History and Physical
Examination of the Older Adult
Noel A. DeBacker, M.D., F.A.C.P.
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The history and physical
examination is the foundation of the medical treatment plan. The
interplay between the physiology of aging and pathologic conditions
more common in the aged complicates and delays diagnosis and appropriate
intervention, often with disastrous consequences. This chapter
assumes that practitioners will perform the thorough history and
physical examination that is expected of an excellent general
internist. It highlights the special considerations required for
the older adult.
The history may take
more time because of sensory or cognitive impairment or simply
because an older patient has had time to accrue numerous details.
Several sessions may be required.
The patient should be
recognized as the primary source of information. If doubts arise
about accuracy, other sources should be contacted with due respect
paid to the sensitivities and confidentiality of the patient.
When interviewing the patient and caregiver together, ask questions
first to the patient, then to the caregiver.
If the patient's responses
to initial questions are clearly inappropriate, turn to the mental
status exam immediately.
The patient should be
dressed and seated. The physician should also be seated and facing
the patient at eye level, speaking clearly with good lip movement.
If the patient is severely hearing impaired and an amplifier
is not available, write questions in large print.
Use honorifics (i.e., Mr., Mrs., Miss, or Ms.) unless the patient
specifically requests you to do otherwise.
Areas requiring special
- Function--(see Functional Status Assessment) Pay attention
to deficits in basic and instrumental activities of daily
living (ADL). Prepare to assess those systems in the physical
examination, looking for reversible conditions that could upgrade
function, e.g., treatment of arthritis to improve dressing capability.
- Medications--(see Pharmacotherapy). Polypharmacy and excessive
dosages are common causes of iatrogenic illness. A "paper
bag" test is often useful to explore this possibility, i.e.,
ask the patient or caregiver to gather all medications into a
paper bag and bring it to the office visit. Be sure to include
over-the-counter (OTC) preparations.
- Review of systems--Cardiovascular illness is the
major cause of death in older adults and these systems should
be investigated thoroughly. Of particular importance also are:
weight change and gastrointestinal (GI) symptoms, headache (temporal
arthritis), dizziness and falls, sleep pattern, sensory impairment,
constipation and other changes in bowel habits (colon cancer),
urinary pattern and incontinence, sexual dysfunction, depression,
cognitive impairment, transient paralysis, paresthesias or visual
changes (transient ischemic attack), musculoskeletal stiffness
or pain (osteoarthritis or polymyalgia rheumatica).
- Social history--(see Psychosocial Issues in Geriatric Medical Care).
Assessment of lifestyle, affect, ognition, function, values,
health beliefs, cultural factors and caregiver issues is also
important. Consultation with a social worker in obtaining this
information and adapting the care plan is often critical but
the initial identification of need for such consultation is part
of the primary care evaluation. A home visit is often very valuable
(see Interacting with Long Term Care Systems, pp. 53-56).
- Nutritional history--(see Nutritional Assessment and Treatment Strategies).
Performing the basic nutritional assessment will identify patients
at risk of malnutrition and in need of referral for dietetic
Limit the time the patient
is in the supine position as this may cause back pain for persons
with osteoarthritis or kyphoscoliosis and shortness of breath
for those with cardiopulmonary disease--having several pillows
on hand for these patients will be greatly appreciated.
Multiple sessions may be required for a complete physical exam
due to patient fatigue. While they are important, the rectal
and pelvic exams may be deferred to a later session, if not urgently
Areas requiring special
- General Observation
and Vital Signs
a. Signs of ADL deficits, poor hygiene, disheveled appearance.
b. Rectal temperature if patient is seriously ill because of
blunted immune response (see Infectious Diseases).
c. Orthostatic changes in blood pressure (BP) and pulse.
d. Osler's maneuver if systolic BP is greater than 160 to screen
for "pseudohypertension"-positive if radial artery
is palpable with cuff inflated above systolic BP level.
e. Weight (at each visit to identify losses early and to establish
f. Signs of malnutrition or trauma (elder abuse and neglect or
- Skin--Neoplasm (especially in sun exposed areas),
nipple retraction, peau d'orange.
