Hematologic/Lymphatic/Immunologic 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

•     Palpation and/or percussion of face with notation of presence or absence of sinus tenderness

Eyes

•    Inspection of conjunctivae and lids

Ears, Nose, Mouth and Throat

•     Otoscopic examination of external auditory canals and tympanic membranes

•     Inspection of nasal mucosa, septum and turbinates

•     Inspection of teeth and gums

•     Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils, 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)

•     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)

Gastrointestinal

(Abdomen)

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

•     Examination of liver and spleen

Genitourinary

Lymphatic

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

Musculoskeletal

Extremities

•     Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Skin

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

Neurological/

Psychiatric

Brief assessment of mental status including

·      Orientation to time, place and person

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

Level of Exam

Perform and Document:

Problem Focused

One to five elements identified by a bullet.

Expanded Problem Focused

At least six  elements identified by a bullet.

Detailed

At least twelve elements identified by a bullet.

Comprehensive

Perform all elements identified by a bullet; document every element in each shaded box and at least one element in each unshaded box.