Wednesday, July 13, 2016

Neurologic, Psyciatric, Lymphatic and Musculoskeletal - Elements of Exam

Lymphatic 

Palpation of lymph nodes in
Neck
two or more areas:
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


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)

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