History and Physical Examination: The Foundation of Patient Assessment
History and physical examination remain the cornerstone of patient assessment across all medical conditions, serving as essential tools to guide diagnosis, direct appropriate testing, identify disease-specific causes requiring targeted therapy, and optimize treatment decisions that directly impact morbidity, mortality, and quality of life. 1
Critical Functions of History and Physical Examination
Diagnostic Direction and Disease-Specific Management
A thorough history and physical examination should direct diagnostic strategies to uncover specific causes that may warrant disease-specific management, preventing unnecessary testing while identifying conditions requiring targeted interventions 1
The history and physical provide information about underlying disease causes, including inherited conditions (requiring 3-generation family history in cardiomyopathy), disease-specific therapies (such as amyloid heart disease), and reasons for acute decompensation 1
Approximately 30% of patients presenting with facial paralysis have identifiable causes other than Bell's palsy that can be detected through comprehensive history and physical examination, preventing misdiagnosis and diagnostic delay 1
Prognostic Assessment and Treatment Guidance
Vital signs and evidence of clinical congestion should be assessed at each encounter to guide overall management, including adjustment of diuretics and other medications (Class 1 recommendation) 1
Clinical congestion assessment through jugular venous distension, orthopnea, bendopnea, Valsalva maneuver response, and leg edema provides prognostic information independent of natriuretic peptides and correlates with quality of life 1
Clinical factors indicating advanced disease should be sought via history and physical examination to identify patients requiring specialized interventions before progression to extremis, when mortality risk substantially increases 1
Identification of Modifiable Risk Factors
History and physical examination identify cardiac and noncardiac disorders, lifestyle and behavioral factors, and social determinants of health that cause or accelerate disease progression 1
Complete medical history must capture all comorbidities including peripheral arterial disease, cerebrovascular disease, pulmonary disease, kidney disease, diabetes mellitus, musculoskeletal and neuromuscular disorders, and depression, as these impact treatment selection and prognosis 2
Social risk factors including problems managing day-to-day activities, not living independently, limited ability to understand treatment recommendations, advanced age, and limited healthcare access need identification 2
Essential Components by Clinical Context
Cardiovascular Assessment
Physical examination must assess cardiopulmonary systems including pulse rate and regularity, blood pressure, auscultation of heart and lungs, palpation and inspection of lower extremities for edema and arterial pulses, post-procedure wound sites, orthopedic and neuromuscular status, and cognitive function 2
Document all known diagnoses with severity assessment and impact on quality of life and functioning 2
Chronic Pain Evaluation
All patients presenting with chronic pain should have documented history and physical examination with assessment that ultimately supports a chosen treatment strategy (strong agreement from expert consensus) 1
Findings from patient history, physical examination, and diagnostic evaluation should be combined to provide the foundation for an individualized treatment plan 1
Physical examination aids in diagnosis of chronic pain disorders, and psychological evaluation helps predict treatment success 1
Cancer-Related Symptom Assessment
When fatigue is rated as moderate to severe (score 4-10 on 0-10 scale), a focused history and physical examination should be conducted, including assessment of disease status, treatment capacity to induce fatigue, and patient response 1
In-depth fatigue assessment includes onset, pattern, duration, change over time, associated or alleviating factors, and interference with function 1
Review of systems helps determine organ systems affected and directs physical evaluation and diagnostic workup 1
Neurological Presentations
For patients with numbness and tingling, detailed history focusing on distribution pattern, temporal profile, associated symptoms, and red flag features distinguishes between benign and urgent neurological conditions 3
Motor involvement (weakness) combined with paresthesias signals urgent conditions requiring immediate workup, as rapidly progressive, asymmetric, proximal, or multifocal patterns mandate urgent evaluation 3
Sensory testing using light touch, pinprick, vibration, and temperature in affected distribution identifies sensory deficits, while systematic strength testing is essential as weakness increases likelihood of abnormal electrodiagnostic findings 3
Common Pitfalls and How to Avoid Them
Medication History Accuracy
Pharmacists obtain better medication histories than physicians and reduce the rate and severity of medication errors during acute admissions, suggesting integration of pharmacy expertise into workflow 2
Evaluate risk-benefit of each drug, possible interactions and adverse effects, adherence to treatment, and unmet needs 2
Avoiding Premature Diagnostic Closure
Poor physical examination skills are a noteworthy threat to patient safety as they can lead to incorrect and missed diagnoses, causing delays in timely implementation of life-saving treatments 4
The physical examination, in addition to thorough history, helps narrow down or establish diagnosis, protecting patients from risks of unnecessary testing while remaining cost-effective 5
Timing and Frequency
Conduct medication reviews at appropriate intervals (annually minimum, more often for high-risk patients) 2
Recent evaluation (usually within 3 months) before definitive procedures establishes appropriateness of treatment by defining disease extent 1
Clinical Value Despite Technological Advances
Even in settings where evidence is lacking, such as annual physical examination of asymptomatic adults, the physical examination benefits the physician-patient relationship 6
In an era where imaging and laboratory tests are easily available but expensive and potentially invasive, skilled physical examination remains an important component of patient evaluation 6
The history and physical examination have been the foundation of medical diagnosis for centuries and are experiencing resurgence in refined form to improve diagnosis 7