General Multi-System Examination

System/Body Area

Elements of Examination

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)

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)

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

Neck

• Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)

• Examination of thyroid (eg, enlargement, tenderness, mass)

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)

Cardiovascular

• Palpation of heart (eg, location, size, thrills)

• Auscultation of heart with notation of abnormal sounds and murmurs

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

Chest (Breasts)

• Inspection of breasts (eg, symmetry, nipple discharge)

• Palpation of breasts and axillae (eg, masses or lumps, tenderness)

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 (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses

• Obtain stool sample for occult blood test when indicated

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)

• 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)

Lymphatic

Palpation of lymph nodes in two or more areas:

• Neck

• Axillae

• Groin

• Other

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, 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

Skin

• Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)

• Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)

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)

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)