What is the recommended approach for a general physical examination for an adult patient?

General Physical Examination for Adults

Core Components of the Examination

The general physical examination should be systematic and comprehensive, including vital signs (blood pressure, heart rate, respiratory rate, temperature), anthropometric measurements (height, weight, waist circumference, BMI calculation), and targeted system-based assessments rather than an unfocused "complete" examination. 1, 2

Essential Vital Signs and Measurements

• Blood pressure should be measured at every visit, targeting <120/80 mmHg 1
• Body mass index (BMI) must be calculated to assess weight status, with a target <25 kg/m² 1
• Waist circumference should be recorded as part of cardiovascular risk assessment 2
• All vital signs including heart rate, respiratory rate, and temperature should be documented 2

Systematic Physical Examination Elements

Cardiovascular examination should include heart auscultation and peripheral pulse assessment 1

Head and neck examination should assess for:

• Thyroid palpation (approaching from the front, not behind, to avoid triggering trauma responses) 3
• Lymph node assessment, particularly noting nodes >1.5 cm, firm texture, reduced mobility, or matted appearance 3
• Oral cavity inspection for ulcerations or masses 3

Skin examination should screen for suspicious lesions during the cancer-related checkup 1

Testicular examination (for males) should include measurement and palpation of testes, checking for masses and varicocele 1

Abdominal examination should include inspection, palpation, and assessment for organomegaly 2

Neurological examination should include assessment of reflexes, motor movements, and gait when clinically indicated 2

History Taking Priorities

Risk Factor Assessment

Tobacco use history must be documented at every visit, including current smoking status, pack-years, and readiness to quit 1

Alcohol consumption should be quantified (drinks per week) with screening for alcohol use disorder 1

Family history should focus on premature cardiovascular disease (before age 65), diabetes, and cancers, particularly prostate cancer diagnosed before age 65 1

Sexual and Trauma History (When Relevant)

• For transgender and gender-diverse patients, include trauma-informed sexual health history, asking about prior unwanted sexual activity, genital dysphoria, and sexually transmitted infections 3
• Document an organ inventory (penis, testes, prostate, breasts, vagina, cervix, uterus, ovaries) to guide appropriate screening 3

Age-Specific Screening Recommendations

Ages 18-39

Lipid profiles should be screened every 5 years, or every 2 years if risk factors are present 1

Fasting glucose or hemoglobin A1C should be screened every 5 years, or every 2 years if BMI ≥25 kg/m² with additional risk factors 1

Ages 40-49

Prostate cancer screening discussion should begin at age 40 for men at higher risk (African American, family history), and at age 50 for average-risk men 1

Ages 50-64

Lipid profile assessment should continue per cardiovascular risk 1

Hemoglobin A1C testing should be repeated every 3 years if normal, and yearly if prediabetes (A1C 5.7-6.4%) 1

Colorectal cancer screening should not be delayed beyond age 45 1

Cancer-Related Checkup Components

The cancer-related checkup should be integrated into periodic health examinations rather than performed as a stand-alone exam. 3 This includes:

• Case-finding examinations of thyroid, testicles, ovaries, lymph nodes, oral region, and skin 3
• Discussion of self-examination techniques for skin, breast, or testicular cancer 3
• Health counseling about smoking cessation, diet, physical activity, and shared decision-making about cancer screening 3

Prostate Cancer Screening Algorithm (When Appropriate)

For men who choose screening after informed decision-making:

• Screen with PSA every 2 years if PSA <2.5 ng/mL 1
• Refer for further evaluation or biopsy if PSA ≥4.0 ng/mL 1
• Proceed to TRUS-guided 12-core biopsy if PSA >10 ng/mL 1
• Do not screen men with <10-year life expectancy, regardless of age 1

Trauma-Informed Examination Approach

For patients with history of trauma, discrimination, or gender dysphoria:

• Establish trust before performing sensitive examinations unless medically urgent 3
• Use a chaperone, asking patient preference for chaperone gender 3
• Explicitly ask permission before examination and explain each step 3
• Allow patient to guide contact (e.g., placing stethoscope on their own chest) 3
• Avoid approaching from behind (e.g., for thyroid examination) 3

Critical Pitfalls to Avoid

Do not perform PSA screening without informed decision-making, discussing overdiagnosis, false positives, and treatment complications 1

Do not delay colorectal cancer screening beyond age 45 1

Do not screen for prostate cancer in men with <10-year life expectancy, regardless of age 1

Do not perform comprehensive annual laboratory screening in asymptomatic adults without specific risk factors, as this lacks evidence of benefit 4, 5

Do not approach the examination as a "complete physical" taught in medical schools; instead, focus on evidence-based, age-appropriate, risk-stratified assessments 6, 7

Immunizations

Annual influenza vaccination should be administered to all adults 1

Tetanus-diphtheria booster should be updated every 10 years per ACIP guidelines 1