Here's the "official" (HCFA - Health Care Financing Agency)
definition of the "General Multi-System Examination:"
System Body Area Elements of Examination
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Constitutional Seven vital signs:
1 Sitting or standing blood pressure
2 supine blood pressure
3 pulse rate and regularity
4 respiration (rate and character)
5 temperature (oral, axillary, rectal, tympanic, other
6 height (length, for babes)
7 weight
general appearance (development, nutrition, grooming etc)
Eyes Inspection of conjuctivae and lids
pupils and irises
optic discs and posterior segments
Ears, Nose, External inspection of ears and nose
Mouth and Throat otoscopic examination of external auditory canals and
TM's
hearing
nasal mucose, septum and turbinates
lips, teeth and gums
oropharynx
Neck neck
thyroid
Respiratory effort
percussion
palpation
auscultation
Cardiovascular palpation
auscultation
carotid arteries
abdominal aorta
femoral arteries
pedal pulses
extremity edema or varicosities
Chest/Breast inspection
palpation, including axillae
Abdomen masses or tenderness
liver and spleen
hernia
perineum and rectal exam
fecal occult blood
Male Genitourinary scrotal contents
penis
prostate
Female GU ("pelvic") external genitalia
urethra
bladder
cervix
uterus
adnexa & parametrium
Lymphatic Palpation of lymph nodes in
neck
axillae
groins
other
Musculoskeletal gait and station
digits and nails
joints bones and muscles of:
head and neck
spine ribs and pelvis
upper extremities
lower extremities
for each area, include inspection, palpation, range of
motion, stability, muscle strength and tone
skin inspection
palpation
Neurologic cranial nerves
deep tendon reflexes
sensation
Psychiatric judgment and insight
mental status, including
orientation to time, place, and person
recent and remote memory
mood and affect
do with this as you will; consider it a resource.
Dan Johnson
