Complete guide to clinical examination

In a medical context where the pressure on primary care continues to grow, the temptation to quickly resort to complementary examinations is increasingly strong. Often perceived as a time-saver or a security measure, this approach can nevertheless constitute a major pitfall in medical practice. A poorly performed clinical examination, whether incomplete or hasty, can distort the entire diagnostic process.

The consequences are not insignificant: unnecessary, costly and sometimes invasive examinations, but above all, a possible delay in treatment which can be detrimental to the patient's prognosis.

Against this backdrop, it's important to get back to basics. A clinical examination carried out in a structured, rigorous and methodical way remains the irreplaceable foundation of any reliable medical approach, and the cornerstone of quality clinical diagnosis.

What is a clinical examination?

The clinical examination is defined as all the steps a healthcare professional takes during a consultation, in immediate face-to-face contact with the patient. Much more than a simple collection of information, it is the foundation of the therapeutic relationship and medical assessment. This essential process is based on three fundamental and inseparable phases: the medical interrogation or anamnesis, the physical examination, and finally, a phase of synthesis and preliminary interpretation of the data. It is this initial analysis that enables coherent diagnostic hypotheses to be formulated.

This whole process is governed by the principle of the hypothetico-deductive approach, which is the basis of modern clinical reasoning. The practitioner doesn't just passively collect data; he or she actively uses it to develop hypotheses, testing them through questions and gestures, and gradually refining them to arrive at a diagnostic conviction. It's also crucial to stress that the clinical examination is always contextualized. Its depth, orientation and the devices to be investigated first depend intrinsically on the reason for consultation, the patient's history and the main complaint that prompted the consultation. An examination for acute chest pain will not be carried out in the same way as a follow-up consultation for a chronic pathology.

Clinical questioning

The interrogation (or anamnesis) is the cornerstone of the examination, and is the stage that guides the entire medical consultation. It must systematically present the key elements of the patient's file, starting with the reason for consultation, then exhaustively exploring personal and family history, any allergies, current treatments, lifestyle and, of course, the history of the disease. The latter, which traces the evolution of symptoms, must be particularly detailed.

For each symptom, the physician must insist on its chronology and precise semiological criteria. This analysis, at the heart of medical semiology, is fundamental: it must clarify the mode of onset (sudden or progressive), duration of evolution, intensity (often assessed on a numerical scale), frequency, triggering or aggravating factors, as well as factors alleviating the symptoms. The quality of this interrogation depends not only on technical rigor, but also on profound human skills. It is essential to value active listening, to master the art of reformulation to ensure mutual understanding and to avoid misunderstandings, thus guaranteeing to build a solid doctor-patient relationship based on trust.

What's more, a good clinician must adapt his or her discourse to each patient. It is necessary to take into account the patient's level of education, emotional state, age and socio-cultural context, in order to ask clear questions and obtain reliable, usable answers. Finally, it's important to emphasize the absolutely central role of the interview in early diagnostic orientation. In the majority of cases, a well-executed medical history will establish a relevant differential diagnosis and drastically reduce the number of hypotheses before the patient has even been touched.

Clinical physical examination

The physical examination is a fundamental step that has evolved considerably. Traditionally, it follows a precise four-step sequence, summarized by the acronym IPPA: Inspection, Palpation, Percussion and Auscultation. Today, however, this approach has been enriched by a technological revolution: clinical ultrasound at the patient's bedside (POCUS). Reference publications such as the Journal of the American Medical Association (JAMA) now position it as a fifth pillar of the physical examination, as essential as the other four. This vision is supported by major organizations such as the American College of Emergency Physicians (ACEP), who encourage its integration into daily practice.

Whether it's a four-stage or five-stage examination, there are a number of general steps that must be followed to ensure quality and patient confidence. Respect for privacy is an absolute priority at all times, as is rigorous hygiene, including systematic hand-washing and the use of clean or disinfected equipment.

To be effective, the physical examination must be systematic. Depending on the context and the reason for consultation, the practitioner may opt for a global approach from head to toe, or a device-by-device examination. The success of this exercise depends on meticulous observation, which enables the identification of sometimes very discreet warning signs. Bilateral comparative analysis is also crucial in identifying any anomalies. Finally, to refine the diagnosis and test hypotheses, the clinician must introduce the notion of specific physical tests according to the device examined, such as the Homans sign in cases of suspected phlebitis, or various neurological manoeuvres.

Complementary examination

Once a complete clinical examination, including the five pillars, has been carried out, the practitioner may deem it necessary to resort to complementary examinations to confirm or refute a diagnostic hypothesis. It is crucial to remember that these tests are intended to support clinical reasoning and should never replace an incomplete or neglected physical examination.

