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 : Head and Face
Elements of Examination: Palpation and/or percussion of face with notation of presence or absence of sinus
tenderness
System/Body Area : Eyes
Elements of Examination:Inspection of conjunctivae and lids
System/Body Area : Ears, Nose,
Mouth and
Throat
Elements of Examination:
- Otoscopic examination of external auditory canals and tympanic membranes
- Inspection of nasal mucosa, septum and turbinates
- Inspection of teeth and gums
- Examination of oropharynx (eg, oral mucosa, 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)
- 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 (pulses, temperature, edema, 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
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