kviolet
Networker
Below is a copy of Dr X pt’s exam:
I found 7 organ systems. I follow 1995 guideline.
Am I correct ?
Physical Exam:
· Gen: Alert WDWN NAD No Pallor Moist Mucosa (1)
· Head: NCAT (body area)
· Eyes: Conj/lids within normal limits (2)
· Neck: No Meningismus No Adenopathy (body area)
· Lungs: CTA No wheezes/rhonchi/rales No retractions (3)
· CV: Normal Perfusion Peripheral Pulses Normal RRR No murmurs/gallops/rubs (4)
· GI: Soft Non-tender – point to body areas “abdomen” not Organ system “GI” because in order to get GI credit it should have more documentation for example mention about HSM or hernias
· Skin: right great toe - base of 1st MTP with blister that then leads into a dark discolored toe, nail is everted at its tip, + erythema proximal to the MTP joint. no tenderness. (5)
normal gait (6) neuro no fluctuance. no induration.
· Extrem: FROM Capillary refill within normal limits Peripheral pulses within normal limits (7)
I found 7 organ systems. I follow 1995 guideline.
Am I correct ?
Physical Exam:
· Gen: Alert WDWN NAD No Pallor Moist Mucosa (1)
· Head: NCAT (body area)
· Eyes: Conj/lids within normal limits (2)
· Neck: No Meningismus No Adenopathy (body area)
· Lungs: CTA No wheezes/rhonchi/rales No retractions (3)
· CV: Normal Perfusion Peripheral Pulses Normal RRR No murmurs/gallops/rubs (4)
· GI: Soft Non-tender – point to body areas “abdomen” not Organ system “GI” because in order to get GI credit it should have more documentation for example mention about HSM or hernias
· Skin: right great toe - base of 1st MTP with blister that then leads into a dark discolored toe, nail is everted at its tip, + erythema proximal to the MTP joint. no tenderness. (5)
normal gait (6) neuro no fluctuance. no induration.
· Extrem: FROM Capillary refill within normal limits Peripheral pulses within normal limits (7)