{php}html_header_show();{/php} {literal} {/literal}

Approved Physical

WNL/ABN SYSTEM SPECIFIC Text Box
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)

get_col_2_wnl()}'>WNL get_col_2_abn()}'>ABN get_col_2_na()}'>N/A

Eyes

Inspection of conjunctiva and lids

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)

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)

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)

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

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)

get_col_8_wnl()}'>WNL get_col_8_abn()}'>ABN get_col_8_na()}'>N/A


Inspection of nasal mucosa, septum and turbinates

get_col_9_wnl()}'>WNL get_col_9_abn()}'>ABN get_col_9_na()}'>N/A


Inspection of lips, teeth and gums

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

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)

get_col_12_wnl()}'>WNL get_col_12_abn()}'>ABN get_col_12_na()}'>N/A


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

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)

get_col_14_wnl()}'>WNL get_col_14_abn()}'>ABN get_col_14_na()}'>N/A


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

get_col_15_wnl()}'>WNL get_col_15_abn()}'>ABN get_col_15_na()}'>N/A


Palpation of chest (eg, tactile fremitus)

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)

get_col_17_wnl()}'>WNL get_col_17_abn()}'>ABN get_col_17_na()}'>N/A

Cardiovascular

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

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

get_col_19_wnl()}'>WNL get_col_19_abn()}'>ABN get_col_19_na()}'>N/A


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

get_col_20_wnl()}'>WNL get_col_20_abn()}'>ABN get_col_20_na()}'>N/A


abdominal aorta (eg, size, bruits)

get_col_21_wnl()}'>WNL get_col_21_abn()}'>ABN get_col_21_na()}'>N/A


femoral arteries (eg, pulse amplitude, bruits)

get_col_22_wnl()}'>WNL get_col_22_abn()}'>ABN get_col_22_na()}'>N/A


pedal pulses (eg, pulse amplitude)

get_col_23_wnl()}'>WNL get_col_23_abn()}'>ABN get_col_23_na()}'>N/A


extremities for edema and/or varicosities

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)

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)

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

get_col_27_wnl()}'>WNL get_col_27_abn()}'>ABN get_col_27_na()}'>N/A


Examination of liver and spleen

get_col_28_wnl()}'>WNL get_col_28_abn()}'>ABN get_col_28_na()}'>N/A


Examination for presence or absence of hernia

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

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

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)

get_col_32_wnl()}'>WNL get_col_32_abn()}'>ABN get_col_32_na()}'>N/A


Examination of the penis

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)

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

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)

get_col_36_wnl()}'>WNL get_col_36_abn()}'>ABN get_col_36_na()}'>N/A


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

get_col_37_wnl()}'>WNL get_col_37_abn()}'>ABN get_col_37_na()}'>N/A


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

get_col_38_wnl()}'>WNL get_col_38_abn()}'>ABN get_col_38_na()}'>N/A


Cervix (eg, general appearance, lesions, discharge)

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)

get_col_40_wnl()}'>WNL get_col_40_abn()}'>ABN get_col_40_na()}'>N/A


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

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:

get_col_42_wnl()}'>WNL get_col_42_abn()}'>ABN get_col_42_na()}'>N/A


Neck

get_col_43_wnl()}'>WNL get_col_43_abn()}'>ABN get_col_43_na()}'>N/A


Axillae

get_col_44_wnl()}'>WNL get_col_44_abn()}'>ABN get_col_44_na()}'>N/A


Groin

get_col_45_wnl()}'>WNL get_col_45_abn()}'>ABN get_col_45_na()}'>N/A


Other

get_col_46_wnl()}'>WNL get_col_46_abn()}'>ABN get_col_46_na()}'>N/A

Musculoskeletal

Examination of gait and station

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)

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:

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

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

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

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

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)

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)

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

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)

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)

get_col_58_wnl()}'>WNL get_col_58_abn()}'>ABN get_col_58_na()}'>N/A

Psychiatric

Description of patient’s judgment and insight

get_col_59_wnl()}'>WNL get_col_59_abn()}'>ABN get_col_59_na()}'>N/A


Brief assessment of mental status including:

get_col_60_wnl()}'>WNL get_col_60_abn()}'>ABN get_col_60_na()}'>N/A


orientation to time, place and person

get_col_61_wnl()}'>WNL get_col_61_abn()}'>ABN get_col_61_na()}'>N/A


recent and remote memory

get_col_62_wnl()}'>WNL get_col_62_abn()}'>ABN get_col_62_na()}'>N/A


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

[Don't Save]