What is the comprehensive head-to-toe physical examination for an adult patient?

Comprehensive Head-to-Toe Physical Examination for Adult Patients

A systematic head-to-toe assessment begins with vital signs and general appearance, then proceeds through each body system using inspection, palpation, percussion, and auscultation to detect both acute illness and chronic disease.

Initial Vital Signs and Measurements

• Measure blood pressure in both arms to identify potential subclavian artery stenosis 1
• Record temperature, pulse rate, respiratory rate, and oxygen saturation 2, 1
• Calculate body mass index (BMI) from height and weight measurements 1
• Assess orthostatic vital signs (blood pressure and heart rate supine, sitting, and after 1-3 minutes of standing) when evaluating syncope, falls, or autonomic dysfunction 2, 3

Common pitfall: Orthostatic hypotension cannot be diagnosed by symptoms alone and requires actual standing blood pressure measurement 3. A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic defines orthostatic hypotension 2.

General Appearance and Mental Status

• Evaluate overall appearance, level of consciousness, and signs of acute distress 1
• Assess body habitus for wasting, obesity, or lipodystrophy 1
• Document mental status using structured assessment: level of consciousness (alert, drowsy, obtunded, coma), orientation to person/place/time, and ability to follow commands 2

Head and Neck Examination

Head

• Inspect for deformities, lesions, asymmetry, and signs of trauma (contusions, tongue lacerations suggesting seizure) 2, 1

Eyes

• Test visual acuity 1
• Examine pupillary responses to light in both bright and dim illumination 4
• Assess extraocular movements for strabismus or ocular misalignment 4
• Perform fundoscopic examination to detect papilledema, optic atrophy, or retinal changes indicating microvascular injury 2, 4

Neck

• Palpate thyroid gland for enlargement or nodules 1
• Examine for jugular venous distention indicating congestive heart failure 2
• Auscultate for carotid bruits suggesting carotid stenosis 2
• Palpate cervical lymph nodes 1

Cardiovascular Examination

• Auscultate heart sounds to identify valvular conditions, irregular rhythms, or murmurs 2
• Assess for signs of myocardial ischemia or aortic dissection 2
• Palpate peripheral pulses: femoral, popliteal, dorsalis pedis, and posterior tibial 1
• Evaluate capillary refill time, rubor on dependency, pallor on elevation, and venous filling time 1

Respiratory Examination

• Inspect chest wall movement and respiratory pattern 2
• Auscultate lung fields to identify comorbid respiratory conditions 2
• Measure pulse oximetry 2

Abdominal Examination

• Inspect, auscultate, percuss, and palpate the abdomen 2
• Assess for hepatomegaly or splenomegaly 1
• Evaluate for signs of hepatic dysfunction 2

Neurological Examination

Motor Function

• Test motor strength in upper and lower extremities using a 0-4 scale (0=no movement, 1=no effort against gravity, 2=falls before 10 seconds, 3=drift before 5 seconds, 4=no drift) 2
• Assess for limb ataxia using finger-to-nose and heel-to-shin tests 4

Sensory Function

• Test with 10-g monofilament for light touch 1
• Assess pinprick or temperature perception 1
• Perform vibration testing with 128-Hz tuning fork 1

Cranial Nerves

• Evaluate gaze (horizontal and vertical eye movements) 2
• Test visual fields for hemianopia 2
• Assess facial movement symmetry 2

Coordination and Gait

• Observe for tremor, ataxia, or abnormal movements 4

Skin and Extremities Examination

• Perform comprehensive skin inspection noting lesions, ulcerations, calluses, or wounds 1
• Examine for jaundice, purpura, or petechiae suggesting hepatic dysfunction, coagulopathies, or platelet disorders 2
• Pay particular attention to feet and pressure points in at-risk patients 1

Special Considerations for Older Adults (≥75 years)

For geriatric patients, a multidisciplinary approach incorporating assessment of frailty is particularly important 2. Evaluate for:

• Weight loss, weakness, exhaustion, reduced physical activity, and physical slowing 2
• Cognitive decline (even without formal dementia diagnosis) 2
• Polypharmacy and drug-drug interactions 2
• Amnesia related to falls or syncope 2

Critical pitfall: Approximately 30% of older adults presenting with nonaccidental falls may have had syncope, but amnesia commonly obscures the history 2.

Initial Laboratory and Diagnostic Studies

When screening for end-organ damage or establishing baseline status, consider 2, 1:

• Complete blood count
• Urinalysis (negative dipstick for protein and hematuria has 100% sensitivity for ruling out acute creatinine elevation) 2
• Serum electrolytes, blood urea nitrogen, serum creatinine
• Fasting blood glucose or glycohemoglobin
• Lipid profile
• Liver function tests
• Thyroid-stimulating hormone
• 12-lead electrocardiogram when indicated 1
• Chest radiograph when indicated 1

Important caveat: Routine chest radiographs and ECGs in asymptomatic hypertensive patients have limited utility, with only 2 of 116 patients in one study requiring therapeutic interventions based on these tests 2.

Documentation

• Record all findings systematically 1
• Document baseline clinical evaluation to enable accurate monitoring of disease evolution 5
• Provide patient education on self-examination techniques (skin checks, foot care) when appropriate 1