What is the recommended work-up for a medical adult physical?

Recommended Work-up for Adult Medical Physical Examination

The recommended work-up for an adult medical physical should include physical activity assessment as a core component, alongside traditional vital signs and screening tests, with specific exercise prescription based on individual health status.

Physical Activity Assessment

Physical activity assessment should be incorporated into every adult medical physical examination as a vital sign 1. This assessment is critical because:

• Physical inactivity is one of the most prevalent cardiovascular risk factors, with 80% of US adults failing to meet recommended activity levels 1
• Regular physical activity assessment can identify patients needing intervention to reduce stroke and cardiovascular disease risk 1
• Physical activity has comparable or superior effects to drug interventions for many conditions 1

Assessment Methods:

• Use validated questionnaires such as:
  • Exercise Vital Sign (two questions): "On average, how many days per week do you engage in moderate to strenuous exercise?" and "On average, how many minutes do you engage in exercise at this level?" 1
  • 9-item Rapid Assessment of Physical Activity 1
• Document results in medical record to track changes over time

Core Components of Adult Physical

1. Vital Signs

   • Blood pressure, heart rate, respiratory rate, temperature
   • BMI calculation
   • Physical activity assessment (as described above)

2. History

   • Review of systems with focus on cardiovascular, respiratory, musculoskeletal, and metabolic symptoms
   • Previous medical conditions and surgeries
   • Family history of cardiovascular disease, cancer, diabetes
   • Medication review
   • Social history (smoking, alcohol, substance use)

3. Physical Examination

   • Comprehensive examination with particular attention to:
     • Cardiovascular system
     • Respiratory system
     • Musculoskeletal system
     • Neurological screening
     • Skin examination

4. Laboratory Testing

   • Lipid profile (high therapeutic yield of 9.2%) 2
   • Complete blood count
   • Comprehensive metabolic panel
   • Thyroid function tests
   • Urinalysis
   • Hemoglobin A1c for diabetes screening

5. Additional Screening Tests

   • Age and risk-appropriate cancer screenings
   • Electrocardiogram (particularly for adults ≥45 years for men, ≥55 years for women planning vigorous exercise) 1

Exercise Prescription

Based on findings from the physical activity assessment, provide a specific exercise prescription using the FITT-PRO framework (Frequency, Intensity, Type, Time, and Progression) 1:

For Healthy Adults:

• Frequency: ≥5 days/week moderate activity or ≥3 days/week vigorous activity 1
• Intensity: 55-90% maximum heart rate or RPE 12-16 1
• Type: Combination of aerobic, resistance, and flexibility exercises
• Time: 150-300 minutes/week of moderate-intensity or 75-150 minutes/week of vigorous-intensity aerobic activity 1
• Resistance Training: 2-3 days/week, 1-3 sets of 8-15 repetitions per exercise 1

For Adults with Chronic Conditions:

• Adjust recommendations based on specific conditions (see disease-specific considerations) 1
• Focus on progressive introduction of activity
• Consider referral to exercise specialists when appropriate

Disease-Specific Considerations

Modify the physical examination and exercise prescription for patients with:

1. Arthritis

   • Focus on improving functionality through cross-training
   • Start with short bouts of low-intensity exercise
   • Gradually increase duration before intensity 1

2. Hypertension

   • Focus on aerobic activities using large muscle groups
   • Exercise 30-60 minutes, 3-7 days/week
   • Monitor response to medication that may affect exercise capacity 1

3. Cardiovascular Disease

   • Consider stress testing before initiating vigorous exercise
   • Focus on moderate-intensity activities with gradual progression
   • Monitor symptoms during activity 1

Common Pitfalls to Avoid

1. Overlooking physical activity assessment

   • Physical activity is often not assessed despite being a critical health indicator 1
   • Include it as a vital sign in every adult physical

2. Providing vague exercise recommendations

   • Give specific, measurable exercise prescriptions with clear parameters 1
   • Example: "Take a 10-minute walk, three times a day, every day of the week at a pace that allows talking but feels moderately hard" 1

3. Failing to address sedentary behavior

   • Counsel patients to break up prolonged sitting time 1
   • Recommend simple strategies like standing during phone calls or taking short walking breaks

4. Not considering barriers to physical activity

   • Assess and address barriers such as time constraints, neighborhood safety, or physical limitations 1
   • Provide strategies to overcome identified barriers

By incorporating these components into the adult medical physical, clinicians can provide comprehensive assessment and evidence-based recommendations that prioritize physical activity as a key health indicator and intervention strategy.