The elements for each system are listed here.
Constitutional (all)
• Three vital signs
• Appearance
Head and face (all)
• Head and face
• Palpation or percussion of face
Eyes (one)
• Inspection of conjunctivae and lids
Ears, nose, mouth and throat (all)
• Otoscopic exam of auditory canals and
tympanic membranes
• Inspection of nasal mucosa, septum and
turbinates
• Inspection of teeth and gums
• Examination of oropharynx
Neck (one)
• Neck
Thyroid
Respiratory (all)
• Auscultation of lungs
• Assessment of respiratory effort
Cardiovascular (all)
• Auscultation of heart
• Observation and palpation of peripheral
vascular system
Gastrointestinal (all)
• Examination of abdomen
• Examination of liver and spleen
Lymphatic (one)
• Palpation of lymph nodes in neck, axillae, groin
or other location
Extremities (one)
• Inspection and palpation of digits and nail
Neurologic/psychiatric (one)
• Time, place, person orientation
• Mood and affect
Other
• Additional exam components determined by
the physician that are appropriate for patient’s
presenting complaint
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