# Exam - Using the 95 guidelines



## grandmacora (Dec 13, 2011)

Using the 95 guidelines what do you find in this exam can I count the no accute distress as Psych?? 

Physical exam: Patient is a well-developed well-nourished female in no acute distress. Examination of the left knee down to positive effusion. Range of motion is normal with the exception of tightness with terminal flexion. She has quite a bit of quad atrophy. Ligaments are stable. She has sensitivity over the posterior medial joint line. This is mildly aggravated with tibial rotation testing. She has no pain over the lateral joint line. Patellofemoral compression testing is negative. She is neurovascularly intact distally.

Height: 5 foot 7 inches, weight 180 pounds, blood pressure 110/80, pulse 63

Am I right with const.-Psych-Musculosk- Neuro and musculoskeletal for the organ systems  also would sensitivity fall under skin?

Thanks so much grandmacora


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## Lashel (Dec 13, 2011)

you definitely have musculoskeletal and neuro. I personnaly, would consider that statement "well developed, well nourished, in no acute distress" as constitutional (general appearance)

You might have some additional HPI mixed in with your exam though. "mildly aggravated with tibial rotation testing" could fall under modifying factors. I don't think the sensitivity would satisfy skin. That is my own personal opinion. 

For exam I would count constitutional, musculoskeletal, and neuro.


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## Sueedwards (Dec 19, 2011)

I agree with you but I am having a hard time seeing the Psych....


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## FTessaBartels (Dec 19, 2011)

*NO psych*

I agree with Lashel .... no psych exam here. Just Constitutional, Musculoskeletal and Neuro.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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