At the outset of each patient encounter, you will face the common questions, “How much should I do?” and “Should my assessment be comprehensive or focused?” For patients you are seeing for the first time in the office or hospital, you will usually choose to conduct a comprehensive assessment, which includes all the elements of the health history and the complete physical examination. In many situations, a more flexible focused or problem-oriented assessment is appropriate, particularly for patients you know well returning for routine care, or those with specific “urgent care” concerns like sore throat or knee pain. You will adjust the scope of your history and physical examination to the situation at hand, keeping several factors in mind: the magnitude and severity of the patient’s problems; the need for thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the time available. Skill in all the components of a comprehensive assessment allows you to select the elements that are most pertinent to the patient’s concerns, yet meet clinical standards for best practice and diagnostic accuracy.

As you can see, the comprehensive examination does more than assess body systems. It is a source of fundamental and personalized knowledge about the patient that strengthens the clinician–patient relationship. Most people seeking care have specific worries or symptoms. The comprehensive examination provides a more complete basis for assessing these concerns and answering patient questions.

For the focused examination, you will select the methods relevant to thorough assessment of the targeted problem. The patient’s symptoms, age, and health history help determine the scope of the focused examination, as does your knowledge of disease patterns. Of all the patients with sore throat, for example, you will need to decide who may have infectious mononucleosis and warrants careful palpation of the liver and spleen and who, by contrast, has a common cold amenable to a more focused examination of the head, neck, and lungs. 

What about the routine clinical check-up, or periodic health examination? Numerous studies have scrutinized the usefulness of the annual well-patient visit for screening and prevention of illness, in contrast to evaluation of symptoms, without coming to a clear consensus.2–10 A growing body of evidence documents the utility of many components of the physical examination, its vital role in decision making, and its potential for savings through decreased testing.11–15 Validated examination techniques include blood pressure measurement, assessment of central venous pressure from the jugular venous pulse, listening to the heart for evidence of valvular disease, detection of hepatic and splenic enlargement, and the pelvic examination with Papanicolaou (Pap) smears. Various consensus panels and expert advisory groups have further expanded recommendations for examination and screening.

What about the newer evidence about the physical examination itself and its relationship to advanced diagnostic testing? Recent studies view the physical examination findings themselves as diagnostic tests and have begun to validate their value by identifying their test characteristics using Bayes’ theorem and the evidence-based tools, Evaluating Clinical Evidence. Over time, “the rational clinical examination” is expected to improve diagnostic decision making, especially as national competencies and best teaching practices for physical examination skills become better understood. Meanwhile, the physical examination yields “the intangible benefits of more time spent … communicating with patients,”a unique therapeutic relationship, more accurate diagnoses, and more selective assessments and plans of care.

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