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Primary Care Physical Exam

get_col_1_wnl()}>

WNL

get_col_1_abn()}>

ABN

get_col_1_na()}>

N/A

Constitutional

General Appearance (eg, development, nutrition, body habitus, deformities, attention to grooming)

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get_col_2_wnl()}>

WNL

get_col_2_abn()}>

ABN

get_col_2_na()}>

N/A

Eyes

Inspection of conjunctiva and lids

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get_col_3_wnl()}>

WNL

get_col_3_abn()}>

ABN

get_col_3_na()}>

N/A

Examination of pupils and irises (eg. Reaction to light and accommodation, size and symmetry)

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get_col_4_wnl()}>

WNL

get_col_4_abn()}>

ABN

get_col_4_na()}>

N/A

Othalmoscopic examination of optic discs (eg size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)

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get_col_5_wnl()}>

WNL

get_col_5_abn()}>

ABN

get_col_5_na()}>

N/A

Ears, Nose, Mouth and Throat

External inspection of ears and nose (overall appearance, scars, lesions, masses)

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get_col_6_wnl()}>

WNL

get_col_6_abn()}>

ABN

get_col_6_na()}>

N/A

Otoscopic examination of external auditory canals and tympanic membranes

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get_col_7_wnl()}>

WNL

get_col_7_abn()}>

ABN

get_col_7_na()}>

N/A

Assessment of hearing (eg, whispered voice, finger rub, tuning fork)

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get_col_8_wnl()}>

WNL

get_col_8_abn()}>

ABN

get_col_8_na()}>

N/A

Inspection of nasal mucosa, septum and turbinates

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get_col_9_wnl()}>

WNL

get_col_9_abn()}>

ABN

get_col_9_na()}>

N/A

Inspection of lips, teeth and gums

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get_col_10_wnl()}>

WNL

get_col_10_abn()}>

ABN

get_col_10_na()}>

N/A

Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

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get_col_11_wnl()}>

WNL

get_col_11_abn()}>

ABN

get_col_11_na()}>

N/A

Neck

Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus)

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get_col_12_wnl()}>

WNL

get_col_12_abn()}>

ABN

get_col_12_na()}>

N/A

Examination of thyroid (eg, enlargement, tenderness, mass)

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get_col_13_wnl()}>

WNL

get_col_13_abn()}>

ABN

get_col_13_na()}>

N/A

Respiratory

Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement)

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get_col_14_wnl()}>

WNL

get_col_14_abn()}>

ABN

get_col_14_na()}>

N/A

Percussion of chest (eg, dullness, flatness, hyperresonance)

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get_col_15_wnl()}>

WNL

get_col_15_abn()}>

ABN

get_col_15_na()}>

N/A

Palpation of chest (eg, tactile fremitus)

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get_col_16_wnl()}>

WNL

get_col_16_abn()}>

ABN

get_col_16_na()}>

N/A

Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)

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get_col_17_wnl()}>

WNL

get_col_17_abn()}>

ABN

get_col_17_na()}>

N/A

Cardiovascular

Palpation of heart (eg, location, size, thrills)

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get_col_18_wnl()}>

WNL

get_col_18_abn()}>

ABN

get_col_18_na()}>

N/A

Auscultation of heart with notation of abnormal sounds and murmurs

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get_col_19_wnl()}>

WNL

get_col_19_abn()}>

ABN

get_col_19_na()}>

N/A

Examination of: carotid arteries (eg, pulse amplitude, bruits)

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get_col_20_wnl()}>

WNL

get_col_20_abn()}>

ABN

get_col_20_na()}>

N/A

abdominal aorta (eg, size, bruits)

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get_col_21_wnl()}>

WNL

get_col_21_abn()}>

ABN

get_col_21_na()}>

N/A

femoral arteries (eg, pulse amplitude, bruits)

{$data->get_col_21_textbox()}

get_col_22_wnl()}>

WNL

get_col_22_abn()}>

ABN

get_col_22_na()}>

N/A

pedal pulses (eg, pulse amplitude)

{$data->get_col_22_textbox()}

get_col_23_wnl()}>

WNL

get_col_23_abn()}>

ABN

get_col_23_na()}>

N/A

extremities for edema and/or varicosities

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get_col_24_wnl()}>

WNL

get_col_24_abn()}>

ABN

get_col_24_na()}>

N/A

Chest (Breasts)

Inspection of breasts (eg, symmetry, nipple discharge)

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get_col_25_wnl()}>

WNL

get_col_25_abn()}>

ABN

get_col_25_na()}>

N/A

Palpation of breasts and axillae (eg, masses or lumps, tenderness)

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get_col_26_wnl()}>

WNL

get_col_26_abn()}>

ABN

get_col_26_na()}>

N/A

Gastrointestinal (Abdomen)

Examination of abdomen with notation of presence of masses or tenderness

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get_col_27_wnl()}>

WNL

get_col_27_abn()}>

ABN

get_col_27_na()}>

N/A

Examination of liver and spleen

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get_col_28_wnl()}>

WNL

get_col_28_abn()}>

ABN

get_col_28_na()}>

N/A

Examination for presence or absence of hernia

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get_col_29_wnl()}>

WNL

get_col_29_abn()}>

ABN

get_col_29_na()}>

N/A

Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses

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get_col_30_wnl()}>

WNL

get_col_30_abn()}>

ABN

get_col_30_na()}>

N/A

Obtain stool sample for occult blood test when indicated

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get_col_31_wnl()}>

WNL

get_col_31_abn()}>

ABN

get_col_31_na()}>

N/A

Male Genitourinary

Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)

