What should be included in a physical exam for an adult or geriatric patient with an unknown medical history and no specific symptoms?

Physical Examination for Adults/Geriatric Patients with Unknown Medical History and No Specific Symptoms

For asymptomatic patients with unknown medical history, perform a focused cardiovascular risk assessment physical examination that includes bilateral blood pressure measurement, peripheral pulse assessment, cardiac auscultation, and basic anthropometric measurements—this approach efficiently screens for life-threatening conditions while avoiding unnecessary comprehensive examinations that provide minimal clinical value in truly asymptomatic individuals. 1

Essential Vital Signs and Anthropometric Measurements

• Measure blood pressure in both arms to identify potential subclavian artery stenosis (a difference ≥15 mmHg is highly suspicious for proximal arterial stenosis) 1, 2
• Document height, weight, BMI calculation, and waist circumference 1
• Assess orthostatic blood pressure changes, particularly important in older adults and those at risk for autonomic dysfunction 1, 2

Cardiovascular Examination

• Perform comprehensive cardiopulmonary examination including cardiac auscultation for murmurs (particularly aortic regurgitation) and irregular rhythms 3, 1
• Assess peripheral pulses in all four extremities (radial, brachial, femoral, dorsalis pedis, posterior tibial) to detect arterial perfusion differentials that may indicate peripheral arterial disease 3
• Palpate for quality of pulsation along arteries and veins, checking for segmental differences 3
• Auscultate for bruits over carotid arteries, subclavian arteries, and abdominal aorta 3
• Consider ankle-brachial index measurement for patients with cardiovascular risk factors 1

Neurological Screening

• Evaluate orientation and screen for cognitive impairment using a validated tool 1
• Assess for focal neurological deficits that might suggest prior cerebrovascular events 3
• Check pupillary responses and visual fields if any concern for vascular compromise 3

Skin and Extremity Examination

• Inspect extremities for color changes, temperature asymmetry, and signs of vascular insufficiency 3, 2
• Examine for edema, particularly in lower extremities 3
• For patients with diabetes risk factors, inspect feet for skin integrity, deformities, and perform 10-gram monofilament testing 1
• Check for signs of chronic venous insufficiency or arterial disease 3

Head and Neck Examination

• Palpate temporal arteries for tenderness (screening for giant cell arteritis in older adults) 3
• Examine thyroid gland for enlargement 3
• Assess jugular venous pressure 3

Respiratory Examination

• Auscultate lungs for wheezes, crackles, or decreased breath sounds 3
• Observe respiratory pattern and effort 3

Abdominal Examination

• Palpate for abdominal aortic aneurysm (particularly in men >65 years or those with vascular disease risk factors) 3
• Auscultate for abdominal bruits suggesting renal or mesenteric arterial stenosis 3

Critical Pitfalls to Avoid

Do not perform an exhaustive "head-to-toe" comprehensive examination on truly asymptomatic patients with no specific complaints—this approach is time-consuming, low-yield, and may lead to false-positive findings requiring unnecessary follow-up testing 4, 5. The evidence-based approach focuses examination components on detecting high-morbidity/high-mortality conditions that are: (1) common in the general population, (2) detectable by physical examination, and (3) amenable to intervention 5.

Recognize that physical examination findings must be interpreted in clinical context—isolated abnormal findings without supporting history or risk factors often represent normal variants rather than pathology 6. The purpose of screening examination is to identify red flags requiring further evaluation, not to diagnose specific conditions 7.

Prioritize cardiovascular and cerebrovascular screening in older adults, as these conditions represent the highest morbidity and mortality risk and are most amenable to preventive interventions 1, 2. Conditions like peripheral arterial disease, carotid stenosis, and abdominal aortic aneurysm are often asymptomatic until catastrophic events occur 3.