Evaluation and Management Services

System/Body Area :Cardiovascular 

Elements of Examination :

• Palpation of heart (eg, location, size, thrills) 
• Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of: 

• carotid arteries (eg, pulse amplitude, bruits) 
• abdominal aorta (eg, size, bruits) 
• femoral arteries (eg, pulse amplitude, bruits) 
• pedal pulses (eg, pulse amplitude) 
• extremities for edema and/or varicosities 

System/Body Area :Chest (Breasts)

Elements of Examination :

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

System/Body Area :Gastrointestinal (Abdomen)

Elements of Examination :

• Examination of abdomen with notation of presence of masses or tenderness 
• Examination of liver and spleen 
• Examination for presence or absence of hernia 
• Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses 
• Obtain stool sample for occult blood test when indicated 

System/Body Area :Genitourinary 

Elements of Examination :

MALE: 

• Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)
•  Examination of the penis 
• Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness) 

FEMALE: 

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

• Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) 
• Examination of urethra (eg, masses, tenderness, scarring) 
• Examination of bladder (eg, fullness, masses, tenderness) Cervix (eg, general appearance, lesions, discharge) 
• Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)