Hi Jim, the provider did not write normal but I was just wondering if that portion of the exam was optimal would the term "normal" be sufficient or would each criterial of the bullet need to be addressed. Here is an excerpt from one of the consult reports.
PHYSICAL EXAMINATION:[/B] Vital Signs: Pulse 75. Blood Pressure 140/70. Height: 5 feet 9 inches, weight 238 pounds. BMI 35.14. Oxygen saturation 95% on room air.
General: The patient is overweight, has difficulty with ambulation. She came walking with a cane into the office, unsteady gait.
HEENT: Normocephalic, pupils equal and react to light, nonicteric sclerae, moist mucous membranes.
Neck: Supple, left carotid bruit preent, no JVD, no palpable nodes.
Chest: Sytmmetric.
Heart: Systolic murmur heard over the entire precordium.
Lungs: Clear.
Abdomen: Obee, nontender, bowel sounds present.
Extremeties: Large hematoma in the left forearm from intravenous line she had last week at the time of cardiac catheterizatoin. She has a bruise on the right forearm. She has an extensive hematoma and discoloration of the skin in most of her left thigh, well-heared scar of surgery from the right hip and the right knee, 2+ edema, no palpable saphenous vein. She is also obese in the legs.
INVESTIGATIONS:
1. Echocardiogram perfomed on Jan. 6,2014 showed normal ejection fraction. The aortic valve showed a peak gradient of 64 mmHg with a mean gradient of 35 mmHg with estimated valve area of 1 square cm with a flow velocity of 4 meters per second with no aortic insufficiency. The mitral valve showed mild mitral regurgitation and mild mitral annular calcification. Pulmonary pressures are 50 mmHg. Concentric left ventricular hypertrophy is present.
2. A cardiac catheterization performed on Jan. 30, 2014 showed a 50% lesion of the LAD, 85% lesion of circumflex, 70% mid-lesion of the marginal, right coronary artery has 30-40%, noncritical.
IMPRESSION:
1. Coronary artery disease
2. Status post myocardial infarction
3. Status post PCI
4. Moderate to severe aortic stenosis
5, Hypertension
6. Diabetes
7. Obesity
8. Poor balance, walks with a walker
9. Hypothyroidism
10. Large hematoma and discoloration of the left thigh
11. Abnormal Allen's test in the left forearm
12. Also superficial hematoma in the left forearm