# Clinical Cases: Clinical Examination Skills

## Case 1: Focused Cardiac Examination with New Murmur

### Patient Presentation
**Demographics:** 72-year-old male retired postal worker

**Chief Complaint:** "I've been getting short of breath climbing the stairs to my apartment."

**History of Present Illness:**
A 72-year-old male presents with a 4-month history of progressive exertional dyspnea. He lives in a third-floor walk-up apartment and previously climbed the stairs without difficulty. Over the past 4 months, he has needed to stop and rest at the second-floor landing. In the past 2 weeks, he has also noted lightheadedness when standing quickly from a seated position, and his wife observed that he briefly lost consciousness while gardening 3 days ago, recovering spontaneously within seconds.

He denies chest pain at rest, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity swelling. He has not seen a physician in 4 years. He reports a prior physician mentioning a "heart sound" during a routine exam approximately 10 years ago, but no follow-up was pursued.

His symptoms are concerning for hemodynamically significant valvular heart disease, and a careful cardiac physical examination is critical for initial assessment and guiding further workup.

**Past Medical History:**
- Hypertension (diagnosed 20 years ago, inconsistently treated)
- Hyperlipidemia (untreated)
- Benign prostatic hyperplasia
- No prior cardiac history documented

**Medications:**
- Hydrochlorothiazide 25 mg daily (inconsistent adherence)
- Tamsulosin 0.4 mg daily

**Social History:**
- Retired postal worker (mail carrier for 35 years)
- Non-smoker
- Occasional glass of wine with dinner
- Lives with wife in third-floor apartment
- Previously active, now limited by dyspnea

**Family History:**
- Father: died of "heart problems" at age 78
- Mother: hypertension, died of stroke at age 81

### Physical Examination
- **Vital Signs:** BP 138/62 mmHg (narrow pulse pressure when corrected for systolic hypertension), HR 72 bpm, RR 18/min, Temp 36.7°C, SpO2 96% on room air
- **General:** Elderly male, appears older than stated age, mildly dyspneic after walking to exam room
- **Carotid pulse:** Parvus et tardus (diminished and slow-rising carotid upstroke bilaterally); no carotid bruits
- **JVP:** Prominent a-wave at 8 cm above sternal angle, consistent with decreased right ventricular compliance
- **Precordial palpation:**
  - PMI sustained and laterally displaced to 6th intercostal space, anterior axillary line
  - Systolic thrill palpable at right 2nd intercostal space (aortic area)
  - No parasternal heave
- **Auscultation:**
  - S1 normal intensity
  - S2: Soft and single (absent A2 component)
  - Grade 4/6 harsh, crescendo-decrescendo systolic ejection murmur, loudest at right upper sternal border (aortic area), radiating to bilateral carotid arteries
  - Murmur peaks late in systole (late-peaking correlates with severe stenosis)
  - S4 gallop present at apex (stiff, hypertrophied left ventricle)
  - No S3 gallop
  - No diastolic murmur detected
- **Lungs:** Bibasilar fine crackles, lower one-third bilaterally
- **Abdomen:** Soft, non-tender, no hepatomegaly
- **Extremities:** Trace bilateral ankle edema, pulses diminished but palpable

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| BNP | 486 pg/mL | <100 pg/mL |
| Troponin I | <0.01 ng/mL | <0.04 ng/mL |
| Hemoglobin | 12.8 g/dL | 13.5-17.5 g/dL |
| Creatinine | 1.3 mg/dL | 0.7-1.3 mg/dL |
| eGFR | 54 mL/min | >60 mL/min |
| BMP | Normal | - |
| Pro-BNP | 2,140 pg/mL | <450 pg/mL (age >75) |

**Imaging/Additional Studies:**
- **ECG:** Normal sinus rhythm, left ventricular hypertrophy by voltage criteria (Sokolow-Lyon), left atrial enlargement, no ST-T wave changes
- **Transthoracic Echocardiogram:**
  - Severely calcified trileaflet aortic valve with restricted opening
  - Aortic valve area: 0.7 cm² (severe AS: <1.0 cm²)
  - Mean transaortic gradient: 48 mmHg (severe: >40 mmHg)
  - Peak aortic velocity: 4.5 m/s (severe: >4.0 m/s)
  - LVEF: 55% (preserved)
  - Concentric LV hypertrophy (septal wall thickness 1.5 cm)
  - Left atrial enlargement
  - Mild mitral regurgitation
- **Chest X-ray:** Cardiomegaly, aortic valve calcification visible, mild pulmonary vascular congestion

