Normal Physical Examination Components and Characteristics
A normal physical examination includes assessment of vital signs, general appearance, and systematic evaluation of all body systems, with findings within expected physiological parameters for the patient's age and health status. 1
Vital Signs Assessment
Vital signs are the cornerstone of any physical examination and include:
- Heart rate: Regular rhythm, 60-100 beats per minute in adults 1
- Blood pressure: Typically 90-140 mmHg systolic and 60-90 mmHg diastolic, measured with patient in appropriate position 1
- Respiratory rate: 12-20 breaths per minute in adults, regular and effortless 1
- Temperature: 36.5-37.5°C (97.7-99.5°F) 1
- Oxygen saturation: ≥95% on room air 1
Note: Pulse intensity should be recorded numerically as: 0 (absent), 1 (diminished), 2 (normal), or 3 (bounding). 1
General Appearance
- Level of consciousness: Alert and responsive 1
- Mobility: Able to walk independently without assistance 1
- Body habitus: Note height, weight, and BMI (normal BMI: 18.5-24.9 kg/m²) 1
Head and Neck Examination
- Jugular venous pressure: Not elevated, typically <3 cm above sternal angle 1
- Carotid pulses: Regular, equal bilaterally without bruits
- Thyroid: Non-palpable or minimally palpable, symmetric
- Lymph nodes: Non-palpable or small, non-tender, mobile
Cardiovascular Examination
- Heart sounds: S1 and S2 present with normal intensity; absence of S3 and S4 1
- Heart murmurs: Absent or physiologic flow murmurs only 1
- Point of maximal impulse: Typically at 5th intercostal space, midclavicular line
- Peripheral pulses: Present and equal bilaterally at all sites (brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial) 1
- Absence of hepatojugular reflux 1
Respiratory Examination
- Inspection: Normal chest wall movement, symmetric
- Palpation: Normal tactile fremitus
- Percussion: Resonant throughout lung fields
- Auscultation: Clear breath sounds bilaterally without adventitious sounds (rales, rhonchi, wheezing) 1
Abdominal Examination
- Inspection: Flat or slightly rounded, no visible pulsations
- Auscultation: Normal bowel sounds, absence of bruits 1
- Palpation: Soft, non-tender, no organomegaly
- Absence of ascites 1
- Liver edge: Not palpable below costal margin 1
Extremities and Skin
- Peripheral edema: Absent 1
- Skin color and temperature: Normal and appropriate for ethnicity, warm
- Capillary refill: <3 seconds
- Absence of trophic skin changes: No distal hair loss or hypertrophic nails 1
Neurological Examination
- Orientation: Oriented to person, place, time 1
- Motor function: Normal strength (5/5) in all extremities 1
- Sensory function: Intact to light touch and pain 1
- Reflexes: Symmetric, 2+ throughout
- Coordination: Normal finger-to-nose and heel-to-shin testing 1
- Gait: Steady, normal base and arm swing
Common Pitfalls in Physical Examination
Inadequate exposure: Ensure proper exposure of body parts being examined while maintaining patient dignity.
Environmental factors: Room temperature, lighting, and noise can affect findings (especially vital signs).
Equipment issues: Improperly calibrated equipment can lead to inaccurate measurements. For blood pressure, using incorrect cuff size can significantly affect readings 2.
Observer variability: Significant interobserver variability exists in vital sign measurements. The expected range of agreement for heart rate is ±13.5%, respiratory rate ±35.5%, systolic BP ±19.0%, and diastolic BP ±25.7% 2.
Age considerations: Normal vital signs may not reliably predict clinical status in geriatric patients, who may require more vigilant monitoring despite seemingly normal findings 3.
Examination sequence: Follow a systematic approach to avoid missing important findings.
By methodically assessing each body system and documenting findings clearly, clinicians can establish a comprehensive baseline of a patient's physical status and identify any deviations that may require further investigation.