- HEENT--Visual acuity, lens exam for cataracts, fundoscopy
(glaucoma, hypertension, diabetic retinopathy), visual fields,
extraocular movements (stroke).
a. Gross auditory acuity, otoscopy to determine possible reversible
causes of hearing loss and disequilibrium (cerumen impaction,
serous otitis media, ruptured tympanic membrane).
b. Inspect the mouth after removal of dentures to assess conditions
that may affect nutrition (neoplasm, stomatitis, oral health,
adequacy of dentures).
c. Palpate temporal artery for tenderness, thickening or nodularity
in the patient complaining of headaches.
a. Dix-Hallpike positional test maneuver for benign positional
vertigo (see Dizziness).
b. Jugular venous pulse is better observed on the right side
since compression of the left innominate vein by an elongated
aortic arch may cause false distension on the left.
a. PMI may be displaced by kyphoscoliosis, so palpation is less
reliable to determine cardiomegaly. Atrial and ventricular arrhythmias
are common. Systolic murmurs are frequently present and most
are due to benign aortic sclerosis. Symptoms, risk of morbidity
and special characteristics that suggest aortic stenosis or endocarditis
should guide evaluation. Diastolic murmurs are always important,
as are right and left ventricular S3 gallops.
b. Signs of arterial insufficiency (hair loss, bruits, decreased
pulses) and venous disease (stasis skin changes and edema) are
common. Arterial ulcers present distally with claudication and
ischemia while venous ulcers present painlessly and are usually
located near the medial malleoli. Most peripheral edema is venous
insufficiency not congestive heart failure (CHF) although the
latter is common and should be ruled out. (The effects of diuretics
on perfusion and electrolyte balance usually outweigh cosmetic
- Lungs--Age-related changes in pulmonary physiology
and age-associated pulmonary pathology often result in rales
that may not indicate pneumonia or pulmonary edema. For this
reason, it is important to document a baseline exam at a time
when the patient is not ill. Localized wheezes may indicate an
obstructing bronchial lesion (carcinoma).
- Breast exam--Tumors may be easier to palpate because
of atrophy and less fibrocystic disease. Remember, men may have
gynecomastia or malignancy.
a. Patients who are unable to lie flat (kyphoscoliosis or cardiopulmonary
disease) may give the impression of distension. This phenomenon
and commonly occurring pulmonary hyperaeration may cause the
liver edge to be palpable below the costal margin without hepatomegaly.
This must be assessed by percussion.
b. Peritoneal signs may be blunted or absent in frail elderly
patients (see Infectious
c. Palpation will assess urinary retention (bladder can be percussed
also) or aortic aneurysm. Ventral, inguinal and femoral hernias
should be checked for reducibility. The sigmoid colon will often
be palpable and a fecal impaction may present as a left lower
- Extremities--Arthritis (rheumatoid, degenerative
and crystalline), deformities, contractures, injuries, podiatric
care, poor hygiene all increase the risk of pain, infection and
gait disturbances. Although basic gait assessment adds little
time to the examination, it yields information that has impact
on independent function and guides consultation with rehabilitation
professionals (see Falls).
Invest in a good pair of nail clippers. Do not hesitate to comment
on style and fit of shoes or to refer to a podiatrist.
- Rectal--Assess for diseases of the prostate,
fecal impaction, integrity of sacral reflexes in persons with
impotence, spinal stenosis or posterior column findings, hemoccult.
- Pelvic examination--Assess for pelvic prolapse, uterine,
adnexal or vaginal neoplasm, infections, estrogen deficit. The
lithotomy position may produce discomfort in the osteoarthritic
patient. An alternative is the left lateral decubitus position
with the right hip flexed more than the left. Pap smears should
be done in elderly women, but the recommended frequency is debated.
Speculum examination may be painful and difficult due to atrophic
changes and vaginal stenosis. A pediatric speculum is often necessary
and, occasionally, the examination is so difficult that gynecologic
consultation is indicated.
a. Mental status examination should be performed in all patients
to establish a baseline in the event of future dysfunction (see
State Examination). This need not occur in the first session.
b. Deep tendon reflexes and vibratory sense may be decreased
c. Deficits of language, coordination and other subtle focal
findings may indicate cerebrovascular disease that is responsible
for cognitive impairment or deficits in instrumental ADL's.
d. Extrapyramidal signs (muscle rigidity, tremor) may indicate
either adverse effects of neuroleptic medication or Parkinson's
disease. In most instances, intention tremor and some resting
tremors are benign conditions. Unilateral tremors may indicate
stroke. A resting tremor with a "pill-rolling" character
is worrisome as is any tremor that impairs function.
When physicians have a
high index of suspicion with knowledge of the subleties of physical
assessment in the older adult, an adequate information base can
guide timely intervention.