With ultrasound now at the heart of clinical practice, thanks to theultraportable ultrasound scanner, the hierarchy of examinations is being redefined. Traditional complementary examinations fall into several categories:

- Biological tests (blood tests, urine analysis, etc.).‍

- Medical imaging tests (X-rays, CT scans, MRIs) are generally prescribed as a second resort, when clinical ultrasonography does not provide a clear answer.‍

- Functional tests (electrocardiogram, respiratory function tests, etc.).

The prescription of these tests must always be guided by medical justification and rigorous clinical relevance . The practitioner must constantly evaluate the cost-benefit ratio to avoid unnecessary or redundant examinations. With this in mind, the integration ofultrasound into general practice is perfectly in line with this efficiency approach. For example, in the face of a persistent cough, abnormal auscultation or signs on pulmonary ultrasound may justify a chest x-ray, but this will not be systematic.

Specific features of the various clinical examinations by equipment

Clinical ultrasonography, as an extension of the physical examination, enables the diagnosis to be refined directly at the patient's bedside. Here is a summary of the objectives and key signs to look for.

● Lung examination

- Key steps: Search for signs of respiratory distress, analysis of frequency and amplitude of movement, chest percussion and auscultation of the lungs. Targeted pleuropulmonary ultrasound can provide valuable diagnostic information.

- Signs to look for: Presence of rales or sibilants on auscultation.

● Cardiovascular examination

- Key steps: Peripheral pulses taken, auscultation of cardiac foci. This examination can be complemented by a targeted cardiac ultrasound to assess overall function.

- Signs to look for: Presence of edema or signs of heart failure.

● Neurological examination

- Key steps: Examination of motor, sensory and reflex functions. Assessment of gait, coordination and cranial pairs.

- Signs to look for: Any asymmetry or lateralization of signs, balance disorders or pupillary anomalies are of vital importance.

● Digestive examination

- Key steps: Inspection of the abdomen, palpation, percussion and auscultation of hydroaeric sounds. Targeted abdominal ultrasound can help identify an effusion or organ abnormality.

● Osteoarticular examination

- Key steps: Static and dynamic inspection, assessment of range of motion and provocative maneuvers. Ultrasound can visualize a joint effusion or soft-tissue lesion.

Following the clinical examination: prescription and follow-up

The clinical examination, however exhaustive it may be, only takes on its full meaning when it is perfectly linked to the medical reasoning that follows. It is not an end in itself, but the starting point for a structured intellectual process. Before any prescription decision is taken, it is essential to stress the vital importance of the clinical summary. This organized summary of functional signs (symptoms) and physical signs (symptoms) helps to clarify the situation, prioritize problems and clearly formulate one or more diagnostic hypotheses.

The logical continuation of this synthesis is a methodical approach: the practitioner develops diagnostic hypotheses, prescribes targeted complementary examinations if necessary to explore them, and once diagnostic confirmation has been obtained, implements appropriate management and treatment. But the process does not end with the initial prescription. It is essential to address the role of follow-up, which is a medical act in its own right. Follow-up is particularly crucial in the management of chronic pathologies, as it enables us to objectively verify the evolution of clinical signs under the effect of treatment, and to adjust the therapeutic strategy accordingly. Last but not least, quality medicine relies on flawless traceability. It is therefore of the utmost importance to record all this information, from the interview to the follow-up plan, in the patient's file. Writing a clear, precise report in professional language is essential to ensure continuity of care and effective communication between the various parties involved in the patient's care.

Clinical examination: frequently asked questions

What are the four stages of a clinical examination?

The traditional four steps of the physical examination are Inspection, Palpation, Percussion and Auscultation (IPPA). However, leading publications such as the Journal of the American Medical Association (JAMA) now recognize clinical ultrasound (POCUS) as a fifth, equally essential pillar of physical assessment at the patient's bedside.

What are the 3 types of diagnosis?

Clinical reasoning generally leads to three levels:

- syndromic diagnosis (identification of a coherent set of symptoms and signs to group them together into a syndrome),

- differential diagnosis (listing the possible causes of a clinical picture)

- and etiological diagnosis (determining the ultimate cause of the disease).

What are clinical signs?

These are the objective manifestations of a pathology, observed by the doctor during the examination (e.g. edema, rales on auscultation), as opposed to symptoms, which are subjective and described by the patient himself.

What is pain interrogation?

This is the precise analysis of pain according to its semiological criteria: mode of onset (sudden or progressive), duration, intensity (often assessed using a numerical scale), and the factors that trigger, aggravate or alleviate it.