What are the steps to complete a physical exam?

Comprehensive Physical Examination: Step-by-Step Guide

A comprehensive physical examination should follow a systematic approach, beginning with proper preparation and proceeding through a logical sequence of assessment techniques to evaluate all body systems thoroughly.

Preparation

• Explain the purpose of the examination to the patient and obtain informed consent before proceeding 1
• Ensure proper room setup with adequate lighting, privacy, and appropriate equipment 2
• Wash hands thoroughly before beginning the examination 2
• Position the patient appropriately (sitting, standing, or lying) depending on the examination component 3
• Introduce yourself clearly, state your role, and confirm the patient's identity 1

General Approach

• Begin with general observation of the patient's appearance, level of distress, and overall condition 2
• Use the systematic sequence of inspection, palpation, percussion, and auscultation for each body system 2
• Document findings thoroughly throughout the examination 3

Vital Signs Assessment

• Measure and record temperature, pulse rate, respiratory rate, blood pressure (both arms), and oxygen saturation 4
• For blood pressure, ensure patient is seated with arm supported at heart level 4
• Note that a brachial systolic blood pressure difference of more than 15 mmHg raises cardiovascular death risk by 50% 4

Head-to-Toe Examination Sequence

1. General Appearance

• Assess level of consciousness, apparent age versus stated age, nutritional status, and overall hygiene 2
• Note any signs of distress, posture, and general mobility 3

2. Skin Assessment

• Inspect skin for color, lesions, rashes, and abnormalities 2
• Assess skin temperature, texture, turgor, and moisture 2
• Document any areas of edema, bruising, or other abnormalities 2

3. Head and Neck Examination

• Inspect head for shape, symmetry, and any abnormalities 2
• Palpate skull for tenderness or irregularities 3
• Examine eyes for visual acuity, pupillary responses, extraocular movements, and fundoscopic examination when indicated 3
• Assess ears for hearing acuity and examine ear canals and tympanic membranes 2
• Examine nose for patency, discharge, and septum alignment 2
• Inspect mouth for dentition, gums, tongue, palate, and pharynx 2
• Palpate thyroid and lymph nodes of the neck 2
• Assess neck range of motion and carotid pulses (auscultate for bruits) 4

4. Chest and Lung Examination

• Inspect chest for shape, symmetry, and respiratory effort 2
• Palpate for tactile fremitus and chest expansion 3
• Percuss for resonance and diaphragmatic excursion 2
• Auscultate lungs in systematic pattern, comparing sides and noting breath sounds 4
• For respiratory assessment, consider using standardized tools like the Borg dyspnea scale when appropriate 4

5. Cardiovascular Examination

• Inspect for jugular venous distention and visible pulsations 2
• Palpate the precordium for thrills, heaves, or abnormal pulsations 3
• Auscultate heart sounds at all four cardiac listening posts (aortic, pulmonic, tricuspid, and mitral areas) 4
• Listen for S1, S2, and any additional heart sounds or murmurs 4
• Document rate, rhythm, and quality of heart sounds 2

6. Abdominal Examination

• Inspect abdomen for contour, symmetry, and visible pulsations 2
• Auscultate for bowel sounds in all four quadrants 2
• Percuss for tympany and dullness 2
• Palpate all four quadrants lightly then deeply for tenderness, masses, or organomegaly 3
• Assess for rebound tenderness if indicated 2

7. Musculoskeletal Examination

• Assess all major joints for range of motion, stability, and pain 2
• Evaluate muscle strength in all extremities using the 5-point scale 3
• Test for symmetry of strength and movement 2
• Assess gait and balance if appropriate 4
• Consider functional performance tests like the Short Physical Performance Battery (SPPB) for comprehensive assessment 4

8. Neurological Examination

• Assess mental status, orientation, and cognitive function 2
• Test cranial nerves I-XII systematically 3
• Evaluate sensory function (light touch, pain, temperature, vibration, proprioception) 2
• Test deep tendon reflexes and assess for pathological reflexes 3
• Evaluate coordination with finger-to-nose and heel-to-shin tests 2

9. Peripheral Vascular Examination

• Inspect extremities for color, hair distribution, and trophic changes 4
• Palpate peripheral pulses (radial, femoral, popliteal, dorsalis pedis, posterior tibial) 4
• Assess for edema and measure capillary refill time 2
• Note temperature gradient of extremities 4

10. Genital and Rectal Examination (when indicated)

• Explicitly obtain specific consent before proceeding with sensitive examinations 5
• Ensure proper draping and privacy 5
• For male patients: examine external genitalia and perform testicular examination 2
• For female patients: perform external genital inspection and pelvic examination as indicated 2
• Perform rectal examination when clinically indicated 2

Special Considerations

• For pediatric patients, modify approach based on developmental stage and use age-appropriate techniques 4
• For elderly patients, pay special attention to functional status, balance, and cognitive assessment 4
• For patients with mobility limitations, adapt positioning as needed while maintaining thoroughness 2
• When examining sensitive areas, always have a chaperone present when appropriate 5
• Use clear, simple communication throughout the examination, explaining what you are doing 6

Documentation

• Record all findings systematically, noting both normal and abnormal results 2
• Use objective terminology and avoid subjective interpretations 3
• Document any patient discomfort or limitations during examination 2
• Summarize key findings and their clinical significance 2

Conclusion of Examination

• Thank the patient for their cooperation 1
• Assist the patient to dress if needed 2
• Summarize findings and discuss next steps 3
• Answer any questions the patient may have 1

This systematic approach ensures a thorough physical examination that can be adapted based on the patient's presenting concerns while maintaining a comprehensive evaluation of all body systems.