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Table 2A: 1995 Documentation Guidelines2
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Table 2B: 1997 Documentation Guidelines2
Ears, Nose, Mouth, and Throat
- External inspection of ears 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; and
- 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); and
- 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); and
- 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; and
- 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); and
- Extremities for edema and/or varicosities.
Chest
- Inspection of breasts (e.g. symmetry, nipple discharge); and
- Palpation of breasts and axillae (e.g. masses or lumps, tenderness).
Gastrointestinal
- 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, and rectal masses; and
- 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; and
- Digital rectal examination of prostate gland (e.g. size, symmetry, nodularity, tenderness).
Genitourinary (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); and
- Adnexa/parametria (e.g. masses, tenderness, organomegaly, nodularity).