E/M Tool Usage: Exam

PHYSICAL EXAM

There’s a couple basic things you need to know about the bullets in the exam portion of the E/M tool. Once you know what each of the bullets stand for then you will be able to place them accordingly. The definition of the bullets are as follows:

Constitutional-Measurement of any 3 of the following 7 vital signs: BP(sitting, supine or standing), Pulse, Respiration, Temperature, Height, Weight and general appearance of the patient(development, nutrition,body habits, deformities, grooming)

Eyes-Inspection, examination or ophthalmoscopic exam(conjunctivac, lids, pupils, irises)

ENT(Ears, Nose, Throat, Mouth)-External inspection ears, nose, auditory canal, tympanic membrane. Inspection of nasal, mucosa, septum, turbinates, lips teeth, gums. Examination of oral mucosa, salivary glands, hard & soft palates, tongue, tonsils, and posterior pharynx.

Neck-examination of neck and thyroid

Respiratory-assessment of respiratory effort, percussion of chest, palpitation of chest, auscultation of lungs.

Cardiovascular-palpitation of heart, auscultation of heart, carotid artery pulse and bruit, abdomianl aorta bruits, femoral artery pulse and bruits, pedal pulses, and extermity edema and/or varicosities.

Chest(Breasts)-inspection and palpitation of breasts.

Gastrointestinal(GI)(Abdomen)-examination of abdomen, liver, spleen, hernia, when indicated anus, perineum, rectum, hemorrhoids, rectal masses.

Genitourinary(GU)-any part of the male or female.

Lymphatic-palpitation of lymph nodes in neck, axillae(armpit), groin…etc

Musculoskeletal-examination of gait/station, palpitation of digits(clubbing, cyanosis, petechiae, ischemia, infection, nodes), examination of bones, joints, muscles, deformities, stability, range of motion, muscle strength.

Skin-inspection and palpitation of skin

Neurologic-test cranial nerves, deep tendons, sensation

Psychiatric-description of patient’s judgement/insight, brief assessment of mental status, orientation to time, place, person, recent/remote memory, mood and effect.

Now let’s look at the exam chart in detail below:

Limited to affected body area or organ system (one body area or system related to problem)	PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s) (additional systems)	EXPANDED PROBLEM FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s) (additional systems up to total of 7 ( more depth and elaboration than above)	DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system (Body areas do not count)	COMPREHENSIVE EXAM

Body area: †Head, including face Chest, including breasts and axillae Abdomen †Neck Back, including spine Genitalia, groin, buttocks †Each extremity OR Organ systems: †Constitutional † Ears, nose, Respiratory † Musculoskeletal †Psych (e.g., vitals, gen app) mouth, throat Gastrointestinal Skin †Hem/lymph/imm †Eyes †Cardiovascular GU † Neuro	1 body area or organ system	2 – 4 body areas or organ systems	5 – 7 body areas or organ systems WITH MORE DEPTH	8 or more organ systems or comprehensive single organ system exam
	PROBLEM FOCUSED	EXPANDED PROBLEM FOCUSED	DETAILED	COMPREHENSIVE

Physical Exam– This is the second part of the patients note from the History.

Vitals: 130/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclerae, moist conjunctiva; no lid-lag; PERRLA
HEENT: AT/NC; oropharynx clear with MMM and no mucosal  ulcerations;auditory canals patent with pearly TMs normal hard and soft palate
Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules
Psych: Appropriate affect, alert and oriented to person, place and time

Labs: HGBA1c 6.8; BUN 25, creatinine 0.8; LDL 88, HGB 12

Physical Exam

Using the 1997 E/M guidelines, this example qualifies as a Comprehensive Physical Exam which requires two bullets in EACH of nine organ systems.  The following bullets and systems were used(*sidebar 1995 guidelines would only require one bullet in each system):

Constitutional

• 3 vital signs
• general appearance

Eyes

• inspection of conjunctiva and lids
• examination of pupils and irises (PERRLA)

Ears, Nose, Mouth, and Throat

• external appearance of the ears and nose (NC/AT)
• examination of oropharynx:

Neck

• examination of neck (e.g., masses, symmetry, tracheal position)
• examination of thyroid

Respiratory

• assessment of respiratory effort (e.g., intercostal retractions)
• auscultation of the lungs

Cardiovascular

• auscultation of the heart with notation of abnormal sounds and murmurs
• assessment of lower extremities for edema and/or varicosities

Gastrointestinal (Abdomen)

• examination of the abdomen with notation of presence of masses or tenderness
• examination of the liver and spleen

Lymphatic (palpation of lymph nodes two or more areas)

• neck
• other (extremities)

Skin

• inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
• palpation of the skin and subcutaneous tissue (temperature and turgor)

Psychiatric

• orientation to time, place, and person
• mood and affect

A total of 10 systems with two bullets each were included, even though the requirement is only for nine systems with two bullets each.

Now, just count how many systems the physician assessed.

1. Constitutional, 2. Eyes, 3. ENT, 4. Neck, 5. Respiratory, 6. Cardiovascular, 7. Gastrointestinal(Abdomen), 8. Lymphatic, 9. Skin, and 10. Psychiatric

After careful review, the physician assessed 10 systems and would make the exam portion COMPREHENSIVE according to the exam chart above.

COMPREHENSIVE EXAM