• Information
  1. General
  2. Vital Signs
  3. Skin
  4. Head
  5. Eyes
  6. Ear
  7. Nose
  8. Throat/Mouth
  9. Neck
  10. Chest
  11. Breasts
  12. Cardiac and Cardiovascular
  13. Abdomen
  14. Rectum / Anus
  15. Genitalia
  16. Extremities
  17. Neurologic
  18. Musculoskeletal
  19. Lymphatic

A. General

1. Overall appearance, nutritional status, weight, height
2. Communication skills, behavior, awareness, orientation, cooperation with examination
3. The periodic overall health evaluation may have benefits in specific areas, but full physical examination in persons without specific complaints of questionable value [3]

B. Vital Signs

1. Blood pressure, pulse, respiratory rate, temperature
2. Oxygen saturation where indicated

C. Skin

1. Color, integrity, texture, temperature, hydration, diaphoresis, edema
2. Lesions
3. Hair, nails

D. Head

1. Size, contour, scalp appearance, symmetry and spacing of facial features
2. Edema, puffiness, erythema, other lesions

E. Eyes

1. Appearance of orbits, conjunctivae, sclerae, eyelids, eyebrows
2. Extraocular movements (CN III, IV, VI)
3. Corneal light reflex (CN II and III)
4. Pupil shape, consensual response to light (and accommodation)
5. Visual fields (acuity optional) - CN II
6. Ophthalmoscopic findings
   1. Retina, optic disc, macula
   2. Retinal vessel size, caliber, arteriovenous crossings (optional cornea, lens findings)
7. Mnemonic: PERRLA
   1. Pupils Equal and Responsive
   2. Reactive to Light and
   3. Accomodation

F. Ear

1. Configuration, position, and alignment of auricles
2. Otoscopic findings: canals and tympanic membrane
3. Hearing Assessment: Weber and Rinne Tests
4. Weber Test
   1. Base of vibrating tuning fork on vertex midline of head
   2. Normal: hear sounds best in both ears
   3. If better in one ear, then sound is lateralized
   4. Occlude this ear with finger and repeat the test
   5. Sound lateralized to deaf ear in conductive loss, to better ear in sensorineural loss
5. Rinne Test
   1. Base of vibrating tuning fork on mastoid
   2. Time the interval until sound no longer heard
   3. Then move fork to place vibrating tines with 1-2cm of auditory canal
   4. Normally, hearing is ~2X longer with air than bone
   5. Conductive hearing loss: bone heard longer than air
   6. Sensorineural hearing loss: air is less than 2X bone

G. Nose

1. External appearance, nasal patency, discharge, crusting, flaring
2. Internal Exam: appearance of turbinates, polyps, septal alignment
3. Presence of sinus swelling or tenderness, odor discrimination

H. Throat/Mouth

1. Appearance of lips, tongue, buccal and oral mucosa
2. Condition of teeth, presence of dental appliances
3. Floor of mouth, pharynx, tonsils, hard and soft palates, uvula
4. Gag reflex, voice quality

I. Neck

1. Mobility, suppleness (range of motion), strength, trachea position
2. Thyroid size, shape, tenderness, anomalies (eg. masses)
3. Lymphadenopathy, swollen salivary glands

J. Chest

1. External Appearance
   1. Anteroposterior diameter
   2. Symmetry of movement with respiration, respiratory rate, use of accessory muscles
2. Auscultation
   1. Air movement
   2. Abnormal sounds - rales (crackles), rhonchi, wheezes, stridor, rubs

K. Breasts [1]

1. External Appearance: Symmetry, masses, scars, discharge, dimpling, erythema
2. Palpation: Tenderness, thickening, masses
3. Lymph node examination: especially axillary, supraclavicular

L. Cardiac and Cardiovascular

1. Surface location of apical impulse, rate, rhythm, amplitude
2. Contour and symmetry of apical impulse and pulse in extremities
3. Comparison between extremities
4. Findings on auscultation [2]
   1. Characteristics of S1 and splitting of S2
   2. Presence of murmurs: first listen for systolic murmers, then diastolic (usually quieter)
   3. Gallops: suspect S4 in young persons, or hypertension, or hypertrophic cardiomyopathy
   4. Suspect S3 in systolic congestive heart failure, low ejection fraction
   5. Clicks (synthetic valve), snaps (mitral valve prolapse)
   6. Cardiologists are able to detect systolic murmurs correctly about 45% of the time [2]
5. Signs of Heart Failure
   1. Jugular venous distention (JVD) - very unreliable (~50% sensitivity for severe failure) [6]
   2. Hepatojugular reflux
   3. Peripheral edema
   4. Presence of S3 gallop
   5. Overall, history, physical, ECG, and chest radiograph do not provide accurate assessment of ejection fraction in patients with CHF [4]
   6. Echocardiography is therefore recommended for ANY patient with possible CHF
6. Signs of Vascular Disease
   1. Presence of carotid, abdominal, renal, or femoral bruits
   2. Presence of carotid bruits associated with >2X risk of future myocardial infarction and 2.3X risk of cardiovascular death versus patients without carotid bruits [9]
   3. Strength of distal pulses, temperature of extremities
   4. Ankle-brachial index (ABI) is the ratio of the ankle to the brachial pressures
   5. ABI 0.91-1.3 is normal range; ABI 0.41-0.9 is mild to moderate PAD
   6. ABI correlates better with exerciser function (6 minute walking distance) than do symptoms of intermittent claudication [5]
   7. ABI <0.9 associated with overall >2X increase in cardiovascular events as well as mortality over 10 years [11]
   8. Leg ulcerations
   9. Hemosiderin deposits with discoloration - lower limbs
7. Calculating ABI
   1. Accurate arm pressures can be obtained using doppler ultrasonographic probe
   2. Determine pressures in dorsalis pedis (DP) and tibialis anterior (TA) arteries
   3. To calculate ABIs, use higher of the two arm pressures
   4. For right ABI, use higher of right leg DP or TA with higher of arm pressures
   5. For left ABI, use higher of left leg DP or TA with higher of arm pressures
   6. ABI = highest right or left leg arterial pressure ÷ highest arm pressure

