How to perform a comprehensive physical examination?

Comprehensive Physical Examination Guide

A comprehensive physical examination should include a thorough assessment of vital signs, head-to-toe evaluation, and targeted organ system examination, with special attention to areas of concern based on the patient's history and risk factors. 1

Initial Approach

• Vital Signs: Measure and record complete vital signs including:

  • Temperature
  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Height and weight (calculate BMI)
  • Oxygen saturation (pulse oximetry)
  • Head circumference in children <3 years 1

• General Appearance: Assess overall body habitus, noting:

  • Signs of distress
  • Nutritional status
  • Evidence of wasting or obesity
  • Abnormal fat distribution 1

Systematic Examination by Body Region

Head and Neck

• Eyes:

  • Visual acuity assessment
  • Pupillary examination
  • Fundoscopic examination (dilated exam for patients with advanced disease or symptoms) 1
  • Refer to ophthalmologist for patients with CD4 <50 cells/µL 1

• Ears:

  • Otoscopic examination
  • Hearing assessment

• Mouth and Throat:

  • Examine oropharynx for lesions, infections, or abnormalities
  • Assess dentition and gingival health
  • Look for evidence of candidiasis, leukoplakia, or ulcerations 1

• Neck:

  • Palpate for lymphadenopathy (note size, consistency, tenderness)
  • Thyroid examination
  • Carotid artery assessment

Cardiovascular

• Auscultate heart in all valve areas
• Assess rate, rhythm, and presence of murmurs
• Evaluate for peripheral vascular disease
• Check for peripheral edema 1

Respiratory

• Inspect chest wall movement
• Percuss and auscultate all lung fields
• Note any abnormal breath sounds or respiratory effort 1

Abdominal

• Inspect for distension or visible masses
• Auscultate bowel sounds
• Palpate for organomegaly, masses, or tenderness
• Percuss for abnormal dullness or tympany 1

Musculoskeletal

• Assess range of motion of major joints
• Evaluate muscle strength in all extremities
• Note any muscle atrophy or asymmetry 2

Neurological

• Mental status assessment
• Cranial nerve examination
• Motor strength testing (grade on 5-point scale)
• Deep tendon reflexes
• Sensory testing
• Coordination and gait assessment 2

Skin

• Examine entire skin surface for:
  • Rashes, lesions, or discoloration
  • Evidence of seborrheic dermatitis, folliculitis, fungal infections
  • Signs of lipodystrophy in patients on certain medications 1

Lymphatic

• Evaluate all major lymph node groups:
  • Cervical, supraclavicular, axillary, epitrochlear, inguinal
  • Note any focal or rapidly progressive lymphadenopathy 1

Genitourinary/Rectal

• Perform comprehensive anogenital examination
• Look for evidence of STDs, lesions, or abnormalities
• Perform pelvic examination in women including visual inspection 1
• Prostate examination in men

Special Considerations

Age-Specific Considerations

• Children:

  • Developmental assessment
  • Growth parameters (plot on standard growth curves)
  • Head circumference for children <3 years 1
  • Age-appropriate approach to make child comfortable 3

• Older Adults:

  • Cognitive assessment
  • Functional status evaluation
  • Fall risk assessment
  • Bone health assessment 2

Risk-Based Assessments

• Cardiovascular Risk:

  • Family history of early coronary heart disease
  • Assessment for hypertension, diabetes, hyperlipidemia 1

• Cancer Screening:

  • Skin examination for suspicious lesions
  • Breast examination in women
  • Prostate examination in men 1

Documentation

• Record all findings systematically
• Document positive and pertinent negative findings
• Use body maps to indicate location of lesions or abnormalities when appropriate 1
• Include assessment of overall health status and risk factors

Efficiency Tips

• Maintain a logical sequence to avoid missing components
• Explain examination steps to the patient
• Position the examination room for optimal auscultation 1
• Ensure appropriate privacy and comfort

Common Pitfalls to Avoid

• Rushing through examination components
• Failing to fully expose areas requiring examination
• Overlooking subtle neurological signs
• Neglecting to perform complete skin examination
• Inadequate documentation of findings

Studies consistently show that 60-80% of diagnoses are made from the medical history and physical examination alone, highlighting the critical importance of a thorough approach 4, 5. The physical examination should be tailored based on the patient's presenting symptoms, but should always be comprehensive enough to detect unexpected findings that may indicate underlying disease.