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System/Body Area
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Elements of Examination
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Constitutional
*All elements must be documented. |
- Measurement of any three of the following seven vital signs:
- Sitting or standing blood pressure
- Supine blood pressure
- Pulse rate and regularity
- Respiration
- Temperature
- Height
- Weight (may be measured and recorded by ancillary staff)
- General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)
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Eyes
*All elements must be documented. |
- Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages)
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| Cardiovascular |
- Examination of carotid arteries (e.g., pulse amplitude, bruits)
- 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)
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Musculoskeletal
*All elements must be documented. |
- Examination of gait and station
Assessment of motor function including:
- Muscle strength in upper and lower extremities
- Muscle tone in upper and lower extremities (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (e.g., fasciculation, tardive dyskinesia)
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| Extremities |
[See musculoskeletal] |
Neurological
*All elements must be documented.
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Evaluation of higher integrative functions including:
- Orientation to time, place and person
- Recent and remote memory
- Attention span and concentration
- Language (e.g., naming objects, repeating phrases, spontaneous speech)
- Fund of knowledge (e.g., awareness of current events, past history, vocabulary)
Test the following cranial nerves:
- Second cranial nerve (e.g., visual acuity, visual fields, fundi)
- Third, fourth and sixth cranial nerves (e.g., pupils, eye movements)
- Fifth cranial nerve (e.g., facial sensation, corneal reflexes)
- Seventh cranial nerve (e.g., facial symmetry, strength)
- Eighth cranial nerve (e.g., hearing with tuning fork, whispered voice and/or finger rub)
- Ninth cranial nerve (e.g., spontaneous or reflex palate movement)
- Eleventh cranial nerve (e.g., shoulder shrug strength)
- Tewlveth cranial nerve (e.g., tongue protrusion)
- Examination of sensation (e.g., by touch, pin, vibration, proprioception)
- Examination of deep tendon reflexes in upper and lower extremities with notation of pathological reflexes (e.g., Babinski)
- Test coordination (e.g., finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)
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