### Clinical Image

![Cardiac Auscultation Landmarks](case_01_image.jpg)

*Diagram of the anterior chest wall showing the four primary cardiac auscultation areas (aortic, pulmonic, tricuspid, mitral) with phonocardiogram tracings demonstrating the crescendo-decrescendo systolic murmur of aortic stenosis. Source: Educational illustration.*

### Diagnosis
**Severe Calcific Aortic Stenosis with Symptomatic Heart Failure (Exertional Dyspnea and Syncope)**

**Key Diagnostic Criteria:**
- Classic symptom triad: exertional dyspnea, syncope, and (eventually) angina
- Harsh crescendo-decrescendo systolic ejection murmur at aortic area radiating to carotids
- Late-peaking murmur with diminished and delayed carotid upstroke (parvus et tardus)
- Soft/absent A2 component of S2
- Systolic thrill at aortic area
- S4 gallop (LV hypertrophy with diastolic dysfunction)
- Echo confirms: AVA 0.7 cm², mean gradient 48 mmHg, peak velocity 4.5 m/s

### Treatment Plan
1. **Urgent cardiology referral** for evaluation for aortic valve replacement (surgical AVR or transcatheter TAVR)
2. Avoid vasodilators (nitrates, ACE inhibitors in high doses) due to risk of severe hypotension in critical AS
3. Avoid excessive diuresis; cautious low-dose furosemide 20 mg daily for pulmonary congestion
4. Activity restriction: avoid strenuous exertion until valve intervention
5. Cardiac catheterization for coronary angiography pre-operatively
6. STS risk score and Heart Team assessment to determine SAVR vs. TAVR
7. Optimize comorbidities pre-operatively (renal function, anemia workup)

### Key Learning Points
- The classic physical examination findings of severe aortic stenosis are a late-peaking crescendo-decrescendo systolic murmur, parvus et tardus carotid pulse, diminished A2, systolic thrill, and S4 gallop
- Murmur intensity does not reliably correlate with severity in aortic stenosis; in critical AS with low cardiac output, the murmur may actually become quieter
- The presence of syncope in aortic stenosis indicates hemodynamically significant obstruction and is associated with a 50% mortality rate at 3 years without intervention
- Parvus et tardus (small and late) carotid pulse is a specific finding for severe AS, reflecting delayed and diminished transmission of the pressure wave across the stenotic valve
- Careful cardiac physical examination can reliably identify severe aortic stenosis and guide urgent echocardiographic confirmation

---

## Case 2: Acute Abdomen Physical Examination

### Patient Presentation
**Demographics:** 28-year-old female graduate student

**Chief Complaint:** "I have terrible pain in my lower right belly that started last night."

**History of Present Illness:**
A 28-year-old female graduate student presents to the emergency department with a 14-hour history of abdominal pain. The pain began periumbilically last evening as a dull, vague discomfort that she initially attributed to something she ate. She took antacids without relief. Over the next 6-8 hours, the pain migrated to the right lower quadrant and became sharp, constant, and progressively severe (8/10). She vomited twice this morning, after the onset of pain. She reports anorexia since the pain began and has had no bowel movement today. She denies diarrhea, urinary symptoms, vaginal discharge, or missed menstrual period. Her last menstrual period was 12 days ago and was normal.

She was previously healthy and has never had abdominal surgery. She denies recent travel, sick contacts, or antibiotic use.

**Past Medical History:**
- No significant medical history
- No prior surgeries
- Regular menstrual cycles (28-day cycle, LMP 12 days ago)

**Medications:**
- Combined oral contraceptive pill
- Ibuprofen as needed for headaches

**Social History:**
- Graduate student in chemistry
- Non-smoker, occasional alcohol
- Sexually active with one male partner, uses OCP for contraception
- No illicit drug use

**Family History:**
- Mother: cholecystectomy at age 42
- No family history of inflammatory bowel disease or colon cancer

