Codes EXAM_GAGeneral appearance
Codes EXAM_GA_SpecGeneral appearance specify
Codes EXAM_SkinSkin
Codes EXAM_Skin_SpecSkin specify
Codes EXAM_HeadHead and neck, including face
Codes EXAM_Head_SpecHead specify
Codes EXAM_EyesEyes
Codes EXAM_Eyes_SpecEyes specify
Codes EXAM_EarsEars, including hearing
Codes EXAM_Ears_SpecEars specify
Codes EXAM_NoseNose, mouth, and throat
Codes EXAM_Nose_SpecNose specify
Codes EXAM_LungsLungs
Codes EXAM_Lungs_SpecLungs specify
Codes EXAM_HeartHeart
Codes EXAM_Heart_SpecHeart specify
Codes EXAM_AbdAbdomen
Codes EXAM_Abd_SpecAbdomen specify
Codes EXAM_ExtExtremities
Codes EXAM_Ext_SpecExtremities specify
Codes EXAM_BackBack, including spine
Codes EXAM_Back_SpecBack specify
Codes EXAM_NeuroNeurological
Codes EXAM_Neuro_SpecNeurological specify
Codes EXAM_HandHandedness
Codes EXAM_MentalMental status
Codes EXAM_Mental_SpecMental specify
Codes EXAM_OtherOther
Codes EXAM_Other_typeOther Type
Codes EXAM_Other_SpecOther specify


Physical and neurological exam


Corrected visual acuity should be assessed using a Rosenbaum Pocket Vision Screener (or a Snellen chart) as well as reading of study-related materials. Corrected visual acuity must be sufficient to permit valid performance on cognitive assessment.

Hearing is assessed by general conversation and finger rub, and is enhanced by Weber test with a 256 Hz tuning fork and Rinne test with a 512 Hz tuning fork. Overall hearing (including hearing augmented with aids) must be sufficient to permit valid performance on cognitive assessment.

Valid performance on cognitive assessment requires the ability to speak clearly enough to be easily understood by the examiner.

Comments on gross abnormalities of mental status should be offered, including abnormalities of appearance and behavior (including comportment), communication, thought process, thought content, emotion and feeling, cognition, judgment, and insight.