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get_col_32_wnl()}>

WNL

get_col_32_abn()}>

ABN

get_col_32_na()}>

N/A

Examination of the penis

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get_col_33_wnl()}>

WNL

get_col_33_abn()}>

ABN

get_col_33_na()}>

N/A

Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness)

{$data->get_col_33_textbox()}

get_col_34_wnl()}>

WNL

get_col_34_abn()}>

ABN

get_col_34_na()}>

N/A

Female Genitourinary

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

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get_col_35_wnl()}>

WNL

get_col_35_abn()}>

ABN

get_col_35_na()}>

N/A

Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)

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get_col_36_wnl()}>

WNL

get_col_36_abn()}>

ABN

get_col_36_na()}>

N/A

Examination of urethra (eg, masses, tenderness, scarring)

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get_col_37_wnl()}>

WNL

get_col_37_abn()}>

ABN

get_col_37_na()}>

N/A

Examination of bladder (eg, fullness, masses, tenderness)

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get_col_38_wnl()}>

WNL

get_col_38_abn()}>

ABN

get_col_38_na()}>

N/A

Cervix (eg, general appearance, lesions, discharge)

{$data->get_col_38_textbox()}

get_col_39_wnl()}>

WNL

get_col_39_abn()}>

ABN

get_col_39_na()}>

N/A

Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support)

{$data->get_col_39_textbox()}

get_col_40_wnl()}>

WNL

get_col_40_abn()}>

ABN

get_col_40_na()}>

N/A

Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)

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get_col_41_wnl()}>

WNL

get_col_41_abn()}>

ABN

get_col_41_na()}>

N/A

Lymphatic

Palpation of lymph nodes in or more areas:

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get_col_42_wnl()}>

WNL

get_col_42_abn()}>

ABN

get_col_42_na()}>

N/A

Neck

{$data->get_col_42_textbox()}

get_col_43_wnl()}>

WNL

get_col_43_abn()}>

ABN

get_col_43_na()}>

N/A

Axillae

{$data->get_col_43_textbox()}

get_col_44_wnl()}>

WNL

get_col_44_abn()}>

ABN

get_col_44_na()}>

N/A

Groin

{$data->get_col_44_textbox()}

get_col_45_wnl()}>

WNL

get_col_45_abn()}>

ABN

get_col_45_na()}>

N/A

Other

{$data->get_col_45_textbox()}

get_col_46_wnl()}>

WNL

get_col_46_abn()}>

ABN

get_col_46_na()}>

N/A

Musculoskeletal

Examination of gait and station

{$data->get_col_46_textbox()}

get_col_47_wnl()}>

WNL

get_col_47_abn()}>

ABN

get_col_47_na()}>

N/A

Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)

{$data->get_col_47_textbox()}

get_col_48_wnl()}>

WNL

get_col_48_abn()}>

ABN

get_col_48_na()}>

N/A

Examination of joints, bones and muscles of 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:

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get_col_49_wnl()}>

WNL

get_col_49_abn()}>

ABN

get_col_49_na()}>

N/A

Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions

{$data->get_col_49_textbox()}

get_col_50_wnl()}>

WNL

get_col_50_abn()}>

ABN

get_col_50_na()}>

N/A

Assessment of range of motion with notation of any pain, crepitation or contracture

{$data->get_col_50_textbox()}

get_col_51_wnl()}>

WNL

get_col_51_abn()}>

ABN

get_col_51_na()}>

N/A

Assessment of stability with notation of any dislocation (luxation), subluxation or laxity

{$data->get_col_51_textbox()}

get_col_52_wnl()}>

WNL

get_col_52_abn()}>

ABN

get_col_52_na()}>

N/A

Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

{$data->get_col_52_textbox()}

get_col_53_wnl()}>

WNL

get_col_53_abn()}>

ABN

get_col_53_na()}>

N/A

Skin

Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers)

{$data->get_col_53_textbox()}

get_col_54_wnl()}>

WNL

get_col_54_abn()}>

ABN

get_col_54_na()}>

N/A

Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)

{$data->get_col_54_textbox()}

get_col_55_wnl()}>

WNL

get_col_55_abn()}>

ABN

get_col_55_na()}>

N/A

Neurologic

Test cranial nerves with notation of any deficits

{$data->get_col_55_textbox()}

get_col_56_wnl()}>

WNL

get_col_56_abn()}>

ABN

get_col_56_na()}>

N/A

Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski)

{$data->get_col_56_textbox()}

get_col_57_wnl()}>

WNL

get_col_57_abn()}>

ABN

get_col_57_na()}>

N/A

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

{$data->get_col_57_textbox()}

get_col_58_wnl()}>

WNL

get_col_58_abn()}>

ABN

get_col_58_na()}>

N/A

Psychiatric

Description of patient�s judgment and insight

{$data->get_col_58_textbox()}

get_col_59_wnl()}>

WNL

get_col_59_abn()}>

ABN

get_col_59_na()}>

N/A

Brief assessment of mental status including:

{$data->get_col_59_textbox()}

get_col_60_wnl()}>

WNL

get_col_60_abn()}>

ABN

get_col_60_na()}>

N/A

orientation to time, place and person

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get_col_61_wnl()}>

WNL

get_col_61_abn()}>

ABN

get_col_61_na()}>

N/A

recent and remote memory

{$data->get_col_61_textbox()}

get_col_62_wnl()}>

WNL

get_col_62_abn()}>

ABN

get_col_62_na()}>

N/A

mood and affect (eg, depression, anxiety, agitation)

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OTHER NOTES

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