# Physical Exam - The physician has dictated this physical exam



## schmsuz (Jan 22, 2013)

The physician has dictated this physical exam and coded it as comprehensive.   I think it is a detailed exam.  Can someone please clarify?  If it is comprehensive, could you explain to me why?  Thank you for your help>

Vitals*
*Weight: 176 lb *Height: 63 in
*Body Surface Area: 1.88 m² *Body Mass Index: 31.18 kg/m²
*Pulse: 72 (Regular)* *Resp.: 20 (Unlabored)*
*BP: 124/66*** (Sitting, Left Arm, Standard)
*Bilateral Blood Pressure:
Left Arm, Sitting, Standard: 124/66
Right Arm, Sitting, Standard: 106/52
*
Physical Exam*
The physical exam findings are as follows:*
General*
Mental Status*- Alert. General Appearance*- Cooperative. Not in acute distress.
Integumentary*
General Characteristics:*Overall examination of the patient's skin reveals* - no bruises. Skin Moisture*- normal skin moisture.
Head and Neck
Neck*
Carotid Arteries*- Bilateral*- normal upstroke. No bruit .
Chest and Lung Exam*
Percussion:*
Quality and Intensity:*- Percussion normal.
Auscultation:*
Breath sounds:*- Normal.
Cardiovascular*
Inspection:*Jugular vein*- Bilateral*- No Distention.
Palpation/Percussion:*
Point of Maximal Impulse:*- Normal.
Auscultation:*Rhythm*- Regular. Heart Sounds*- S1 WNL and S2 WNL. No S3 or S4.
Murmurs & Other Heart Sounds:*Auscultation of the heart reveals - No Murmurs.
Peripheral Vascular*
Lower Extremity:*
Palpation:*Femoral pulse*- Bilateral*- Normal. Dorsalis pedis pulse*- Bilateral*- Normal. Edema*- Bilateral*- No edema.
Neurologic*
Neurologic evaluation reveals* - normal sensation.
Mental Status:*Affect*- normal.
Motor:*
Strength: - Intact.


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## MikeEnos (Jan 23, 2013)

I got detailed exam by 95 guidelines.  You need 8 organ systems for a comprehensive exam.  I got:


Constitutional
Integumentary
Cardiovascular
Respiratory
Neurologic
Musculoskeletal
Psychiatric (arguable)

Here's some they easily could have documented to make it Comprehensive

Eyes
Ears, Nose, Mouth, Throat
Hematalogic/Lymphatic
Gastrointestinal

I didn't check 97 guidelines because just eyeballing it, there doesn't appear to be enough.  If anyone would care to take a stab at it with 97 guidelines, feel free.


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## schmsuz (Jan 23, 2013)

Thank you for your help!


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