# Heent - different body systems



## AB87 (Jun 8, 2012)

We are using the 95' Guidelines and i want to know is "HEENT" one Bullet or is this considered to be 2 different body systems?


Gen: Drowsy, but arouses to name.
*Eyes: EOMs intact*
*HEN*T: NC/AT, ++ periorbital edema, oropharynx clear, mucous membranes moist
Neck: no lymphadenopathy
CV: S1 and S2 RRR, no murmurs
Lungs: BBS, + rales bilaterally
Abd: soft, non-tender, non-distended, bowel sounds positive, no hepatosplenomegaly 
GU: deferred
Ext: warm and well perfused, no clubbing, cyanosis, or edema
Skin: no rashes


OR



· GENERAL APPEARANCE:body wall edema resolved; alert and active, good cry

· *HEENT*:	NG in place; clear and moist mucosa; anterior fontanel soft, flat.

· NECK:	supple, no cervical lymphadenopathy

· LUNGS:	clear to auscultation bilaterally; no signs of distress; in room air, fully saturated. Noted by RN to have increased tachypnea during feedings.

· CARDIOVASCULAR:	HR sinus-- Capillary refill less than < 3 seconds. Equal pulses x 4. warm and well perfused

· ABDOMEN:Normoactive bowel sounds, abdomen soft, non-tender, liver at 1cm below the coastal 
· PERINEUM:mild perianal diaper rash with superficial skin breakdown- improving
· RECTAL:	Inspection revealed a normal situated anus, patent

· GENITOURINARY:Tanner I female; voiding to diapers

· MUSCULOSKELETAL:MAE x4

· NEUROLOGICAL:alert and active, good cry, good tone

· SKIN:CVL clean dry and intact R fem. Mediastinal incision healing, well approximated.  Former right CT site improving, dry and scabbed.  Site cleaned and left open to air.  Former left CTsite now scabbed, clean and dry, open to air.  Right chest dressing removed. site clean dry and intact, no erythema. left open to air.

· LYMPHATIC:Axillary, inguinal and cervical lymph nodes not enlarged

· PSYCHIATRIC:Mom at bedside; updated during rounds


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## Tonyj (Jun 8, 2012)

I use it as 2 organ systems. Eyes and ENT


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## jwesterhoff (Jun 8, 2012)

Using 1995 rules it would be counted as 2 areas. I've attached a web-site regarding E/M coding. Scoll towards the bottom for 1995 rules. Hope this helps..

http://emuniversity.com/PhysicalExam.html


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