### Physical Examination
- **Vital Signs:** BP 118/74 mmHg, HR 96 bpm, RR 18/min, Temp 38.2°C (100.8°F), SpO2 99% on room air
- **General:** Young woman lying still on stretcher with knees flexed, reluctant to move, appears uncomfortable
- **Abdominal Inspection:** Flat abdomen, no distension, no visible scars, no discoloration
- **Auscultation:** Hypoactive bowel sounds in all quadrants
- **Percussion:**
  - Tympanitic throughout
  - Localized tenderness to percussion in RLQ
  - No shifting dullness
- **Palpation (systematic, beginning away from site of pain):**
  - LUQ: Soft, non-tender
  - LLQ: Soft, non-tender
  - RUQ: Soft, mild tenderness
  - RLQ: Marked tenderness with involuntary guarding at McBurney's point (one-third the distance from ASIS to umbilicus)
  - No palpable masses
  - No hepatosplenomegaly
- **Special Abdominal Signs:**
  - **Rovsing's sign:** POSITIVE (palpation of LLQ produces referred pain in RLQ)
  - **Psoas sign:** POSITIVE (pain with passive extension of right hip -- suggests retrocecal inflammation)
  - **Obturator sign:** NEGATIVE (no pain with internal rotation of flexed right hip)
  - **Rebound tenderness:** POSITIVE in RLQ (localized peritoneal irritation)
  - **Dunphy's sign:** POSITIVE (pain worsens with coughing)
- **Rectal examination:** Tenderness on right side of rectum
- **Pelvic examination:** Cervical os closed, no cervical motion tenderness, no adnexal masses, minimal right adnexal tenderness

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| WBC | 14,200/µL | 4,500-11,000/µL |
| Neutrophils | 82% | 40-70% |
| Hemoglobin | 13.4 g/dL | 12.0-16.0 g/dL |
| Platelets | 268,000/µL | 150,000-400,000/µL |
| CRP | 4.8 mg/dL | <0.5 mg/dL |
| Urinalysis | 3-5 WBC/hpf, no bacteria, no nitrites | Normal |
| Urine hCG | Negative | Negative |
| Lipase | 32 U/L | 10-140 U/L |
| Lactate | 1.2 mmol/L | 0.5-2.0 mmol/L |

**Imaging/Additional Studies:**
- **CT abdomen/pelvis with IV contrast:**
  - Dilated appendix (11 mm diameter, normal <6 mm)
  - Appendiceal wall enhancement and thickening
  - Periappendiceal fat stranding
  - No appendicolith identified
  - Small amount of free fluid in pelvis
  - No free air
  - No evidence of abscess formation

### Clinical Image

![Abdominal Examination Technique](case_02_image.jpg)

*Diagram of the abdomen divided into four quadrants with labeled surface anatomy landmarks, McBurney's point location, and illustrations of special examination signs for appendicitis (Rovsing's sign, psoas sign, obturator sign). Source: Educational illustration.*

### Diagnosis
**Acute Appendicitis (Uncomplicated)**

**Key Diagnostic Criteria:**
- Classic pain migration from periumbilical to RLQ (visceral to somatic pain transition)
- Anorexia followed by vomiting (sequence is important: pain precedes vomiting in appendicitis)
- Low-grade fever with leukocytosis and left shift
- McBurney's point tenderness with involuntary guarding
- Positive Rovsing's, psoas, and Dunphy's signs
- CT confirming dilated, inflamed appendix with periappendiceal fat stranding
- Alvarado Score: 9/10 (high probability)

### Treatment Plan
1. NPO status, IV fluid resuscitation with lactated Ringer's
2. IV antibiotics: cefoxitin 2g IV (or piperacillin-tazobactam if penicillin-allergic)
3. Pain management: IV morphine 4 mg (analgesics do NOT mask peritoneal signs -- this is a debunked myth)
4. Urgent surgical consultation for laparoscopic appendectomy
5. Laparoscopic appendectomy performed within 12 hours of presentation
6. Post-operative: advance diet as tolerated, early ambulation, discharge when tolerating PO and afebrile
7. Pathology review of appendix specimen

### Key Learning Points
- The classic presentation of appendicitis follows a predictable pain migration pattern: vague periumbilical visceral pain (appendiceal distension stimulating T10 visceral afferents) localizing to RLQ somatic pain (parietal peritoneal inflammation)
- Systematic abdominal examination should begin palpation AWAY from the area of maximal pain to avoid causing guarding that obscures findings
- Rovsing's sign (referred RLQ pain with LLQ palpation) indicates peritoneal irritation and has a sensitivity of 22-68% but specificity of 58-96% for appendicitis
- The psoas sign suggests retrocecal appendicitis (the appendix lies against the psoas muscle); the obturator sign suggests pelvic appendicitis
- Withholding analgesia to "preserve examination findings" is no longer supported by evidence and constitutes inadequate pain management