M. Abdomen

1. Shape, contour, skin discolorations, visible aorta pulsations
2. SIgns of Intra-Abdominal Hemorrhage [10]
   1. Found with severe pancreatitis; rarely with ectopic pregnancy, malignancy (liver or metastases), perforated duodenal ulcer, liver abscess, splenic rupture
   2. Cullen's Sign - periumbilical blue-red hemorrhage, appears as trauma
   3. Turner's Sign - black/blue/red bruise like discoloration on abdominal skin
3. Auscultation findings (Bowel Sounds)
   1. Normal
   2. Normal pitch, hyperactive: gaseous distension, partial obstruction
   3. High pitch: partial or complete mechanical obstruction
   4. Decreased or absent: ileus (functional obstruction), peritonitis, perforation
4. Palpation findings
   1. Each of four quadrants
   2. Pelvic area
   3. Costovertebral angle
   4. Spleen - not a sensitive test in low risk patients
   5. Right upper quadrant for tenderness
   6. Positive Murphy sign - pain and arrested inspiration when examiner's fingers hooked under right costal margin during deep inspiration [7]
5. Percussion findings
   1. Liver - total span
   2. Spleen
6. The sensitivity of the physical exam for splenomegaly is poor and highly variable
7. Physical exam is insufficient for diagnosis of cholecystitis [7]
8. Opiate treatment may alter physical exam findings but no significant change in management in patients with abdominal pain [6]

N. Rectum / Anus

1. External Structures
   1. Hemorrhoids, fissures, skin tags
   2. Sphincter control: "Anal Wink" test
2. Rectal Digital Examination
   1. Rectal wall contour, tenderness, prostate size, contour and consistency
   2. Color and consistency of stool, occult blood

O. Genitalia

1. Female
   1. Appearance, pubic hair, external genitalia
   2. Palpation findings
   3. Vaginal speculum exam: appearance, lesions, discharge (Pap smear)
   4. Bimanual findings: size, tenderness of uterus, adnexa and ovaries
2. Male
   1. Appearance, circumcision status, location and size of urethral opening
   2. Discharge, lesions, pubic hair, palpation findings
   3. Scrotum: hernia, scrotal swelling, pain

P. Extremities

1. General: Temperature, color, hair distribution
2. Particular attention to lower extremities: swelling (edema), skin texture, nails, veins
3. Evaluation of Thrombosis
   1. Tenderness
   2. Erythema
   3. Cord
   4. Homans' sign
4. Pulses
   1. Radial pulse, (brachial pulse)
   2. Femoral, Dorsalis pedis and posterior tibial pulses, (Popliteal Pulse)
   3. ABI (see above) - to detect peripheral arterial disease (PAD)
   4. ABI <0.9 associated with overall >2X increase in cardiovascular events as well as mortality over 10 years [11]

Q. Neurologic

1. Cranial Nerves (findings for each or specify those tested)
2. Cerebellar and motor function (gait, balance, coordination)
3. Sensory function and symmetry
4. Deep tendon reflexes (symmetry and grade)
5. Mental status (thought processes, cognitive function, speech and language)

R. Musculoskeletal

1. Alignment of extremities and spine, symmetry of body parts
2. Muscle strength
3. Joints
   1. Joint appearance, deformities
   2. Range of motion passive and active, presence of pain, tenderness, crepitus

S. Lymphatic

1. Size, shape, tenderness, discreetness, mobility
2. Presence in neck, epitrochlear, axillary, or inguinal areas

References

1. Barton MB, Harris R, Fletcher SW. 1999. JAMA. 282(13):1270
2. Etchells E, Bell C, Robb K. 1997. JAMA. 277(7):564
3. Bouware LE, Marinopoulos S, Phillips KA, et al. 2007. Ann Intern Med. 146(4):289
4. Thomas JT, Kelly RF, Thomas SJ, et al. 2002. Am J Med. 112(6):437
5. McDermott MM, Greenland P, Liu K, et al. 2002. Ann Intern Med. 136(12):873
6. Cook DJ and Simel DI. 1996. JAMA. 275:630
7. Trowbridge RL, Rutkowski NK, Shojania KG. 2003. JAMA. 289(1):80
8. Ranji SR, Goldman LE, Simel DL, Shojania KG. 2006. JAMA. 296(14):1762
9. Pickett CA, Jackson JL, Hemann BA, Atwood JE. 2008. Lancet. 371(9624):1587
10. Chauhan s, Gupta M, Sachdev A, et al. 2008. Lancet. 372(9632):54
11. Ankle Brachial Index Collaboration. 2008. JAMA. 300(2):197