trinalankford
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I have a physician who will document vital signs (constitutional) and then an extremity exam but absolutely nothing else, as follows:
There is a puncture wound in the plantar heel, surrounding soft tissue swelling, but no erythema, drainage, or purulence. Ankle is normal to inspection, nontender, normal ROM. Leg is uninjured above the ankle. Gait not tested due to pain. Neuro: Sensation is normal. Vascular: No vascular compromise. Skin: Warm, dry, intact.
We are having trouble coming to a consensus in our office. Some say the neuro, vascular, and skin should be counted separately, so Detailed PE. Some say they are components of the extremity exam, since the descriptions above pertain specifically to the extremities only, i.e., no cranial nerve exam, etc., so Prob Focused PE (single BA).
Thoughts? Thank you!
There is a puncture wound in the plantar heel, surrounding soft tissue swelling, but no erythema, drainage, or purulence. Ankle is normal to inspection, nontender, normal ROM. Leg is uninjured above the ankle. Gait not tested due to pain. Neuro: Sensation is normal. Vascular: No vascular compromise. Skin: Warm, dry, intact.
We are having trouble coming to a consensus in our office. Some say the neuro, vascular, and skin should be counted separately, so Detailed PE. Some say they are components of the extremity exam, since the descriptions above pertain specifically to the extremities only, i.e., no cranial nerve exam, etc., so Prob Focused PE (single BA).
Thoughts? Thank you!