CONTENT AND DOCUMENTATION REQUIREMENTS

System/Body Area : Constitutional 

Elements of Examination : 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) 

System/Body Area : Eyes

Elements of Examination : 

• 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) 

System/Body Area : Ears, Nose, Mouth and Throat

Elements of Examination : 

• 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

System/Body Area : Neck

Elements of Examination : 

Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass) 

System/Body Area : Respiratory

Elements of Examination : 

• 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)