What should be included in a comprehensive annual physical exam note?

Comprehensive Annual Physical Examination Template

A comprehensive annual physical examination should include a thorough medical history, complete physical examination, age and gender-appropriate screening tests, and preventive health counseling to identify and address health risks early, ultimately reducing morbidity and mortality. 1, 2

Medical History Components

Past Medical History

• Review of previous diagnoses, hospitalizations, and treatments 1
• Review of previous treatment regimens and response 1
• Assessment of frequency/cause/severity of past hospitalizations 1

Family History

• Family history of diabetes, cancer, and other hereditary conditions in first-degree relatives 1, 3
• Family history of autoimmune disorders 1

Social History

• Tobacco, alcohol, and substance use assessment 1
• Physical activity and sleep behaviors 1
• Eating patterns and weight history 1
• Occupational history and environmental exposures 1, 3

Medication Review

• Current medication regimen, including prescription and over-the-counter medications 1
• Medication-taking behavior and adherence 1
• Medication intolerance or side effects 1
• Complementary and alternative medicine use 1

Preventive Care History

• Vaccination history and needs 1
• Last dental visit 1
• Last eye examination 1
• Previous cancer screenings and results 1, 3

Social Determinants of Health

• Identify existing social supports 1
• Identify surrogate decision maker, advanced care plan 1
• Assess food security, housing stability, transportation access, financial security, and community safety 1

Physical Examination Components

Vital Signs

• Height, weight, and BMI calculation 1
• Blood pressure determination 1, 2
• Heart rate and respiratory rate 4
• Temperature 4

General Appearance

• Overall appearance, nutritional status, and hydration 4
• Mental status and affect 4

Head, Eyes, Ears, Nose, and Throat

• Visual acuity assessment 1
• Fundoscopic examination (refer to specialist if needed) 1
• Hearing assessment 2
• Thyroid palpation 1
• Oral cavity examination for lesions 1, 3

Cardiovascular System

• Heart auscultation for murmurs, gallops, or rubs 1
• Assessment of peripheral pulses 1
• Evaluation for edema 4

Respiratory System

• Lung auscultation for abnormal breath sounds 1
• Assessment of respiratory effort 4

Abdominal Examination

• Inspection, auscultation, and palpation of abdomen 1
• Assessment for organomegaly or masses 4

Musculoskeletal System

• Assessment of joint range of motion and stability 4
• Muscle strength testing 4
• Spine examination 4

Neurological Examination

• Cranial nerve assessment 4
• Sensory examination 1
• Deep tendon reflexes 1
• Coordination and gait assessment 4

Skin Examination

• Inspection for suspicious lesions, rashes, or abnormalities 1
• Assessment for acanthosis nigricans or other skin conditions 1

Gender-Specific Examinations

• For women: Clinical breast examination (annually after age 40, every 3 years for ages 20-39) 1, 3
• For men: Testicular examination 1
• For men over 50: Prostate examination 1, 2

Foot Examination (Especially Important for Diabetes)

• Visual inspection of skin integrity, callous formation, deformities 1
• Assessment of pedal pulses 1
• Neurological testing with 10-g monofilament, vibration, or pinprick sensation 1

Laboratory and Screening Tests

Core Laboratory Tests

• Complete blood count (CBC) 2
• Comprehensive metabolic panel (CMP) 2
• Lipid profile (total, LDL, HDL cholesterol, triglycerides) 1, 2
• Hemoglobin A1C 1, 2
• Urinalysis with albumin-to-creatinine ratio 1, 2

Age and Sex-Specific Tests

• Thyroid-stimulating hormone (TSH), particularly for women and older adults 2
• Prostate-specific antigen (PSA) for men over 50 1, 2
• Vitamin B12 levels for patients on metformin 1, 2
• Serum potassium for patients on ACE inhibitors, ARBs, or diuretics 1, 2

Cancer Screening

• Cervical cancer screening: Pap test every 3 years with conventional tests or every 2 years with liquid-based tests for women 1, 3
• Breast cancer screening: Mammography annually beginning at age 40 for women 1
• Colorectal cancer screening: Beginning at age 50 with options including FOBT/FIT annually, flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years 1

Preventive Health Counseling

Lifestyle Counseling

• Diet and nutrition guidance 1
• Physical activity recommendations 1
• Tobacco cessation counseling 1
• Alcohol and substance use counseling 1

Disease Prevention

• Cancer prevention strategies 1, 3
• Cardiovascular disease prevention 1, 2
• Diabetes prevention and management 1
• Mental health screening for depression, anxiety, and disordered eating 1

Safety Counseling

• Sun exposure protection 1, 3
• Injury prevention 1
• Sexual health and safe practices 1, 3

Assessment and Plan

Problem List

• Document all active and chronic conditions 4
• Prioritize problems based on acuity and impact on health 4

Preventive Care Plan

• Recommended vaccinations based on age and risk factors 1
• Schedule for future screening tests 1, 2
• Referrals to specialists as needed 1

Follow-up Plan

• Timing for next visit 1
• Specific follow-up for abnormal findings 4
• Patient education materials provided 1

Common Pitfalls to Avoid

• Failing to consider patient-specific risk factors when determining which tests to order 2
• Overlooking the need for more frequent monitoring in patients with chronic conditions 2
• Ordering unnecessary screening tests not recommended for specific age groups 3
• Performing annual tests when guidelines recommend less frequent screening 3
• Neglecting to provide adequate education about recognizing and reporting new symptoms 3