# Exam- Expanded Problem Focused or Detailed



## SHobbs (Nov 26, 2012)

I took this exam as expanded problem focused, but the provider thinks this should be detailed because of the multiple organ systems evaluated.  Should this be detailed? 


General Appearance: The child appears well, comfortable, cooperative, in good state of nutrition. Appears playful.
Skin & Lymphatics: No noticeable skin rashes or lesions, no palpable lymph node enlargements. Skin is warm with good turgor.
HEENT:
Head: Normocephalic and atraumatic. No abnormalities.
Eyes: Inspection reveals no eye abnormalities.
Ears: TM's and EAC's are clear.
Nose: Exam shows: discharge present in nose consisting of purulent nasal drainage.
Mouth and Pharynx: Exam reveals no petechiae, exudates or mucoid discharge on posterior pharynx, no ulcers or erythema, tonsils not enlarged.
Respiratory: Equal chest expansion with no asymmetry. Normal rate, rhythm, depth and effort of breathing. No tachypnea. No intercostal, subcostal or supraclavicular retractions noted or use of accessory muscles of respirations. No rales or crackles. Rhonchi noted bilaterally diffuse. No wheeze.
Cardiovascular: Heart sounds are distinct and of appropriate intensity. Regular rate and rhythm. No murmurs. Femoral artery pulsations are normal and bilaterally equal.
Gastrointestinal: Abdomen is soft and non-tender and is free of organomegaly or mass. Bowels sounds are active in all four quadrants. No bruits are heard.


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## Pam Brooks (Nov 26, 2012)

You didn't mention the chief complaint, but based solely on the documentation (not related to medical necessity) this definitely meets a detailed exam for the 1995 examination guidelines,  particularly since your ENT exam is in detail.  It almost looks like you could also get a comprehensive 95 exam, if you count lymph.


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