Comprehensive Physical Assessment Approach
A systematic physical assessment should follow a structured sequence beginning with vital signs and medical history, then proceeding through the traditional four pillars of inspection, palpation, percussion, and auscultation, applied in a head-to-toe manner across all organ systems. 1
Initial Assessment and History
Begin by obtaining complete vital signs including height, weight, blood pressure, temperature, heart rate, respiratory rate, and oxygen saturation 1. For suspected hypertension, use proper BP measurement techniques with automated oscillometric devices to minimize white coat effect 1.
Document a comprehensive medical history that includes:
- Current symptoms and their characteristics 1
- Past medical conditions, particularly cardiovascular disease, malignancies, and neurologic disorders 1
- Complete medication list including over-the-counter drugs 1
- Family history of hereditary conditions 1
- Social history including tobacco, alcohol, and illicit drug use 1
- Sexual history when clinically relevant, obtained in a non-judgmental manner 1
Physical Examination Technique
Apply the four traditional pillars systematically: inspection, palpation, percussion, and auscultation 2, 3. These techniques should be performed in a logical sequence across all body systems 4.
Inspection
Conduct a comprehensive visual assessment of the patient, including skin integrity, color, lesions, wounds, dressings, drains, and invasive lines 1, 5. Observe the patient's general appearance, level of distress, and ability to transfer and mobilize 5.
Palpation
Use touch to gather information about organ size, tenderness, masses, and tissue characteristics 2, 3. Key areas include:
- Pulse rate and rhythm assessment 5
- Abdominal examination for organ enlargement 4
- Lymph node evaluation in all regions (cervical, axillary, inguinal) 1, 4
- Skin assessment for pressure injury signs 5
Percussion
Strike the chest and abdomen to determine the state of underlying tissues and organ borders 2, 3. This technique helps differentiate between air-filled, fluid-filled, and solid structures 3.
Auscultation
Listen to and interpret sound transmission through the chest wall and abdomen using a stethoscope 2, 3. Ensure you use both the bell and diaphragm appropriately 4. Assess:
System-Specific Assessment Priorities
Respiratory System
Evaluate the complete respiratory system including upper and lower airways 1. Measure respiratory rate, evaluate work of breathing, and assess oxygen saturation 5. For suspected central airway obstruction, prioritize respiratory assessment and consider CT imaging 1.
Cardiovascular System
Assess circulation comprehensively by palpating pulse rate and rhythm, measuring blood pressure by auscultation, and evaluating peripheral perfusion 5. Perform orthostatic vital signs when clinically indicated 1.
Neurological System
Evaluate level of consciousness, speech quality, and pain assessment 5. Assess neck mobility and cranial nerve function when indicated 1.
Integumentary System
Inspect and palpate skin for integrity, temperature, moisture, turgor, and signs of pressure injury 5. Document any wounds, lesions, or abnormalities 1.
Emerging Fifth Pillar: Bedside Ultrasound
Consider incorporating point-of-care ultrasound (insonation) as a fifth pillar of physical examination when available 6. This technology can enhance traditional examination findings and improve diagnostic accuracy, particularly for cardiovascular and respiratory assessments 6.
Laboratory and Imaging Integration
Order appropriate laboratory tests based on clinical findings, including complete blood count, fasting blood glucose, lipid profile, serum creatinine with eGFR, electrolytes, thyroid-stimulating hormone, urinalysis, and electrocardiogram 1.
Obtain imaging studies when clinical suspicion warrants, such as CT or MRI with contrast for neck masses with increased malignancy risk, or chest CT for suspected central airway obstruction 1.
Critical Pitfalls to Avoid
- Never fail to measure complete vital signs at the beginning of every assessment 4
- Avoid confusing liver and spleen during abdominal palpation 4
- Do not skip anterior breath sound auscultation 4
- Never forget to palpate the aorta, axillary, and inguinal lymph nodes 4
- Avoid failing to use the bell of the stethoscope for low-pitched sounds 4
- Do not perform inadequate breast examinations when indicated 4
- Never skip skin inspection as a routine component 4
- Avoid relying solely on fine-needle aspiration when excisional biopsy is indicated for lymph node abnormalities 1
- Do not assume cystic neck masses are benign without complete evaluation 1
- Never fail to perform orthostatic vital signs in patients with dizziness, syncope, or volume depletion 1
Documentation and Follow-Up
Document findings systematically and establish 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.