Constitutional | - Measurement of any three of the following seven vital signs: (1) sitting or standing blood pressure, (2) supine blood pressure, (3) pulse rate and regularity, (4) respiration, (5) temperature, (6) height, (7) weight (may be measured and recorded by ancillary staff)
- General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
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Eyes | - Inspection of conjunctivae and lids
- Examination of pupils and irises (eg, reaction to light and accommodation, size, and symmetry)
- Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
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Ears, Nose, Mouth, and Throat | - External inspection of ears and nose (eg, overall appearance, scars, lesions, masses)
- Otoscopic examination of external auditory canals and tympanic membranes
- Assessment of hearing (eg, whispered voice, finger rub, tuning fork)
- Inspection of nasal mucosa, septum, and turbinates
- Inspection of lips, teeth, and gums
- Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx
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Neck | - Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)
- Examination of thyroid (eg, enlargement, tenderness, mass)
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Respiratory | - Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)
- Percussion of chest (eg, dullness, flatness, hyperresonance)
- Palpation of chest (eg, tactile fremitus)
- Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
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Cardiovascular | - Palpation of heart (eg, location, size, thrills)
- Auscultation of heart with notation of abnormal sounds and murmurs
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| Examination of:
- carotid arteries (eg, pulse amplitude, bruits)
- abdominal aorta (eg, size, bruits)
- femoral arteries (eg, pulse amplitude, bruits)
- pedal pulses (eg, pulse amplitude)
- extremities for edema and/or varicosities
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Chest (Breasts) | - Inspection of breasts (eg, symmetry, nipple discharge)
- Palpation of breasts and axillae (eg, masses or lumps, tenderness)
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Gastrointestinal (Abdomen) | - Examination of abdomen with notation of presence of masses or tenderness
- Examination of liver and spleen
- Examination for presence or absence of hernia
- Examination of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
- Obtain stool sample for occult blood test when indicated
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Genitourinary | Male: - Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)
- Examination of the penis
- Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness)
Female: Pelvic examination (with or without specimen collection for smears and cultures), including - Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
- Examination of urethra (eg, masses, tenderness, scarring)
- Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)
- Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
- Examination of bladder (eg, fullness, masses, tenderness)
- Cervix (eg, general appearance, lesions, discharge)
- Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)
- Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
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Lymphatic | Palpation of lymph nodes in two or more areas: |
Musculoskeletal | - Examination of gait and station
- Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones, and muscles of one or more of the following six areas: (1) head and neck; (2) spine, ribs, and pelvis; (3) right upper extremity; (4) left upper extremity; (5) right lower extremity; and (6) left lower extremity. The examination of a given area includes: - Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, or effusions
- Assessment of range of motion with notation of any pain, crepitation or contracture
- Assessment of stability with notation of any dislocation (luxation), subluxation, or laxity
- Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
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Skin | - Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)
- Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)
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Neurologic | - Test cranial nerves with notation of any deficits
- Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski)
- Examination of sensation (eg, by touch, pin, vibration, proprioception)
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Psychiatric | - Description of patient's judgment and insight
Brief assessment of mental status including: - Orientation to time, place, and person
- Recent and remote memory
- Mood and affect (eg, depression, anxiety, agitation)
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