There is no such thing as a complete physical examination

A reader writes, “Can you do a post on what procedures constitute a thorough physical, in your opinion? I haven’t had one in several years and thinking of making an appointment now. The last doctor I went to didn’t even listen to my heart or go though the motions with feeling my belly and that stuff. And of the last 3 doctors I went to, I realized they didn’t bring up my immunization records. Is this usually left for the patients to bring up on their own?”

Good question. What exactly is a physical? Does it include blood work? What about an EKG? Cardiac stress test? Is the “Executive Physical”, an orgy of “more is better” previously paid lavishly, really better than a “camp physical”?

Here’s the thing: there is no such thing as a “complete physical examination.” There are literally hundreds of different maneuvers and procedures that encompass various aspects of physical diagnosis. Performing every last one of these on even a single patient would not only take many hours, it would be a colossal waste of time.

A “physical” is a misnomer. The clinical portion of a medical workup is more correctly termed the “history and physical.” Of the two, everyone agrees that the history — information elicited from the patient, sometimes from family members or other medical records — is far more likely to yield useful information. It is the information gleaned from the history that guides the physical.

Knee pain? The history should include mechanism of injury, and physical exam should evaluate for McMurry, Lachman, and drawer signs, among other maneuvers. Bellyache? Need to know about associated symptoms such as nausea, vomiting, stool pattern, flatus, and the exam better include careful auscultation (listening) for bowel sounds and palpation (feeling) for masses, fluid, possible shifting dullness, plus eliciting any guarding or rebound, and probably a rectal exam looking for blood. It makes no sense to use a tuning fork for Rinne and Weber tests to evaluate different kinds of hearing loss on someone with heartburn. Likewise, evaluating the debilitating heel pain of plantar fasciitis does not require listening to the lungs. I trust you get the idea.

The question appears to be about the “routine physical” in the absence of any specific medical concern. A more accurate term for this is a “preventive service” visit, for which there are specific guidelines.

First and foremost, I need to make sure that there really are no medical concerns. More than once I’ve had a patient request a “complete” physical — there was something deliberate about the way they pronounced the word “complete” — when it quickly became clear that there was a concern, usually sexual or rectal, that the patient was reluctant to mention. Obviously their thought was that I would discover the problem on my own during the examination, and it would be taken care of without them having to say anything. Unfortunately, as I told these patients, it doesn’t work that way. There really is no way to bypass the history. I like to tell people that no one ever died of embarrassment, even though they may have wanted to.

Once I’m sure the patient really is healthy, we can proceed.

The mainstay of the preventive visit is still the history, though in this case it takes the form of a risk factor assessment: any family history of certain conditions (cancer, heart disease), plus lifestyle issues like smoking, diet, and exercise habits. It’s been stated that upwards of 90% of modern American ills could be prevented if no one smoked, everyone exercised regularly, avoided excessive sun exposure, and maintained an ideal body weight, a figure with which I do not disagree. Determination of the patient’s immunization status is also part and parcel of the history portion of a preventive visit.

When you stop to think about it, the whole idea of prevention is to find things that may be wrong with the patient that they can’t feel (ie, before they have symptoms), that can produce symptoms eventually, and that we can do something about to prevent that from happening. When you look at it like that, the list of possible entities is surprisingly short:

  • High blood pressure
  • High cholesterol
  • Chronic kidney failure
  • Certain cancers and pre-cancers

Although I’m sure people will think they can add to that list, the vast majority of other conditions really do present with symptoms of some kind, however subtle.

Next, as with the “sick” visit, we perform a targeted physical examination.

I would have to say that measurement of the blood pressure is perhaps the single most important component of a preventive physical. High blood pressure is not only asymptomatic, but guides me to examine the eyegrounds (the back of they eye, the retina) with my ophthalmoscope, looking for early evidence of damage from blood pressure. I make sure to listen to the carotid arteries in the neck. I’ve found bruits (a whoosh, whoosh, whoosh sound) indicative of dangerous narrowing that can presage a stroke — that are completely asymptomatic! I make it a point to listen to the heart regularly. I’ve detected murmurs, abnormal sounds between the lub and the dub, indicating damaged heart valves, and sent people to surgery before any damage occurred to the heart muscle itself. Bear in mind, though, that a targeted cardiovascular exam may not be indicated in everyone. Beyond that, everyone (including me) has their own set of standard maneuvers that constitute looking someone over briefly but thoroughly.

Other preventive care procedures such as pap tests, clinical breast examinations, mammographies, colonoscopies, PSAs and so on are recommended at specific intervals for specific ages of patients of appropriate genders. USPTF doesn’t appear to have any specific guidelines on “routine” blood testing, except for specific conditions (annual fasting blood sugars looking for diabetes in patients with a positive family history, for instance). Screening fasting cholesterol testing once every five years is probably appropriate, again, guided by family history and other factors discovered in the personal history.

So the answer to, “What constitutes a thorough physical?” is the same as the answer to a surprising number of questions I am asked: It depends.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • Matt Sutton

    I have come to find that it is really the rectogenital exam that makes a pt feel they have gotten a “complete” physical, whether they have any specific concern in that region or not. I have had a number of 25-40 year old male patients who have come to me for preventive service visits (what they call “a physical”) and I have done the cursory brief head to toe exam, but not looked under their shorts, only to have them return within a few weeks to months, again requesting “a physical.” I now make it a point to tell my male patients that I do not routinely perform genital and rectal exams for asymptomatic patients, but that I’m happy to if they would like. This seems to do the trick, and virtually everyone declines.