General Multi-System Examination

System/Body Area :Lymphatic

Elements of Examination :
Palpation of lymph nodes in two or more areas: 

• Neck 
• Axillae 
• Groin 
• Other 

System/Body Area :Musculoskeletal 

Elements of Examination :

• 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 

System/Body Area :Skin

Elements of Examination :

• Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers) 
• Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening) 

System/Body Area :Neurologic

Elements of Examination :

• 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)

System/Body Area :Psychiatric

Elements of Examination :
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)