Complete Physical Examination Guide
A complete physical examination should systematically assess vital signs, all major organ systems, and functional status through inspection, palpation, percussion, and auscultation, with the specific components tailored to the clinical context while maintaining a structured head-to-toe approach. 1, 2
Essential Pre-Examination Components
Patient History Collection
- Document demographic data: name, date of birth, gender, ethnicity 1
- Chief complaint and present illness: patient's primary concern with detailed chronology 1
- Past medical history: previous conditions, surgeries, hospitalizations 1
- Medications and allergies: current prescriptions, over-the-counter drugs, adverse reactions 1
- Family history: diseases with genetic predisposition, particularly cardiovascular disease, diabetes, cancer 1
- Social history: occupation, tobacco/alcohol/drug use, sexual history, living situation 1
- Review of systems: systematic inquiry about symptoms in all body systems not covered in chief complaint 1
The history and physical examination remain the primary assessment methods and should guide diagnostic testing selection, not be replaced by it. 3, 4, 5
Vital Signs and Anthropometrics
- Blood pressure: measure in both arms (difference >15-20 mmHg suggests subclavian stenosis) 2
- Pulse: rate, rhythm, regularity 2
- Respiratory rate and oxygen saturation 2
- Temperature 2
- Height and weight: calculate BMI 2
Systematic Physical Examination by Region
General Appearance
- Overall assessment: body habitus, nutritional status, distress level, hygiene 1
- Skin examination: lesions, rashes, pigmentation changes, signs of systemic disease 1
Head, Eyes, Ears, Nose, Throat (HEENT)
- Eyes: visual acuity, pupil reactivity, extraocular movements, fundoscopic examination 3, 1
- Confrontation visual fields 3
- Slit-lamp examination when indicated for anterior segment pathology 3
- Mouth and throat: dentition, oral mucosa, pharynx, tonsils 1
Neck
- Lymph nodes: cervical, supraclavicular, submandibular chains 1
- Thyroid: size, nodules, tenderness 1
- Carotid pulses: presence, bruits 1
Cardiovascular System
- Auscultation: heart rate, rhythm, murmurs, gallops, rubs at all valve areas 2
- Peripheral pulses: palpate and grade brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial 2
- Pulse grading scale: 0=absent, 1=diminished, 2=normal, 3=bounding 2
- Peripheral edema: presence and severity 1
Respiratory System
- Inspection: respiratory effort, use of accessory muscles, chest wall symmetry 1
- Auscultation: breath sounds, crackles, wheezes, diminished sounds in all lung fields 2
- Percussion: resonance, dullness 1
Abdominal Examination
- Inspection: contour, scars, distension 1
- Auscultation: bowel sounds (before palpation) 1
- Palpation: tenderness, masses, organomegaly, guarding, rebound 1
- Percussion: tympany, shifting dullness 1
Musculoskeletal System
- Range of motion: all major joints (shoulder, elbow, wrist, hip, knee, ankle) 2
- Joint examination: deformities, swelling, tenderness, instability 2
- Muscle strength testing: all extremities using 0-5 grading scale 2
- Gait and balance assessment 2
Neurological Examination
- Mental status: orientation, memory, attention 1
- Cranial nerves: systematic testing of CN II-XII 1
- Motor examination: tone, strength, coordination 2
- Sensory examination:
- Deep tendon reflexes: biceps, triceps, brachioradialis, patellar, ankle 2
- Pathological reflexes: Babinski sign 1
Genitourinary Examination
Specialized Examination Components
Rectal Examination (When Indicated)
For constipation evaluation, the digital rectal examination must assess: 3
- Perianal inspection: descent during simulated defecation, anal reflex, soiling 3
- Anal tone: resting and squeeze augmentation 3
- Puborectalis muscle: contraction during squeeze 3
- Expulsionary effort: "expel my finger" maneuver 3
- Structural abnormalities: rectocele, prolapse 3
Ophthalmologic Assessment (Glaucoma Suspect)
- Intraocular pressure: Goldmann applanation tonometry before gonioscopy or dilation 3
- Gonioscopy: angle assessment 3
- Central corneal thickness determination 3
- Optic nerve head and retinal nerve fiber layer evaluation 3
Male Infertility Evaluation
All infertile men require physical examination including: 3
- Reproductive organ assessment: testicular size, consistency, masses 3
- Varicocele examination: standing and supine 3
- Secondary sexual characteristics 3
Critical Clinical Pearls
Pulse Oximetry Limitations
If using pulse oximetry, recognize these limitations: 3
- Patient factors: skin pigmentation (may overestimate saturation in darker skin), nail polish, perfusion, cardiac output 3
- Device factors: battery level, calibration, size/orientation 3
- Environmental factors: temperature extremes, movement, external light 3
- Black patients have 3 times higher frequency of missed hypoxemia compared to White patients 3
Red Flags Requiring Urgent Evaluation
- Progressive neurological deficits 2
- Cauda equina syndrome signs 2
- Infection, malignancy, fracture indicators 2
- Loss of previously acquired developmental skills (pediatric) 6
Documentation Requirements
- Create individualized assessment documenting current status and findings 2
- Use validated outcome measures when applicable 2
- Record time of day for IOP measurements to assess diurnal variation 3
Age-Specific Considerations
Pediatric (24-Month Well-Child Example)
- Growth parameters: height, weight, head circumference on WHO/CDC curves 6
- Developmental screening: validated tools (ASQ, PEDS, M-CHAT) 6
- Red reflex testing: screen for retinoblastoma 6
- Dental examination: caries, eruption pattern 6
Elderly Patients
- Functional assessment: activities of daily living, instrumental ADLs 1
- Cognitive screening 1
- Fall risk assessment 1
- Frailty evaluation 1
A normal physical examination does not exclude significant pathology—clinical suspicion based on history should guide further diagnostic evaluation. 3, 4