Genitourinary Exam

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)

Head and Face

Eyes

Ears, Nose, Mouth and Throat

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)

• Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

Cardiovascular

• Auscultation of heart with notation of abnormal sounds and murmurs

• Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)

[See genitourinary (female)]

Gastrointestinal

(Abdomen)

• Examination of abdomen with notation of presence of masses or tenderness

• Examination for presence or absence of hernia

• Examination of liver and spleen

• Obtain stool sample for occult blood test when indicated

Genitourinary

MALE:

• Inspection of anus and perineum

Examination (with or without specimen collection for smears and cultures) of genitalia including:

• Scrotum (eg, lesions, cysts, rashes)

• Epididymides (eg, size, symmetry, masses)

• Testes (eg, size, symmetry, masses)

• Urethral meatus (eg, size, location, lesions, discharge)

• Penis (eg, lesions, presence or absence of foreskin, foreskin retractability, plaque, masses, scarring, deformities)

Digital rectal examination including:

• Prostate gland (eg, size, symmetry, nodularity, tenderness)

• Seminal vesicles (eg, symmetry, tenderness, masses, enlargement)

• Sphincter tone, presence of hemorrhoids, rectal masses

Genitourinary

(Cont’d)

FEMALE:

Includes at least seven of the following eleven elements identified by bullets:

• Inspection and palpation of breasts (eg, masses or lumps, tenderness, symmetry, nipple discharge)

• Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses

Pelvic examination (with or without specimen collection for smears and cultures) including:

• External genitalia (eg, general appearance, hair distribution, lesions)

• Urethral meatus (eg, size, location, lesions, prolapse)

• Urethra (eg, masses, tenderness, scarring)

• Bladder (eg, fullness, masses, tenderness)

• Vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)

• Cervix (eg, general appearance, lesions, discharge)

• Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)

• Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)

• Anus and perineum

Lymphatic

• Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal

Extremities

Skin

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

Neurological/

Psychiatric

Brief assessment of mental status including

• Orientation (eg, time, place and person) and

• Mood and affect (eg, depression, anxiety, agitation)