Constitutional

* All elements must be documented.

• 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 (e.g., development, nutrition, body habitus, deformities, attention to grooming)
• Assessment of ability to communicate (e.g., use of sign language or other communication aids) and quality of voice

Head and Face

* All elements must be documented.

• Inspection of head and face (e.g., overall appearance, scars, lesions and masses)
• Palpation and/or percussion of face with notation of presence or absence of sinus tenderness
• Examination of salivary glands
• Assessment of facial strength

Eyes

• Test ocular motility including primary gaze alignment

Ears, Nose,

* All elements must be documented.

• Otoscopic examination of external auditory canals and tympanic membranes including pneumo-otoscopy with notation of mobility of membranes
• Assessment of hearing with tuning forks and clinical speech reception thresholds (e.g., whispered voice, finger rub)
• External inspection of ears and nose (e.g., overall appearance, scars, lesions and masses)
• Inspection of nasal mucosa, septum and turbinates
• Inspection of lips, teeth and gums
• Examination of oropharynx: oral mucosa, hard and soft palates, tongue, tonsils and posterior pharynx (e.g., asymmetry, lesions, hydration of mucosal surfaces)
• Inspection of pharyngeal walls and pyriform sinuses (e.g., pooling of saliva, asymmetry, lesions)
• Examination by mirror of larynx including the condition of the epiglottis, false vocal cords, true vocal cords and mobility of larynx (Use of mirror not required in children.)
• Examination by mirror of nasopharynx including appearance of the mucosa, adenoids, posterior choanae and eustachian tubes. (Use of mirror not required in children.)

Neck

* All elements must be documented.

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

Respiratory

• Inspection of chest including symmetry, expansion and/or assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
• Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

Cardiovascular

• Auscultation of heart with notation of abnormal sounds and murmurs
• Examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g., pulses, temperature, edema, tenderness)

Lymphatic

• Palpation of lymph nodes in neck, axillae, groin and/or other location

Neurological/

• Test cranial nerves with notation of any deficits

• Orientation to time, place and person
• Mood and affect (e.g., depression, anxiety, agitation)