Musculoskeletal 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 : Cardiovascular  

Elements of Examination: Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

System/Body Area : Lymphatic

Elements of Examination:Palpation of lymph nodes in neck, axillae, groin and/or other location

System/Body Area : Musculoskeleta

Elements of Examination:

Examination of gait and station

 Examination of joint(s), bone(s) and muscle(s)/ tendon(s) of four 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, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
• Assessment of range of motion with notation of any pain (eg, straight leg raising), 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

 NOTE: For the comprehensive level of examination, all four of the elements identified by a bullet must be performed and documented for each of four anatomic areas. For the three lower levels of examination, each element is counted separately for each body area. For example, assessing range of motion in two extremities constitutes two elements

System/Body Area : Skin 

Elements of Examination:

Inspection and/or palpation of skin and subcutaneous tissue (eg, scars, rashes, lesions, cafe-au-lait spots, ulcers) in four of the following six areas: 1) head and neck; 2) trunk; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. 

NOTE: For the comprehensive level, the examination of all four anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of two extremities constitutes two elements.

System/Body Area : Neurological/ Psychiatric

Elements of Examination:

Test coordination (eg, finger/nose, heel/ knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children) 

Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (eg, Babinski) 

Examination of sensation (eg, by touch, pin, vibration, proprioception)

Brief assessment of mental status including 

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