Obturator Sign, Psoas Sign, Murphy's Sign, etc.) GU (as indicated) • Inspection, Auscultation, Percussion, Palpation Male Reproductive • Inspection and Palpation Female Reproductive • Inspection, Percussion, Palpation, Speculum Examination, Bimanual Examination Musculoskeletal • Inspection, Palpation (including epitrochlear nodes), Active/Passive ROM, Strength and Tone, Spine, Special Maneuvers as indicated (e.g., Drawers, McMurray, etc.) Neurologic • Cranial nerves, DTRs, Motor Function, Coordination, Gait, Sensory, Babinski Lymphatic • Palpate head and neck nodes Mental Health/Cognitive • Orientation, Mini-Mental State Examination (MMSE), Mental Status, Geriatric Depression Scale, Confusion Assessment Method (CAM), etc.
Total for Physical Examination [-1 point for each pertinent missing component of the PE (e.g., components of the system); (-) 2.5-5 points for partial or complete omission of a pertinent system] 18
Diagnostics
X-ray, EKG, Labs, etc. 2
Total Points for Diagnostics 2
Assessment/Diagnosis
Accurate diagnosis based on history and PE 2. Five plausible differential diagnoses with a rationale for each selection 2
Plan
Develops a complete plan of care appropriate for the actual diagnosis and baseline medical conditions. 2
Appropriate Education/Anticipatory Guidance 1
Total for Assessment/Plan 5
Total Possible Points 50