# Physical Exam - What is the Extent of Physical Exam here



## Partha (Jul 2, 2010)

What is the Extent of Physical Exam here:

Vitals: 
              Height: 6'0”
              Weight: 160

Physical Examination:  Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. Gait is normal.  Skin is intact. No rashes, abrasions, contusions, or lacerations.  No venous stasis. No pulses. No varicosities. No dyspnea. Reflexes are normal patellar. No clonus. 

Knee: Range of motion is apprximatly from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is effusion. Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting. 

Hip: Exam is unremarkable. Normal range of motion, flexion approximately 105 degrees, extension approximately 10 degrees, abduction approximately 25 degrees, adduction approximately 30 degrees, internal rotation approximately 30 degrees, external rotation approximately 30 degrees.

Neck: Neck is supple. No JVD.


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## FTessaBartels (Jul 2, 2010)

*Detailed*

Detailed per 1995 guidelines.

F Tessa Bartels, CPC, CEMC


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## Jagadish (Jul 2, 2010)

I see an 8 system general multi system exam (comprehensive) as per 1995 guidelines.

Constitutional, psychiatry, eyes, musculoskeletal, integumentary, cardiovascular, nervous, neck.


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## FTessaBartels (Jul 9, 2010)

*Neck is NOT an organ system*

Per the 1995 guidelines for a comprehensive exam you need to document 8 of the following 12 systems:
Constitutional
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitoruinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/Lymphatic/Immunological

"Neck" is NOT one of the organ systems.

By the way ... just looking at this documentation I shake my head  "no pulses"  Really?  No pulse at all?

F Tessa Bartels, CPC, CEMC


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## RebeccaWoodward* (Jul 9, 2010)

Tessa, 

You crack me up...


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## FTessaBartels (Jul 9, 2010)

*Well ... it's Friday afternoon*



rebeccawoodward said:


> Tessa,
> 
> You crack me up...



Well, Rebecca ... it's Friday afternoon... isn't it great to end the week with a laugh?  Have a good weekend!
Tessa


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## Jagadish (Jul 15, 2010)

If not neck, no dyspnea can be taken as exam element from respiratory system which makes this as comprehensive exam under 1995 DGs.


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## RebeccaWoodward* (Jul 15, 2010)

I can't say I agree with your view...

Dyspnea by definition=difficult or labored respiration.  This can be visually ascertained  by the physician.

I would not apply this exam statement to neck.  This would follow under *Respiratory* (97 DG)... "assessment of respiratory effort"  thus able to use this statement under respiratory for the 95's; or at least, I would.


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## Jagadish (Jul 15, 2010)

pls review my post again, i counted it under respiratory only. 





rebeccawoodward said:


> I can't say I agree with your view...
> 
> Dyspnea by definition=difficult or labored respiration.  This can be visually ascertained  by the physician.
> 
> I would not apply this exam statement to neck.  This would follow under *Respiratory* (97 DG)... "assessment of respiratory effort"  thus able to use this statement under respiratory for the 95's; or at least, I would.


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