Examples of Medical Examination Questions Across Various Specialties
Medical examination questions should focus on comprehensive assessment of systems with particular attention to high-yield findings that impact morbidity, mortality, and quality of life outcomes.
General Medical Examination Components
History Taking Questions
- What are the chief complaints and their duration?
- What are the characteristics of symptoms (e.g., exertional versus non-exertional pain)? 1
- Is there a family history of sudden death, aborted sudden death, hyperlipidemia, or pulmonary hypertension? 1
- What is the patient's vaccination history and needs? 1
- What medications is the patient currently taking, including over-the-counter and supplements?
- What are the patient's eating patterns and weight history? 1
- What are the patient's physical activity and sleep behaviors? 1
Physical Examination Components
- Vital signs including orthostatic blood pressure measurements when indicated 1, 2
- Height, weight, and BMI calculation 1, 2
- Comprehensive skin examination with attention to:
- Fundoscopic examination or referral to eye specialist 1, 2
- Comprehensive foot examination including:
Cardiology Examination Questions
History
- Does the patient have chest pain? If so, what are the characteristics (location, radiation, quality, severity, timing, aggravating/alleviating factors)?
- Is there a history of syncope or presyncope? What are the triggers, postural changes, frequency, duration, and recovery? 1
- Is there a family history of premature coronary artery disease? 1
Physical Examination
- What are the carotid artery findings, including auscultation for bruits? 2
- Are there abnormal heart sounds, murmurs, or rubs? 2
- Is there evidence of heart failure (edema, jugular venous distention, pulmonary crackles)? 1
- What is the estimated cardiac event risk (Framingham risk)? 1
ECG Interpretation Questions
- Are there abnormalities of cardiac rhythm? 1
- Sinus rhythm, sinus tachycardia, sinus bradycardia, sinus arrhythmia
- Atrial fibrillation, atrial flutter, atrial tachycardia
- Ventricular tachycardia, ventricular fibrillation
- Atrioventricular blocks (first, second, or third degree)
- Are there signs of ventricular hypertrophy? 1
- Are there intraventricular conduction disturbances? 1
- Are there repolarization abnormalities? 1
Neurology Examination Questions
History
- Is there a history of headaches, vision changes, weakness, numbness, or difficulty with speech or coordination?
- Has the patient experienced any seizures or loss of consciousness?
- Is there a history of stroke or transient ischemic attack? 1
Physical Examination
- What is the patient's level of consciousness and mental status?
- Are there abnormalities in cranial nerve function?
- Is there evidence of motor weakness, sensory deficits, or abnormal reflexes?
- Are there signs of meningeal irritation?
- Is there evidence of cerebellar dysfunction (ataxia, dysmetria, nystagmus)?
Neurological Complications Assessment
- In patients with infective endocarditis, assess for neurological complications: 1, 3, 4
- Ischemic stroke (occurs in approximately 60% of neurological complications)
- Hemorrhagic stroke (occurs in approximately 21% of neurological complications)
- Brain abscess (occurs in approximately 3-14% of neurological complications)
- Meningitis (occurs in approximately 16% of neurological complications)
- Diffuse encephalopathy (occurs in approximately 13% of neurological complications)
Infectious Disease Examination Questions
History
- Is there a history of fever, chills, night sweats, or weight loss?
- Has the patient traveled to areas with endemic infectious diseases?
- Is there a history of immunocompromise or HIV infection?
- What is the patient's vaccination status? 1
Physical Examination
- Is there evidence of fever or hypothermia?
- Are there skin lesions suggestive of infection?
- Is there lymphadenopathy? 2
- Are there signs of endocarditis (murmurs, petechiae, splinter hemorrhages, Janeway lesions, Osler nodes)?
HIV-Specific Assessment
- For patients with HIV infection, conduct a comprehensive evaluation including: 1
- CD4 count and viral load assessment
- Screening for opportunistic infections
- Evaluation for medication side effects
- Assessment for HIV-associated complications
Gastrointestinal and Hepatology Examination Questions
History
- Is there a history of abdominal pain, nausea, vomiting, diarrhea, or constipation?
- Has the patient experienced jaundice, dark urine, or light-colored stools?
- Is there a history of gastrointestinal bleeding?
Physical Examination
- Is there abdominal tenderness, masses, or organomegaly? 2
- Are bowel sounds normal, hyperactive, or absent? 2
- Is there evidence of ascites or fluid wave?
- Are there signs of liver disease (jaundice, spider angiomata, palmar erythema, caput medusae)?
Liver Failure Assessment
- In patients with suspected liver failure, assess for: 1
- Encephalopathy (altered mental status, asterixis)
- Coagulopathy (bruising, bleeding)
- Jaundice
- Ascites
- Portal hypertension
Documentation Recommendations
- Document all findings systematically by body system 2
- Include both normal and abnormal findings 2
- Record specific measurements such as blood pressure and temperature 2
- Use standardized scales for grading when appropriate (e.g., heart murmurs, muscle strength)
Common Pitfalls to Avoid
- Failing to perform a comprehensive review of systems
- Overlooking subtle physical examination findings
- Not correlating history with physical examination findings
- Inadequate documentation of findings
- Neglecting to assess for medication side effects or interactions
- Focusing only on the primary complaint without considering comorbidities
Remember that a thorough medical examination forms the foundation for accurate diagnosis and effective treatment planning, with direct impact on patient morbidity, mortality, and quality of life.