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Exam Bullets
 

 


Constitutional

* Three vital signs
* General appearance

Eyes

* Inspection of conjunctivae and lids
* Examination of pupils and irises (PERRLA)
* Ophthalmoscopic discs and posterior segments

Ears, Nose, Mouth, and Throat

* External appearance of the ears and nose (overall appearance, scars, lesions, masses)
* Otoscopic examination of the external auditory canals and tympanic membranes
* Assessment of hearing
* 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

Neck

* Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
* Examination of thyroid

Respiratory

* Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
* Percussion of chest (e.g., dullness, flatness, hyperresonance)
* Palpation of chest (e.g., tactile fremitus)
* Auscultation of the lungs

Cardiovascular

* Palpation of the heart (location, size, thrills)
* Auscultation of the heart with notation of abnormal sounds and murmurs
* Assessment of lower extremities for edema and/or varicosities
* Examination of the carotid arteries (e.g., pulse amplitude, bruits)
* Examination of abdominal aorta (e.g., size, bruits)
* Examination of the femoral arteries (e.g., pulse amplitude, bruits)
* Examination of the pedal pulses (e.g., pulse amplitude)

Chest (Breasts)

* Inspection of the breasts (e.g., symmetry, nipple discharge)
* Palpation of the breasts and axillae (e.g., masses, lumps, tenderness)

Gastrointestinal (Abdomen)

* Examination of the abdomen with notation of presence of masses or tenderness
* Examination of the liver and spleen
* Examination for the presence or absence of hernias
* Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
* Obtain stool for occult blood testing when indicated

Genitourinary (Male)

* Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass)
* Examination of the penis
* Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness)

Genitourinary (Female)

Pelvic examination (with or without specimen collection for smears and cultures, which may include:

* Examination of the external genitalia (e.g., general appearance, hair distribution, lesions)
* Examination of the urethra (e.g., masses, tenderness, scarring)
* Examination of the bladder (e.g., fullness, masses, tenderness)
* Examination of the cervix (e.g., general appearance, discharge, lesions)
* Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
* Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)

Lymphatic

Palpation of lymph nodes two or more areas:

* Neck
* Axillae
* Groin
* Other

Musculoskeletal

* Examination of gait and station
* Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)

Examination of the 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
6. left lower extremity

The examination of a given area may include:

# 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, subluxation, or laxity
# Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any atrophy or abnormal movements

Skin

* Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
* Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)

Neurologic

* Test cranial nerves with notation of any deficits
* Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi)
* Examination of sensation (e.g., by touch, pin, vibration, proprioception)

Psychiatric

* Description of patient’s judgment and insight

Brief assessment of mental status which may include

* orientation to time, place, and person
* recent and remote memory
* mood and affect

E/M University Coding Tip: the 1995 physical exam rules may seem appealing, but they are too vague and subjective to be relied upon to withstand a systematic audit. It is recommended that physicians utilize the more concrete 1997 physical exam rules (see above)

 

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