Skin 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

• Inspection of conjunctivae and lids

Ears, Nose, Mouth

and Throat

• Inspection of lips, teeth and gums

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

Neck

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

Respiratory

Cardiovascular

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

Chest (Breasts)

Gastrointestinal

(Abdomen)

• Examination of liver and spleen

• Examination of anus for condyloma and other lesions

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

• Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities

• Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas:

• Head, including the face and

• Neck

• Chest, including breasts and axillae

• Abdomen

• Genitalia, groin, buttocks

• Back

• Right upper extremity

• Left upper extremity

• Right lower extremity

• Left lower extremity

NOTE: For the comprehensive level, the examination of at least eight anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the right upper extremity and the left upper extremity constitutes two elements.

• Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis

Neurological/

Psychiatric

Brief assessment of mental status including

· Orientation to time, place and person

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