What are the essential components of a complete physical examination?

Complete Physical Examination Guide

Essential Patient History Components

A comprehensive physical examination must begin with systematic collection of demographic data, chief complaint, detailed present illness history, and complete medical, family, and social histories. 1

Demographic and Current Health Information

• Document patient name, date of birth, gender, and ethnicity 1
• Record the patient's primary concern and their self-evaluation of current health status 1
• Obtain detailed history of present illness with onset, duration, severity, and associated symptoms 2

Past Medical History

• Document all past medical conditions and chronic diseases 1
• Record previous surgeries and hospitalizations with dates 1
• List all current medications including dosages and frequency 1
• Document all known allergies and adverse drug reactions 1

Family History

• Identify familial diseases with genetic predisposition, particularly cardiovascular disease, diabetes, and cancer 1
• Specifically ask about family history of sudden death, especially in cardiovascular evaluation 3
• Document family history of abdominal aortic aneurysm (AAA) 3

Social History

• Assess occupation and occupational exposures 1
• Document tobacco use (cigarettes per day and years smoked, as smoking increases peripheral arterial disease risk 2-6 fold) 3
• Record alcohol consumption patterns 1
• Assess for illicit drug use 1
• Document family and living situation 1
• Obtain sexual history when relevant 1

Symptom-Specific History

For patients with suspected vascular disease, inquire about:

• Exertional limitation of lower extremity muscles (fatigue, aching, numbness, or pain in buttock, thigh, calf, or foot) 3
• Poorly healing or nonhealing wounds of legs or feet 3
• Pain at rest in lower leg or foot and its relation to position 3
• Postprandial abdominal pain associated with eating and weight loss 3

For hypertensive patients, ask about:

• Chest pain, shortness of breath, palpitations, claudication, peripheral edema 3
• Headaches, blurred vision, nocturia, hematuria, dizziness 3
• Muscle weakness, tetany, cramps, arrhythmias (suggesting hypokalemia/primary aldosteronism) 3
• Sweating, palpitations, frequent headaches (suggesting pheochromocytoma) 3
• Snoring and daytime sleepiness (suggesting obstructive sleep apnea) 3

Vital Signs and General Appearance

• Measure blood pressure in both arms using Goldmann applanation method when possible 3
• Record pulse rate, rhythm, and character 3
• Document respiratory rate and pattern 1
• Measure temperature 1
• Calculate body mass index (BMI) and waist circumference 3
• Assess general appearance for signs of distress or chronic illness 1

Head, Eyes, Ears, Nose, and Throat Examination

Head and Neck

• Inspect neck for visible thyroid enlargement, asymmetry, or nodules 4
• Note any surgical scars from previous procedures 4
• Measure neck circumference (>40 cm suggests obstructive sleep apnea) 3
• Palpate thyroid gland with neck slightly extended, assessing for symmetry, nodules, and fixation 4
• Examine for enlarged thyroid suggesting thyroid disease 3

Eyes

• Assess pupil size, shape, and reactivity 3
• Check for relative afferent pupillary defect 3
• Perform fundoscopy to detect retinal changes, hemorrhages, papilledema, arteriovenous nicking 3
• Evaluate for corneal edema, conjunctival hyperemia, and iris abnormalities 3
• Perform gonioscopy when angle closure is suspected 3

Mouth and Throat

• Examine oral cavity for dental caries, tooth eruption pattern, and oral hygiene 5
• Inspect for lesions, particularly in patients with alcohol use history 3

Cardiovascular Examination

The cardiovascular examination must include systematic assessment of jugular venous pressure, precordial palpation, auscultation, and comprehensive peripheral vascular evaluation. 3

Central Cardiovascular Assessment

• Assess jugular venous pulse and pressure 3
• Palpate apex beat and note point of maximal impulse 3
• Auscultate for heart sounds, noting intensity and any extra sounds 3
• Listen for murmurs, documenting intensity and location 3

Peripheral Vascular Examination

• Palpate pulses at brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial sites 3
• Grade pulse intensity numerically: 0 (absent), 1 (diminished), 2 (normal), 3 (bounding) 3
• Perform Allen's test when knowledge of hand perfusion is needed 3
• Auscultate femoral arteries for bruits 3
• Listen for carotid, abdominal, and femoral bruits 3
• Check for radio-femoral delay 3

