daniel
True Blue
I'm I Breaking this down correctly?
Objective:
Physical Exam
VITAL SIGNS - B/P-124/ 102 T- 36.1 P-88 R- 18
GEN- Calm, communicative, no acute distress, obese
(2 bullets: one for vital signs, general appearance)
HEENT- PERRL, EOMI, moist membranes, no lesions, nose & ears WNL. Sclerae Anicteric.
(4 bullets: two for PERRL WNL, Sclerae Anicteric:two for moist mem-
membranes, no lesions, nose & ears WNL
NECK- Supple, no adenopathy, trachea midline, jugular venous pressure WNL. No Thyromegaly.
(2 bullets: one exam of neck, one for exam of thyroid
CHEST- fine wheezing, few R base crackles, slightly decreased L base, good effort
( 1 bullet: one for Auscultation of the lungs)
HEART- Regular rate & rhythm, no murmurs.
(2 bullets: one for Auscultation of the heart, one for pulling edema
ext exam
ABD- Soft, non-tender, non-distended, +BS, obese, no mass.
(1 bullet: Exam of abdomen
EXT- No cyanosis, clubbing, edema.
( 1 bullet: Inspection of or palpation of digits and nails. Used this section for credit in the musculoskeltal exam:
SKIN- No rashes or lesions. No induration.
(2 bullets: one bullet for Inspection of skin and subcutaneous tissue
one bullet for Palpation of the skin and subcutaneous tissue
NEURO- Alert & oriented x4, strong and symmetric, CN 2-12 WNL. nl mood and affect
(1 bullet: CN 2-12 WNL)
I pulled Alert & Oriented X4, nl mood and affect to use for Psych exam
Which have me 2 bullets.
Total of 17 bullets, 6 organs systems only met with 2 bullets within.
This is a detailed exam.
Am I on the right track.
Daniel, CPC
Objective:
Physical Exam
VITAL SIGNS - B/P-124/ 102 T- 36.1 P-88 R- 18
GEN- Calm, communicative, no acute distress, obese
(2 bullets: one for vital signs, general appearance)
HEENT- PERRL, EOMI, moist membranes, no lesions, nose & ears WNL. Sclerae Anicteric.
(4 bullets: two for PERRL WNL, Sclerae Anicteric:two for moist mem-
membranes, no lesions, nose & ears WNL
NECK- Supple, no adenopathy, trachea midline, jugular venous pressure WNL. No Thyromegaly.
(2 bullets: one exam of neck, one for exam of thyroid
CHEST- fine wheezing, few R base crackles, slightly decreased L base, good effort
( 1 bullet: one for Auscultation of the lungs)
HEART- Regular rate & rhythm, no murmurs.
(2 bullets: one for Auscultation of the heart, one for pulling edema
ext exam
ABD- Soft, non-tender, non-distended, +BS, obese, no mass.
(1 bullet: Exam of abdomen
EXT- No cyanosis, clubbing, edema.
( 1 bullet: Inspection of or palpation of digits and nails. Used this section for credit in the musculoskeltal exam:
SKIN- No rashes or lesions. No induration.
(2 bullets: one bullet for Inspection of skin and subcutaneous tissue
one bullet for Palpation of the skin and subcutaneous tissue
NEURO- Alert & oriented x4, strong and symmetric, CN 2-12 WNL. nl mood and affect
(1 bullet: CN 2-12 WNL)
I pulled Alert & Oriented X4, nl mood and affect to use for Psych exam
Which have me 2 bullets.
Total of 17 bullets, 6 organs systems only met with 2 bullets within.
This is a detailed exam.
Am I on the right track.
Daniel, CPC