What should be included in a comprehensive physical exam description?

Comprehensive Physical Examination Description

A comprehensive physical examination should systematically assess vital signs, general appearance, and all major organ systems with specific attention to findings that may indicate serious underlying pathology or guide management decisions.

Essential Vital Signs and Measurements

• Measure and document temperature, pulse, respiratory rate, blood pressure, oxygen saturation, height, and weight at every comprehensive examination 1.
• Obtain orthostatic vital signs (blood pressure and pulse) when evaluating patients with suspected autonomic dysfunction, dehydration, or unexplained symptoms like dizziness 1.
• Calculate and document BMI (or age-appropriate percentiles in children) as part of the baseline assessment 1, 2.

General Appearance and Body Habitus

• Assess overall appearance including level of consciousness, age-appropriate responsiveness to environment, and signs of acute distress 1.
• Evaluate for evidence of wasting, obesity, lipodystrophy, or dysmorphic features that may suggest underlying metabolic, endocrine, or genetic conditions 1, 2.
• Observe for signs of frailty and assess ambulatory ability in appropriate patient populations 1.

Skin Examination

• Inspect all skin surfaces for color, perfusion, rashes, lesions, bruising, or evidence of injury 1.
• Look specifically for acanthosis nigricans, seborrheic dermatitis, psoriasis, folliculitis, onychomycosis, molluscum contagiosum, Kaposi sarcoma, herpes simplex or zoster, and signs of injection site complications in relevant patient populations 1.
• Examine for petechiae, purpura, ecchymoses, or subcutaneous nodules that may indicate systemic disease 1.

Head, Eyes, Ears, Nose, and Throat (HEENT)

• Examine head shape, fontanelles (in infants), and palpate for masses or evidence of trauma 1, 2.
• Perform fundoscopic examination or assess red reflex to screen for retinal abnormalities, cotton wool spots, hemorrhages, or signs of increased intracranial pressure 1, 2.
• Evaluate pupillary response to light and extraocular movements 1.
• Inspect conjunctiva for hemorrhage, pallor, or icterus 1.
• Examine tympanic membranes for signs of infection or effusion 1.
• Assess nasal passages for congestion, blood, or obstruction 1.
• Thoroughly examine the oral cavity for candidiasis (thrush, palatal erythema, angular cheilosis), oral hairy leukoplakia, aphthous ulcers, gingivitis, periodontal disease, dental caries, tooth eruption pattern, Kaposi sarcoma, torn frenulum, and tonsillar or parotid gland enlargement 1, 2.

Neck Examination

• Palpate thyroid gland for enlargement or nodules 1.
• Assess neck mobility and range of motion 1.
• Examine for jugular venous distention as an indicator of volume status or cardiac function 1.

Lymphatic System

• Palpate all major lymph node regions including cervical, supraclavicular, axillary, and inguinal areas for enlargement, tenderness, or abnormal characteristics 1.

Cardiovascular Examination

• Auscultate heart for rhythm, rate, murmurs, gallops, and rubs 1.
• Palpate peripheral pulses (including pedal pulses) and assess for symmetry and quality 1.
• Evaluate for peripheral edema in lower extremities 1.

Pulmonary Examination

• Auscultate all lung fields for breath sounds, wheezes, crackles, or decreased air entry 1.
• Assess respiratory effort and pattern 1.

Abdominal Examination

• Inspect abdomen for distention, masses, or visible abnormalities 1.
• Auscultate for bowel sounds before palpation 3.
• Palpate for hepatomegaly, splenomegaly, masses, or tenderness 1.
• Assess for organomegaly and abnormal pulsations 1.

Breast Examination

• Examine breasts for masses, asymmetry, skin changes, or nipple discharge when clinically indicated 1.

Genitourinary Examination

• Inspect external genitalia for ulcers, warts, chancres, rashes, discharge, or abnormalities 1.
• Perform gynecologic examination when indicated 1.
• Assess for varicocele in males when evaluating abdominal or flank complaints 1.

Musculoskeletal Examination

• Palpate chest wall for rib tenderness, crepitus, or irregularities 1.
• Examine extremities for deformities, injuries, or signs of fracture 1.
• Assess joint range of motion and stability when relevant 1.

Neurological Examination

• Assess alertness, responsiveness, and mental status 1.
• Evaluate muscle tone, strength, and symmetry of movement 1, 2.
• Test sensory function including vibration, pinprick, and temperature sensation 1.
• Perform 10-gram monofilament examination in patients with diabetes 1.
• Assess deep tendon reflexes for symmetry 1.
• Evaluate cranial nerve function including response to sound and visual stimuli 1.
• Screen for focal neurological deficits or asymmetries that may indicate central nervous system pathology 1, 2.

Specialized Examinations Based on Clinical Context

Airway Assessment (Pre-Procedural Sedation)

• Evaluate airway anatomy including obesity, short thick neck, cervical spine disease, decreased hyoid-mental distance, and structural abnormalities of mouth, jaw, and oral cavity 1.
• Assess Mallampati score to predict difficult intubation by evaluating visualization of faucial pillars and uvula on maximal mouth opening 1.

Comprehensive Foot Examination (Diabetes)

• Perform visual inspection for skin integrity, callous formation, foot deformity, ulcers, and toenail abnormalities 1.
• Assess pedal pulses and consider ankle-brachial index if diminished 1.
• Test temperature sensation, vibration, pinprick, and 10-gram monofilament 1.

Dermatologic Assessment (Immune-Related Adverse Events)

• Conduct full skin examination of all surfaces and mucous membranes including eyes, nares, oropharynx, genitals, and perianal area 1.
• Assess for pustules, blisters, erosions, and areas of dusky erythema that may be painful to palpation 1.
• Evaluate for facial or distal-extremity swelling and lymphadenopathy 1.

Common Pitfalls to Avoid

• Never assume orthostatic hypotension is absent without measuring standing blood pressure, as symptoms alone are unreliable 4.
• Do not skip the fundoscopic examination, as it provides critical information about systemic disease and increased intracranial pressure 1, 2.
• Avoid performing only a focused examination when a comprehensive assessment is indicated, as this may miss important findings in asymptomatic organ systems 1, 5.
• Do not neglect to examine all mucous membranes when evaluating skin complaints, as mucosal involvement significantly changes management 1.