What is the recommended approach to a physical exam?

Recommended Approach to a Physical Examination

A comprehensive physical examination should include a thorough history and focused examination of the respiratory system, vital signs assessment, and evaluation of all body systems with special attention to areas of concern based on the patient's presentation. 1

History Taking Components

• Begin with a detailed medical history including symptoms, comorbid conditions, medications, and previous therapies 1
• Document family medical history, especially conditions that might predispose to malignancies, neurologic diseases, and atherosclerotic disease 1
• Obtain a comprehensive social history including tobacco, alcohol, and illicit drug use 1
• Assess sexual history in an open, non-judgmental manner, including partners, practices, and risk behaviors 1
• Document housing situation, employment status, and support systems 1

Physical Examination Sequence

Initial Assessment

• Measure complete vital signs including height, weight, blood pressure (seated and standing to assess for orthostatic changes), temperature, and respiratory rate 1
• For patients with suspected hypertension, follow proper BP measurement techniques and consider automated oscillometric devices to minimize white coat effect 1
• For children under 3 years, measure and plot head circumference against standard growth curves 1

Systematic Examination Approach

1. Respiratory System Assessment (priority focus per CHEST guidelines)

   • Comprehensive evaluation of upper and lower airways 1
   • Assessment of thyromental distance (normal > three finger breadths) 1
   • Evaluation of neck mobility and oral opening 1

2. Head and Neck Examination

   • Funduscopic examination (refer to ophthalmologist for dilated exam if advanced disease or ocular symptoms) 1
   • Careful examination of oropharynx for evidence of candidiasis, leukoplakia, or other lesions 1
   • Neck mass evaluation for fixation, consistency, size >1.5 cm, and overlying skin ulceration 1

3. Cardiopulmonary Examination

   • Comprehensive cardiopulmonary assessment including evaluation for peripheral vascular disease 1
   • Assessment for central obesity, facial rounding, and other signs of endocrine disorders 1

4. Abdominal Examination

   • Evaluation for hepatomegaly, splenomegaly, and masses 1
   • Assessment of body habitus for evidence of lipodystrophy in patients on certain medications 1

5. Skin Examination

   • Inspection for seborrheic dermatitis, malignancies, folliculitis, fungal infections, and other dermatologic conditions 1

6. Neurological Examination

   • Consider neurology referral for assessment of neurocognitive disorders when indicated 1

7. Lymph Node Examination

   • Evaluation of all lymphoid regions 1
   • Assessment of localized lymphadenopathy which may require further evaluation 1

8. Anogenital Examination

   • Careful examination for evidence of malignancy or sexually transmitted infections 1
   • For women, include breast palpation and pelvic examination 1

Special Considerations

• For patients with suspected central airway obstruction, focus on respiratory system assessment and consider CT imaging 1
• For patients with suspected neck mass, avoid routine antibiotic therapy unless clear signs of bacterial infection are present 1
• For patients with suspected anorectal foreign bodies, perform digital rectal examination carefully and consider imaging before examination 1
• For patients with suspected hypertension, include laboratory tests such as fasting blood glucose, complete blood count, lipid profile, and renal function tests 1

Imaging and Laboratory Testing

• Order appropriate imaging based on clinical suspicion:

  • For neck masses with increased risk of malignancy, order CT or MRI with contrast 1
  • For suspected central airway obstruction, obtain CT scan of the chest 1
  • For suspected anorectal foreign bodies, obtain plain X-ray films of chest, abdomen, and pelvis 1

• Basic laboratory testing should include:

  • Complete blood count, fasting blood glucose, lipid profile 1
  • Serum creatinine with eGFR, electrolytes 1
  • Thyroid-stimulating hormone 1
  • Urinalysis 1
  • Electrocardiogram 1

Follow-Up Planning

• Document a clear follow-up plan to assess resolution or establish final diagnosis 1
• Advise patients about specific criteria that would trigger the need for additional evaluation 1
• For patients with high-risk findings, explain the significance and recommended diagnostic tests 1

Common Pitfalls to Avoid

• Relying solely on fine-needle aspiration for diagnosis of lymph node abnormalities when excisional biopsy is indicated 1
• Assuming a cystic neck mass is benign without complete evaluation 1
• Prescribing antibiotics for neck masses without clear signs of bacterial infection 1
• Delaying surgical treatment for unstable patients to perform imaging studies 1
• Failing to perform orthostatic vital sign measurements in appropriate patients 1
• Overlooking the importance of physical examination in the era of advanced imaging and laboratory testing 2, 3