What are the key components of a thorough physical exam and how should it be dictated?

Physical Examination Documentation

A thorough physical examination should be systematically documented using the sequence of inspection, palpation, percussion, and auscultation, with specific attention to vital signs, organ systems, and targeted findings based on the patient's presenting symptoms and risk factors. 1

Essential Vital Signs and Measurements

• Measure blood pressure in both arms to identify subclavian artery stenosis (difference >15-20 mmHg is significant). 1
• Document pulse rate and regularity, respiratory rate, oxygen saturation, and temperature. 1
• Record height, weight, and calculate body mass index (BMI). 1
• For pediatric patients, plot measurements on WHO or CDC growth curves. 2

Systematic Head-to-Toe Examination Components

Head, Eyes, Ears, Nose, and Throat

• Assess craniofacial structure for abnormalities affecting mandible, maxilla, and nasal anatomy. 3
• Examine eyes for extraocular movements, pupillary response, and conjunctival hemorrhage. 3
• Inspect tympanic membranes and assess for unilateral serous otitis media (may suggest nasopharyngeal malignancy). 3
• Perform visual and digital examination of oral cavity, including ventral and lateral tongue surfaces and floor of mouth. 3
• Examine oropharynx with palpation of tongue base and tonsillar fossae. 3

Cardiovascular System

• Auscultate heart for rate, rhythm, murmurs, gallops, or rubs. 1
• Palpate all peripheral pulses (brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial) and grade intensity numerically: 0=absent, 1=diminished, 2=normal, 3=bounding. 1
• Auscultate abdomen and flanks for bruits indicating vascular pathology. 4

Pulmonary System

• Auscultate lungs for breath sounds, crackles, wheezes, or diminished sounds in all fields. 1
• Palpate chest for rib tenderness, crepitus, or irregularities. 3

Abdominal Examination

• Begin with inspection for distension, visible peristalsis, pulsations, skin changes, surgical scars, and asymmetry. 4
• Auscultate before palpation in all four quadrants, noting bowel sound character, frequency, and pitch. 4
• Percuss all four quadrants to detect abnormal fluid, masses, or organomegaly; assess for shifting dullness when ascites is suspected. 4
• Palpate starting away from painful areas, progressing from light to deep palpation; note aortic pulsation and maximal diameter. 4
• Assess for organomegaly, masses, distention, and tenderness. 3, 4

Musculoskeletal Examination

• Evaluate range of motion of all major joints systematically (shoulder, elbow, wrist, hip, knee, ankle). 1
• Identify joint deformities, swelling, tenderness, or instability. 1
• Test muscle strength in all extremities using standardized 0-5 grading scale. 1
• Assess muscle tone, symmetry of movement, and limb deformities consistent with fracture. 3

Neurological Examination

• Perform itemized assessment of cranial nerves: ocular motility, facial sensation and movement, hearing, palate elevation, gag reflex, vocal fold movement, tongue mobility, and shoulder elevation. 3
• Test deep tendon reflexes, including ankle reflexes bilaterally. 1
• Perform 10-gram monofilament testing for protective sensation, particularly in feet of diabetic patients. 1
• Test pinprick or temperature perception in all extremities. 1
• Assess alertness, responsiveness to sound and visual stimuli, general tone, and symmetry of reflexes and movement. 3

Skin and Extremities

• Examine skin for color, perfusion, evidence of injury (bruising or erythema), lesions, and birthmarks. 3
• Remove shoes and socks to inspect feet for color, temperature, skin integrity, ulcerations, hair loss, and atrophy of subcutaneous tissues. 3, 4
• Assess for peripheral edema in lower extremities. 3

Genitourinary and Rectal Examination

• Perform digital rectal examination when indicated for suspected lower GI pathology, constipation evaluation, or when assessing for occult blood. 4
• Assess perineal descent during simulated evacuation and elevation during squeeze in left lateral position for defecatory disorders. 4
• Observe perianal skin for fecal soiling and test anal reflex. 4

Risk-Stratified Examination Components

For Patients with Diabetes or Cardiovascular Risk Factors

• Evaluate for peripheral arterial disease: assess for intermittent claudication, cold feet, decreased or absent pulses, and hair loss. 3
• Measure toe pressures and Doppler pressures at ankle if blood flow to forefoot is questionable. 3
• Screen for retinopathy and nephropathy complications. 3

For Patients at Risk for Head and Neck Malignancy

• Perform comprehensive examination of neck mass for firmness, size, fixation, location, and presence of additional lymphadenopathy. 3
• Use bimanual palpation of floor of mouth and entire neck. 3
• Palpate parotid and submandibular glands and thyroid gland to assess for masses. 3

For Patients with Suspected Overactive Bladder

• Perform abdominal exam, rectal/genitourinary exam, and assess lower extremities for edema. 3
• Assess cognitive function and ability to dress independently (informative of motor skills related to toileting). 3

Critical Red Flags Requiring Documentation

• Screen for serious pathology including infection, malignancy, fracture, inflammatory conditions, progressive neurological deficits, and cauda equina syndrome. 1
• Document any asymmetry in movement or tone suggesting neuromotor concerns. 2
• Note loss of previously acquired skills indicating possible progressive neuromuscular disorder. 2

Documentation Structure

• Create individualized treatment plan documenting current status, rehabilitation goals, and intervention strategies. 1
• Use validated outcome measures to track progress objectively. 1
• Document findings systematically by organ system to ensure completeness. 5

Common Pitfalls to Avoid

• Do not skip auscultation before palpation in abdominal examination, as palpation can alter bowel sounds. 4
• Do not rely solely on dorsalis pedis and posterior tibial pulses to rule out ischemic changes in the forefoot; obtain toe pressures if blood flow is questionable. 3
• Do not delay surgical consultation if high clinical suspicion exists despite negative imaging. 4
• Poor physical examination skills lead to missed diagnoses and delays in life-saving treatments. 6