Comprehensive Physical Examination Protocol for a 37-Year-Old Female in Family Medicine
A complete physical examination for a 37-year-old female should include a systematic assessment of all body systems with particular attention to age-appropriate preventive screening and gender-specific evaluations.
Initial Assessment
- Vital signs: Blood pressure, heart rate, respiratory rate, temperature, height, weight, and BMI calculation
- General appearance: Overall health status, alertness, and signs of distress
History Components
Medical History
- Past medical conditions and surgeries
- Current medications (prescription and non-prescription) and allergies
- Family medical history with emphasis on:
- Breast, ovarian, and colorectal cancer
- Cardiovascular disease (especially myocardial infarction in first-degree relatives before age 55 for males and 65 for females)
- Diabetes, hypertension, hyperlipidemia
- Thyroid disorders
- Neurological conditions
Social History
- Tobacco, alcohol, and substance use
- Diet and exercise habits
- Occupation and potential exposures
- Housing situation
- Social support systems
- Sexual history (in private, non-judgmental manner)
Review of Systems
- Constitutional: Fever, weight changes, fatigue
- Cardiovascular: Chest pain, palpitations, dyspnea on exertion
- Respiratory: Cough, wheezing, shortness of breath
- Gastrointestinal: Abdominal pain, changes in bowel habits
- Genitourinary: Urinary symptoms, menstrual history
- Musculoskeletal: Joint pain, muscle weakness
- Neurological: Headaches, dizziness, numbness
- Psychiatric: Mood, sleep patterns, stress
- Endocrine: Polyuria, polydipsia, heat/cold intolerance
- Skin: Rashes, lesions, changes in moles
Physical Examination Components
Head and Neck
- Thyroid examination for enlargement, nodules, or tenderness 1
- Lymph node palpation
- Oral cavity inspection for lesions or infections
Cardiovascular
- Heart auscultation for rate, rhythm, and murmurs
- Assessment for peripheral vascular disease 1
Respiratory
- Lung auscultation for breath sounds and abnormalities
Abdominal
- Inspection for distension or asymmetry
- Auscultation for bowel sounds
- Palpation for tenderness, organomegaly, or masses
Breast Examination
- Clinical breast examination (CBE) should be performed 1
- Inspect for symmetry, skin changes, or nipple discharge
- Palpate systematically for masses or tenderness
- Note: The USPSTF states there is insufficient evidence to assess the balance of benefits and harms of CBE, but ACOG recommends annual examination 1
Pelvic Examination
- External genitalia inspection for lesions, inflammation, or abnormalities
- Speculum examination to visualize cervix and vagina
- Bimanual examination to assess uterus and adnexa for size, shape, position, mobility, and tenderness 1
- Cervical cytology (Pap smear) according to guidelines (every 3 years for women 21-65 years, or every 5 years with HPV co-testing for women 30-65 years) 1
Musculoskeletal
- Assessment of major joints for range of motion and pain
- Spine examination for alignment and tenderness
Neurological
- Mental status evaluation
- Cranial nerve assessment
- Motor strength and sensory testing
- Deep tendon reflexes
- Coordination and gait
Skin
- Full skin examination for suspicious lesions, rashes, or other abnormalities 1
Age-Appropriate Screening
- Cervical cancer: Pap smear every 3 years or Pap with HPV co-testing every 5 years for women 30-65 years 1
- Breast cancer: Discuss mammography options (USPSTF recommends biennial screening starting at age 50, but individual risk factors may warrant earlier screening) 1
- Colorectal cancer: Discuss screening options if family history indicates early screening (otherwise typically begins at age 45-50)
- STI screening: Based on risk factors and sexual history
- Depression screening: Using validated tools
- Alcohol misuse screening
Special Considerations
- Reproductive planning: Discuss contraception or preconception health based on the patient's goals 1
- Immunization status: Review and update as needed
- Lifestyle counseling: Diet, exercise, smoking cessation if applicable
Common Pitfalls to Avoid
- Skipping components due to time constraints: A thorough exam is essential for preventive care
- Failing to address sensitive topics: Sexual health and mental health are integral components
- Not documenting family history adequately: This is crucial for risk assessment 2
- Overlooking social determinants of health: Housing, employment, and support systems impact health outcomes 3
- Neglecting patient education: Use the exam as an opportunity for health promotion
Documentation Requirements
- Document all components of the history and physical examination
- Note normal and abnormal findings
- Record screening recommendations and follow-up plans
- Include patient education provided
By following this comprehensive protocol, family physicians can ensure that adult female patients receive appropriate preventive care and screening while establishing rapport and trust through the physical examination process 4.