What are the steps to perform a physical exam?

Physical Examination: A Systematic Approach

Begin with a focused medical history including current symptoms, medications, comorbidities, and relevant risk factors, followed by a systematic head-to-toe examination that includes vital signs, inspection, palpation, percussion, and auscultation in sequence. 1

Pre-Examination Preparation

Patient Instructions

• Patients should not eat for 2-3 hours before examination 2
• Routine medications may be taken with small amounts of water 2
• Patients should wear comfortable clothing and appropriate footwear 2
• For smokers, abstain from smoking for at least 8 hours before examination 2

History Taking Components

• Document current symptoms with specific attention to onset, progression, and severity 2, 1
• Record all medications taken over the previous 2 months, including over-the-counter and complementary therapies, with dates started and stopped 2
• Obtain family history focusing on conditions predisposing to malignancies, neurologic diseases, and atherosclerotic disease 1
• Assess social history including tobacco, alcohol, and illicit drug use 1
• Document previous drug allergies with specific reaction types 2

Vital Signs and Initial Assessment

Core Measurements

• Measure and record body weight, height, blood pressure (sitting and standing), temperature, respiratory rate, and oxygen saturation 2, 1
• For suspected hypertension, use proper BP measurement techniques and consider automated oscillometric devices to minimize white coat effect 1
• Perform orthostatic vital signs when clinically indicated (failure to do so is a common pitfall) 1

Initial Observations

• Assess general appearance, level of consciousness, and signs of distress 2
• Observe respiratory pattern and effort 2
• Note any obvious deformities, asymmetry, or abnormal movements 3

Systematic Physical Examination Sequence

Head and Neck

• Examine all mucosal sites (eyes, mouth, nose, genitalia) for lesions, erosions, or inflammation 2
• Assess neck mobility and oral opening 1
• Evaluate all lymphoid regions systematically (cervical, supraclavicular, axillary, inguinal) 1
• Palpate thyroid gland 3

Cardiovascular System

• Obtain a resting supine 12-lead ECG before any exercise or stress testing 2
• Auscultate heart sounds in all positions, noting any murmurs, gallops, or extra sounds 2
• Assess jugular venous distension at 45 degrees and with abdominal pressure (hepatojugular reflux) 2
• Jugular venous distension is the most reliable sign of volume overload 2
• Palpate peripheral pulses and assess for edema 2

Respiratory System

• Evaluate upper and lower airways systematically 1
• Auscultate anterior and posterior breath sounds bilaterally 4
• Note that most patients with chronic heart failure do not have rales, even with elevated filling pressures 2
• Assess for wheezing, rales, or decreased breath sounds 2

Abdominal Examination

• Inspect for distension, masses, or visible pulsations 3
• Auscultate before palpation to avoid altering bowel sounds 3
• Palpate liver, spleen, and aorta systematically 4
• Assess for hepatomegaly, which may indicate volume overload 2
• Check for ascites if indicated 2

Musculoskeletal and Neurological

• Assess range of motion and joint stability 3
• Perform focused neurological examination based on symptoms 2
• For suspected concussion, use standardized assessment tools including cognitive testing and balance examination 2

Skin and Extremities

• Inspect all skin surfaces for lesions, target lesions, purpuric macules, blisters, or areas of epidermal detachment 2
• Document extent of any skin findings on a body map 2
• For insulin-dependent patients, examine injection sites at least annually for lipohypertrophy (palpation with lubricating gel is more sensitive than visual inspection) 2
• Assess peripheral edema in legs, presacral area, and scrotum 2
• Evaluate for signs of hypoperfusion: cool extremities, narrow pulse pressure, altered mentation 2

Volume Status Assessment

This is critically important for patients with heart failure or fluid disorders: 2

• Jugular venous distension (basal or with abdominal compression) is the most reliable indicator 2
• Most patients with peripheral edema have volume overload, though consider non-cardiac causes 2
• Absence of rales does not exclude elevated left-sided filling pressures in chronic conditions 2
• Serial body weight changes are the best indicator of short-term fluid status changes 2

Functional Assessment

Exercise Capacity

• Ask patients to describe specific activities they can no longer perform (more useful than general questions) 2
• Inquire about ability to dress, bathe, climb stairs, and perform household chores without stopping 2
• Consider direct observation during a walk around the clinic or up stairs 2
• The NYHA functional classification has significant interobserver variability 2

Special Examination Techniques

For Suspected Central Airway Obstruction

• Focus on respiratory system assessment 1
• Consider CT imaging of the chest 1

For Suspected Neck Mass

• Avoid routine antibiotic therapy unless clear signs of bacterial infection are present 1
• Order CT or MRI with contrast for masses with increased malignancy risk 1

For Lipohypertrophy Detection

• Examination is ideally performed with patient lying down and disrobed to underwear 2
• Use lubricating gel to facilitate palpation 2
• Mark extreme edges of lesions with skin-safe marker for future measurement 2
• Photograph visible lesions after obtaining consent 2

Common Pitfalls to Avoid

• Failing to measure vital signs completely (including orthostatic measurements when appropriate) 1, 4
• Inadequate inspection of skin surfaces 4
• Confusion of liver and spleen on palpation 4
• Failure to use bell of stethoscope appropriately 4
• Inadequate examination of lymph nodes (axillary and inguinal commonly missed) 4
• Relying solely on fine-needle aspiration when excisional biopsy is indicated 1
• Assuming cystic masses are benign without complete evaluation 1

Documentation and Follow-Up

• Record all findings systematically, including negative findings 2, 3
• Document a clear follow-up plan 1
• Advise patients about specific criteria that would trigger need for additional evaluation 1
• Compare current findings to previous examinations when available 2

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