Information regarding major illnesses, surgeries, injuries, and hospitalizations is part of the

Constitutional

• Measurements 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 the patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Eyes

• Inspection of conjunctivae and lids
• Examination of pupils and irises (e.g., reaction to light and accommodation, size and symmetry)
• Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages)

Ear, Nose, Mouth, and Throat

• External inspection of ear and nose (e.g., overall appearance, scars, lesions, masses)
• Otoscopic examination of external auditory canals and tympanic membranes
• Assessment of hearing (e.g., whispered voice, finger rub, tuning fork)
• Inspection of nasal mucosa, septum and turbinates
• Inspection of lips, teeth and gums
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

Neck

• Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
• Examination of thyroid (e.g., enlargement, tenderness, mass)

Respiratory

• Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
• Percussion of chest (e.g., dullness, flatness, hyperresonance)
• Palpation of chest (e.g., tactile fremitus)
• Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

Cardiovascular

• Palpation of heart (e.g., location, size, thrills)
• Auscultation of heart with notation of abnormal sounds and murmurs

Examination of:

• carotid arteries (e.g., pulse, amplitude, bruits)
• abdominal aorta (e.g., size, bruits)
• femoral arteries (e.g., pulse, amplitude, bruits)
• pedal pulses (e.g., pulse, amplitude)
• extremities for edema and/or varicosities

Chest (Breasts)

• Inspection of breasts (e.g., symmetry, nipple discharge)
• Palpation of breasts and axillae (e.g., masses or lumps, tenderness)

Gastrointestinal (Abdomen)

• Examination of abdomen with notation of presence of masses or tenderness
• Examination of liver and spleen
• Examination for presence or absence of hernia
• Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
• Obtain stool sample for occult blood test when indicated

Genitourinary

MALE:

• Examination of the scrotal contents (e.g., hydrocele, spermatocele, tenderness of cord, testicular mass)
• Examination of the penis
• Digital rectal examination of prostate gland (e.g., size, symmetry, nodularity, tenderness)

FEMALE:

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

• Examination of external genitalia (e.g., general appearance, hair distribution, lesions) and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)
• Examination of urethra (e.g., masses, tenderness, scarring)
• Examination of bladder (e.g., fullness, masses, tenderness)
• Cervix (e.g., general appearance, lesions, discharge)
• Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
• Adnexa/parametria (e.g., masses. tenderness, organomegaly, nodularity)

Lymphatic

Palpation of lymph nodes in two or more areas:

• Neck
• Axillae
• Groin
• Other

Musculoskeletal

• Examination of gait and station
• Inspection and/or palpation of digits and nails (e.g., 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 (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

Skin

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

Neurologic

• Test cranial nerves with notation of any deficits
• Examination of deep tendon reflexes with notation of pathological reflexes (e.g., Babinski)
• Examination of sensation (e.g., by touch, pin, vibration, proprioception)

Psychiatric

• 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 (e.g., depression, anxiety, agitation)

Which type of examination involves the affected area of the illness and other systems or related organs?

What are the 3 key components of evaluation and management?

What are the 4 levels of history in E&M coding?

Which type of history includes documentation of four or more elements of the history?