking aids 3.
- General Appearance: Conscious level, distress, body habitus, spot diagnosis faces (acromegaly, Cushing's, malar rash, heliotrope rash) 4.
- Stability: Vital signs + GCS + distress assessment.
- **Kussmaul breathing (tachypnoea + normal SpO₂) = metabolic acidosis — get ABG!
- ** 5.
- Head: Pallor, jaundice, xanthelasma, ptosis, proptosis, cyanosis, facial rashes 6.
- Neck: Lymph nodes, JVP, carotid pulse, goitre, scars, catheters, distended veins (SVCO) 7.
- Upper Limbs: Clubbing, nail changes, IE signs (splinter haemorrhages, Osler's nodes, Janeway lesions), joint deformity, AV fistula, rash 8.
- Lower Limbs: Oedema (pitting vs non-pitting), ulcers (venous vs arterial vs neuropathic), varicose veins, gangrene, purpura, muscle wasting 9.
- Principle: Inspection > Palpation > Auscultation.
- Head to toe.
- Open-minded.
- Guided by target system but never ignore unexpected findings.
Active Recall - General Examination
[1] Lecture slides: CFB (MED02) Clinical Demonstration on general examination.pdf (all pages) [2] Senior notes: Ryan Ho Cardiology.pdf (p4 — CVS general examination) [3] Senior notes: Ryan Ho Respiratory.pdf (p4–5 — respiratory general examination) [4] Senior notes: Ryan Ho GI.pdf (p5 — abdominal general examination) [5] Senior notes: Ryan Ho Endocrine.pdf (p7 — thyroid examination) [6] Senior notes: Ryan Ho Critical Care.pdf (p4 — primary survey and airway management) [7] Senior notes: Block A - Fever and a murmur_ Valvular heart diseases; Infective endocarditis.pdf (p45 — IE signs) [8] Senior notes: Block A - Pallor_ diagnosis of anaemia; nutritional anaemia; anaemia of systemic diseases.pdf (p3 — clinical presentation) [9] Senior notes: Block A - Glomerular and Tubulo-interstitial Diseases and Acute Kidney Injury.pdf (p20 — nephrotic syndrome PE) [10] Lecture slides: Clinical Demonstration_Vascular.pdf (p1 — peripheral vascular examination) [11] Senior notes: Ryan Ho Haemtology.pdf (p4 — haematological examination) [12] Senior notes: Ryan Ho Rheumatology.pdf (p4 — rheumatological examination) [13] Senior notes: Maksim Medicine Notes.pdf (p81 — DM physical examination) [14] Senior notes: Ryan Ho Neurology.pdf (p5 — neurological general examination) [15] Past papers: 2025 Fourth Summative SAQ.pdf (p5, Q3 — lung mass physical signs) [16] Senior notes: Block A - Shortness of breath on exertion_ heart failure.pdf (p7 — HF signs sensitivity/specificity)
CFB PSY02 Classification And Diagnosis Of Psychiatric Illness
Classification and diagnosis of psychiatric illness involves the systematic categorization of mental disorders using standardized criteria such as the ICD and DSM to guide clinical assessment, communication, and treatment planning.
CFB OPHTH01 Common Eye Diseases
Common eye diseases encompass frequently encountered ophthalmic conditions—such as cataracts, glaucoma, conjunctivitis, diabetic retinopathy, and age-related macular degeneration—that affect vision and ocular health across the general population.