sharonvalwa
Contributor
Hi, question on assigning bullets using the '97 general exam multi-system exam. Can someone please validate my findings. Also, 1 question:
Q - "Capillary refill is less than 2 seconds" - is this counted in the Cardiovascular , last bullet which states, "extremities for edema and/or variscosities"?
Exam:
GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.
HEAD: normocephalic.
EYES: PERRL, EOMI. Fundi normal, vision is grossly intact.
EARS: External auditory canals and tympanic membranes clear, hearing grossly intact.
NOSE: No nasal discharge.
THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition.
NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds.
LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds.
ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses.
MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait.
BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm.
EXTREMITIES: No edema. No cyanosis. Peripheral pulses intact. No varicosities.
NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal.
SKIN: Skin normal color, texture and turgor with no lesions or eruptions.
PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination.
Const - 2 bullets
Eyes - 2 bullets
ENMT - 6 bullets
Neck - 2 bullets
Resp - 1 bullet
Cardio - 2 bullets
GI - 1 bullet
Musculo - 1 bullet
Skin - 1 bullet
Neuro - 1 bullet
Psych - 2 bullets
Detailed Exam
Q - "Capillary refill is less than 2 seconds" - is this counted in the Cardiovascular , last bullet which states, "extremities for edema and/or variscosities"?
Exam:
GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.
HEAD: normocephalic.
EYES: PERRL, EOMI. Fundi normal, vision is grossly intact.
EARS: External auditory canals and tympanic membranes clear, hearing grossly intact.
NOSE: No nasal discharge.
THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition.
NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds.
LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds.
ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses.
MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait.
BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm.
EXTREMITIES: No edema. No cyanosis. Peripheral pulses intact. No varicosities.
NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal.
SKIN: Skin normal color, texture and turgor with no lesions or eruptions.
PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination.
Const - 2 bullets
Eyes - 2 bullets
ENMT - 6 bullets
Neck - 2 bullets
Resp - 1 bullet
Cardio - 2 bullets
GI - 1 bullet
Musculo - 1 bullet
Skin - 1 bullet
Neuro - 1 bullet
Psych - 2 bullets
Detailed Exam