---

## Case 3: Neurological Examination for Stroke Assessment

### Patient Presentation
**Demographics:** 67-year-old male retired electrician

**Chief Complaint:** Per wife: "His face is drooping and he can't move his right arm. It started about 45 minutes ago."

**History of Present Illness:**
A 67-year-old right-handed male is brought to the emergency department by EMS after his wife noticed sudden onset of right facial droop, right arm weakness, and difficulty speaking while they were eating breakfast. She reports that at 7:15 AM he was completely normal, and at 7:45 AM (approximately 45 minutes prior to ED arrival) she noticed he dropped his coffee cup with his right hand, his face appeared asymmetric, and his speech became slurred and difficult to understand. She immediately called 911.

EMS reports: Glasgow Coma Scale 13 (E4, V4, M5), Cincinnati Prehospital Stroke Scale positive for all three components (facial droop, arm drift, abnormal speech), blood glucose 142 mg/dL. The patient is within the 4.5-hour window for IV thrombolysis.

A rapid, focused neurological examination is critical for confirming stroke, lateralizing the lesion, calculating the NIH Stroke Scale score, and determining eligibility for acute intervention.

**Past Medical History:**
- Atrial fibrillation (paroxysmal, diagnosed 2 years ago)
- Hypertension
- Type 2 diabetes mellitus
- Hyperlipidemia
- NOT on anticoagulation (patient declined warfarin 2 years ago; was not offered DOAC)

**Medications:**
- Aspirin 81 mg daily
- Metformin 500 mg BID
- Amlodipine 10 mg daily
- Atorvastatin 40 mg daily

**Social History:**
- Retired electrician
- Former smoker (quit 5 years ago, 30 pack-year history)
- Social alcohol (2-3 beers per week)
- Lives with wife in single-story home
- Independent in all ADLs at baseline

**Family History:**
- Father: stroke at age 74
- Mother: hypertension, alive at 89

### Physical Examination
- **Vital Signs:** BP 178/96 mmHg, HR 88 bpm (irregularly irregular), RR 16/min, Temp 36.9°C, SpO2 96% on room air, Blood glucose 142 mg/dL
- **General:** Alert but confused elderly male, frustrated by inability to communicate
- **Neurological Examination (NIH Stroke Scale):**
  - **1a. Level of Consciousness:** Alert (0)
  - **1b. LOC Questions (age, month):** Answers one correctly (1)
  - **1c. LOC Commands (open/close eyes, grip/release):** Performs both correctly (0)
  - **2. Best Gaze:** Normal horizontal eye movements (0)
  - **3. Visual Fields:** Right homonymous hemianopia on confrontation testing (2)
  - **4. Facial Palsy:** Right lower facial droop, unable to show teeth on right; forehead spared bilaterally (indicating UMN pattern) (2)
  - **5a. Left Arm Motor:** No drift (0)
  - **5b. Right Arm Motor:** Drifts down within 10 seconds, does not hit bed (2)
  - **6a. Left Leg Motor:** No drift (0)
  - **6b. Right Leg Motor:** Drifts down, some effort against gravity (2)
  - **7. Limb Ataxia:** Unable to assess right side due to weakness; left side normal (0)
  - **8. Sensory:** Decreased pinprick sensation on right arm and leg (1)
  - **9. Best Language:** Comprehends simple commands but output is non-fluent, effortful, telegraphic (Broca's aphasia pattern) (2)
  - **10. Dysarthria:** Moderate slurring, intelligible with effort (1)
  - **11. Extinction/Inattention:** Right-sided extinction on double simultaneous stimulation (1)
  - **TOTAL NIHSS:** 14 (moderate-severe stroke)
- **Additional Neurological Findings:**
  - Right upper motor neuron facial weakness (lower face only; forehead sparing)
  - Right pronator drift
  - Right Babinski sign positive (upgoing plantar response)
  - Increased tone in right upper extremity
  - Right-sided sensory neglect
- **Cardiovascular:** Irregularly irregular rhythm (atrial fibrillation), no murmurs
- **Lungs:** Clear bilaterally