Lower Extremity Vascular Assessment

• Remove shoes and socks completely 3
• Inspect feet for color, temperature, and skin integrity 3
• Evaluate intertriginous areas for breakdown 3
• Document presence of ulcerations 3
• Look for distal hair loss, trophic skin changes, and hypertrophic nails (suggesting severe peripheral arterial disease) 3

Respiratory Examination

• Assess diaphragmatic excursion 3
• Evaluate inspiratory effort 3
• Auscultate for clarity of breath sounds 3
• Listen for basal crackles suggesting heart failure 3

Abdominal Examination

Inspection and Palpation

• Palpate abdomen for aortic pulsation and measure maximal diameter 3
• Assess for enlarged kidneys 3
• Evaluate for tenderness, masses, or organomegaly 1

Auscultation

• Auscultate abdomen and flanks for bruits 3
• Listen specifically for renal artery bruits 3

Rectal and Pelvic Examination

Digital Rectal Examination (for constipation evaluation)

• Position patient in left lateral position with buttocks separated 3
• Observe perineal descent during simulated evacuation and elevation during squeeze 3
• Examine perianal skin for fecal soiling 3
• Test anal reflex with light pinprick or scratch 3
• Observe anal verge during simulated defecation for patulous opening or mucosal prolapse 3
• Assess resting sphincter tone and augmentation with squeezing effort 3
• Palpate puborectalis muscle for contraction during squeeze 3
• Check for acute localized tenderness along puborectalis (levator ani syndrome) 3
• Instruct patient to "expel my finger" to assess expulsionary forces 3
• Evaluate for rectocele or consider gynecologic consultation 3

Skin Examination

• Inspect skin for lesions, birthmarks, or signs of abuse 5
• Look for acne, balding, or signs of androgen excess 3
• Examine for acanthosis nigricans (suggesting insulin resistance, or rarely insulinoma or gastric adenocarcinoma) 3
• Check for fatty deposits and colored striae (suggesting Cushing disease/syndrome) 3
• Assess for peripheral edema 3

Musculoskeletal Examination

• Observe muscle tone, strength, and symmetry of movement 5
• Assess for any focal deficits or asymmetries 5
• Evaluate gait and mobility 1

Neurological Examination

• Perform cranial nerve examination 3
• Assess global sensory and motor function 3
• Check for relative afferent pupillary defect 3
• Evaluate for any focal neurological deficits 5

Special Population Considerations

Diabetic Patients

• Perform comprehensive foot examination 1
• Screen for diabetic retinopathy 1
• Assess for signs of neuropathy and nephropathy 1
• Evaluate for cardiovascular complications 1

Elderly Patients

• Assess functional and cognitive performance 1
• Evaluate for frailty and fall risk 1
• Determine need for assistive devices 1
• Consider mental status examination as routine 6

Pediatric Patients (24-month example)

• Measure and plot height, weight, and head circumference on growth curves 5
• Perform fundoscopic examination or red reflex testing 5
• Assess developmental milestones using validated screening tools 5

Laboratory and Diagnostic Testing

Order laboratory tests based on history and examination findings rather than routinely, prioritizing tests that will change management. 1

Basic Screening Tests

• Complete blood count 3
• Serum sodium, potassium, creatinine, and estimated glomerular filtration rate 3
• Fasting glucose and lipid profile when available 3
• Thyroid-stimulating hormone (TSH) for suspected thyroid disease 3
• Dipstick urinalysis 3
• 12-lead ECG for detection of atrial fibrillation, left ventricular hypertrophy, or ischemic heart disease 3

Condition-Specific Testing

• Two-hour oral glucose tolerance test for diabetes screening in high-risk patients 3
• Prolactin level for hyperprolactinemia 3
• Total or free testosterone for suspected hyperandrogenism 3
• Ankle-brachial index for peripheral arterial disease 3

Common Pitfalls to Avoid

• Do not rely solely on pulse examination for vascular assessment, as it has limited sensitivity and specificity and must be supplemented by objective vascular testing 3
• Do not assume a normal digital rectal examination excludes pelvic floor dysfunction in patients with constipation 3
• Do not measure central corneal thickness during acute angle-closure crisis; postpone until resolution 3
• Do not forget to remove shoes and socks completely when examining for peripheral arterial disease 3
• Remember that after complete bowel purge, it takes several days for normal fecal mass to form, which may confuse constipation assessment 3
• Always inquire about medications with constipation as side effect (opiates, anticholinergics, calcium channel blockers) 3