Eye Examination

Elements of Examination :

• Test visual acuity (Does not include determination of refractive error) 
• Gross visual field testing by confrontation 
• Test ocular motility including primary gaze alignment 
• Inspection of bulbar and palpebral conjunctivae 
• Examination of ocular adnexae including lids (eg, ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes 
• Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (eg, anisocoria) and morphology 
• Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film 
• Slit lamp examination of the anterior chambers including depth, cells, and flare Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus
•  Measurement of intraocular pressures (except in children and patients with trauma or infectious disease) 

Ophthalmoscopic examination through dilated pupils (unless contraindicated) of Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation) and nerve fiber layer Posterior segments including retina and vessels (eg, exudates and hemorrhages)

Genitourinary Examination 

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: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) 

Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) 

System/Body Area:Cardiovascular

Elements of Examination : 

Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (e.g. pulses, temperature, edema, tenderness) 

System/Body Area:Chest (Breasts)

System/Body Area:Gastrointestinal (Abdomen)

 

Elements of Examination : 

Examination of abdomen with notation of presence of masses or tenderness 

Examination for presence or absence of hernia 

Examination of liver and spleen 

Obtain stool sample for occult blood when indicated 

System/Body Area:Genitourinary

 

Elements of Examination : 

MALE: Inspection of anus and perineum 

• Examination (with or without specimen collection for smears and cultures) of genitalia including: 
• Scrotum (eg, lesions, cysts, rashes) Epididymides (eg, size, symmetry, masses) 
• Testes (eg, size, symmetry, masses)
• Urethral meatus (eg, size, location, lesions, discharge) 
• Penis (eg, lesions, presence or absence of foreskin, foreskin retractability, plaque, masses, scarring, deformities) 

Digital rectal examination including: 

• Prostate gland (eg, size, symmetry, nodularity, tenderness)
• Seminal vesicles (eg, symmetry, tenderness, masses, enlargement) 
• Sphincter tone, presence of hemorrhoids, rectal masses 

System/Body Area:Genitourinary

 

Elements of Examination : 

FEMALE:

Includes at least seven of the following eleven elements identified by bullets:

•  Inspection and palpation of breasts (eg, masses or lumps, tenderness, symmetry, nipple discharge) 
•  Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses  

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

• External genitalia (eg, general appearance, hair distribution, lesions) 
• Urethral meatus (eg, size, location, lesions, prolapse) 
• Urethra (eg, masses, tenderness, scarring) 
• Bladder (eg, fullness, masses, tenderness) 
• Vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) 
• Cervix (eg, general appearance, lesions, discharge) 
• Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity) 
• Anus and perineum