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| Glucose (point of care) | 142 mg/dL | 70-100 mg/dL |
| INR | 1.0 | 0.9-1.1 |
| PTT | 28 seconds | 25-35 seconds |
| Platelets | 198,000/µL | 150,000-400,000/µL |
| Creatinine | 1.1 mg/dL | 0.7-1.3 mg/dL |
| Troponin I | <0.01 ng/mL | <0.04 ng/mL |
| Hemoglobin | 14.2 g/dL | 13.5-17.5 g/dL |

**Imaging/Additional Studies:**
- **CT Head without contrast (door-to-CT time: 8 minutes):** No hemorrhage; no early ischemic changes; ASPECTS score 9/10 (subtle loss of gray-white differentiation in left insular cortex)
- **CT Angiogram (head and neck):** Occlusion of left middle cerebral artery M1 segment; no significant carotid stenosis; patent circle of Willis otherwise
- **CT Perfusion:** Large penumbral territory (ischemic but salvageable tissue) in left MCA distribution; core infarct volume 12 mL; mismatch ratio 6.2 (favorable for intervention)
- **ECG:** Atrial fibrillation with ventricular rate 88 bpm

### Clinical Image

![NIHSS Examination Components](case_03_image.jpg)

*Diagram illustrating the key components of the NIH Stroke Scale (NIHSS) neurological examination, showing assessment areas for consciousness, gaze, visual fields, facial palsy, motor function, ataxia, sensory, language, dysarthria, and extinction. Source: Educational illustration.*

### Diagnosis
**Acute Left Middle Cerebral Artery Ischemic Stroke (Cardioembolic, Secondary to Atrial Fibrillation), NIHSS 14**

**Key Diagnostic Criteria:**
- Sudden onset of right-sided weakness, facial droop, and non-fluent aphasia (left MCA territory)
- Upper motor neuron pattern facial weakness (forehead sparing)
- Right homonymous hemianopia (optic radiation involvement)
- Broca's aphasia (left frontal lobe)
- NIHSS 14 indicating moderate-severe deficit
- CT Angiogram confirming left M1 MCA occlusion
- Known atrial fibrillation without anticoagulation (embolic source)
- CHA₂DS₂-VASc score: 5 (AF, age 65-74, HTN, DM, vascular disease history = high stroke risk)

### Treatment Plan
1. **IV alteplase (tPA):** 0.9 mg/kg (max 90 mg), 10% as bolus, remainder over 60 minutes -- door-to-needle time goal <45 minutes
2. **Mechanical thrombectomy:** Given large vessel occlusion (M1 MCA) with favorable perfusion imaging (large penumbra, small core), proceed to endovascular thrombectomy -- door-to-groin puncture goal <90 minutes
3. **Blood pressure management:** Permissive hypertension up to 185/110 pre-tPA; post-tPA maintain <180/105 for 24 hours with IV labetalol or nicardipine infusion
4. **Admit to Neuro ICU/Stroke Unit:** Continuous cardiac monitoring, neuro checks every 15 minutes for first 2 hours, then hourly; NPO until swallowing assessment
5. **Anticoagulation:** Initiate DOAC (apixaban 5 mg BID) after 24-hour follow-up imaging confirms no hemorrhagic conversion; indefinite anticoagulation for AF (CHA₂DS₂-VASc 5)
6. **Secondary prevention:** High-intensity statin, blood pressure optimization, glucose management
7. **Rehabilitation:** Early PT/OT/Speech therapy assessment within 24 hours; discharge planning for inpatient rehabilitation

### Key Learning Points
- The NIH Stroke Scale is a standardized, reproducible neurological assessment that quantifies stroke severity and guides treatment decisions (NIHSS ≥6 with LVO is a strong indicator for thrombectomy evaluation)
- Upper motor neuron (UMN) facial weakness spares the forehead because the upper face receives bilateral cortical innervation, while lower face receives only contralateral innervation
- Localization of stroke deficits to vascular territories is a fundamental clinical skill: right hemiparesis + right facial droop + Broca's aphasia + right hemianopia = left MCA territory
- The time-critical nature of stroke care requires a rapid, focused neurological examination; the NIHSS can be performed in under 7 minutes by trained examiners
- Atrial fibrillation is the most common cause of cardioembolic stroke; this case illustrates the consequence of inadequate anticoagulation (CHA₂DS₂-VASc score of 5 carries an annual stroke risk of approximately 6.7%)