What is involved in a comprehensive physical exam?

Components of a Comprehensive Physical Examination

A comprehensive physical examination should include a thorough history, complete physical assessment, and appropriate laboratory testing tailored to the patient's age, risk factors, and presenting concerns. 1

History Taking Components

• Begin with a detailed medical history including current symptoms, past medical conditions, surgical history, medications, allergies, and previous therapies 1, 2
• Document a comprehensive 3-generation family history to identify relatives with genetic conditions or patterns of disease 1
• Obtain a complete social history including tobacco, alcohol, and substance use 2
• Assess functional capacity, exercise habits, sleep patterns, and dietary habits 1
• Document psychosocial factors including mental health history, stress levels, and social support systems 1
• Review all current medications including prescription, over-the-counter, and supplements 1

Physical Examination Sequence

Vital Signs

• Measure complete vital signs: height, weight, BMI, blood pressure, temperature, heart rate, respiratory rate, and oxygen saturation 1, 3
• Consider orthostatic vital signs when indicated (blood pressure and pulse measurements lying, sitting, and standing) 1

General Assessment

• Evaluate overall appearance, level of consciousness, and apparent distress 3
• Assess body habitus, looking for evidence of wasting, obesity, or abnormal fat distribution 3

Head and Neck Examination

• Inspect head for deformities, lesions, and symmetry 3
• Examine eyes including visual acuity, extraocular movements, and fundoscopic examination 1
• Assess ears for hearing acuity and examine ear canals and tympanic membranes 2
• Examine nose and sinuses for patency and discharge 2
• Inspect oral cavity including teeth, gums, tongue, and pharynx 2
• Palpate thyroid and lymph nodes in the neck 1, 3

Cardiopulmonary Assessment

• Auscultate lungs for breath sounds, crackles, wheezes, or rubs 3
• Inspect chest wall for symmetry of movement and use of accessory muscles 3
• Auscultate heart for rate, rhythm, and presence of murmurs, gallops, or rubs 3
• Assess jugular venous pressure and carotid arteries 3

Abdominal Assessment

• Inspect for distension, visible peristalsis, or pulsations 3
• Auscultate for bowel sounds and bruits 3
• Palpate for tenderness, masses, organomegaly, or pulsatile masses 3
• Assess for rebound tenderness and guarding 2

Musculoskeletal Assessment

• Evaluate range of motion of major joints 3
• Test muscle strength in all extremities 3
• Assess for joint deformities, swelling, or tenderness 3
• Evaluate gait and balance 3

Neurological Assessment

• Evaluate mental status and cognitive function 3
• Assess cranial nerves 2
• Test sensory function using light touch, pinprick, temperature perception, and vibration testing 3
• Evaluate deep tendon reflexes 3
• Assess coordination, gait, and balance 3

Skin Assessment

• Inspect skin for integrity, color, moisture, temperature, and turgor 3
• Identify any lesions, ulcerations, or wounds 3
• Pay particular attention to high-risk areas such as pressure points 3

Special Considerations for Specific Populations

For Patients with Diabetes

• Perform comprehensive foot examination including skin integrity assessment, foot deformity evaluation, neurological assessment with the 10-g monofilament, and vascular assessment 1, 3
• Screen for complications including retinopathy, nephropathy, and neuropathy 1
• Monitor blood pressure and lipid profiles more frequently 1

For Patients with Cardiovascular Risk

• Include more detailed cardiovascular assessment with attention to peripheral pulses, bruits, and signs of heart failure 3
• Consider ECG for baseline assessment 1

For Patients with Eating Disorders

• Include detailed weight history, patterns of eating behaviors, and compensatory behaviors 1
• Assess vital signs with attention to orthostatic changes 1
• Perform comprehensive review of systems to identify complications 1

Laboratory and Diagnostic Testing

• Basic laboratory testing should include complete blood count, comprehensive metabolic panel, lipid profile, and urinalysis for most adults 1, 2
• Consider thyroid function tests, especially in patients with risk factors 1
• For patients with diabetes, include A1C, lipid profile, liver function tests, and urinary albumin-to-creatinine ratio 1
• ECG is recommended for patients with cardiovascular risk factors or symptoms 1
• Additional testing should be guided by specific symptoms, risk factors, and findings on physical examination 2, 4

Documentation and Follow-Up Planning

• Document all findings thoroughly, noting both normal and abnormal results 5
• Create a clear follow-up plan with specific timeframes based on findings 2
• Provide patient education on self-examination techniques when appropriate 1
• Establish appropriate referrals to specialists based on findings 1

Common Pitfalls to Avoid

• Failing to perform orthostatic vital sign measurements in appropriate patients 2
• Relying solely on laboratory tests without thorough physical examination 4, 5
• Overlooking the importance of the review of systems, which has been shown to have higher therapeutic yield (7%) than many routine laboratory tests 5
• Neglecting to examine areas that may reveal important findings, such as the fundoscopic examination or comprehensive foot examination in diabetic patients 1, 3

Remember that the physical examination remains a valuable diagnostic tool that can often establish a diagnosis without the need for expensive or invasive testing 4, 5.