Evaluation and Management Services

Chest (Breasts)

System/Body Area: Gastrointestinal (Abdomen)

Elements of Examination: 

• Examination of abdomen with notation of presence of masses or tenderness 
• Examination of liver and spleen 
• Obtain stool sample for occult blood from patients who are being considered for thrombolytic or anticoagulant therapy

Genitourinary (Abdomen) 

Lymphatic 

System/Body Area: Musculoskeletal

Elements of Examination:

• Examination of the back with notation of kyphosis or scoliosis 
• Examination of gait with notation of ability to undergo exercise testing and/or participation in exercise programs 
• Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements.

System/Body Area: Extremities

Elements of Examination:Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, Osler’s nodes)

System/Body Area: Skin

Elements of Examination:Inspection and/or palpation of skin and subcutaneous tissue (eg, stasis dermatitis, ulcers, scars, xanthomas) 

System/Body Area: Neurological/ Psychiatric

Elements of Examination:

Brief assessment of mental status including

• Orientation to time, place and person, 
• Mood and affect (eg, depression, anxiety, agitation)