m.matos@chcfl.com
Contributor
We are in debate in the office on whether this exam is considered Exp. problem focus or detailed using the 1195 Guidelines.
Would like some other opinions:
General Examination:
GENERAL APPEARANCE: alert and oriented x 3, no acute distress, well nourished. NECK: no thyromegaly, no lymphadenopathy, non-tender. HEART: regular rate and rhythm, normal S1S2, no murmurs, click or rubs. LUNGS: clear to auscultation bilaterally, no wheezes/rhonchi/rales, regular breathing rate and effort. ABDOMEN: soft, Nontender/Nondistended, bowel sounds present. EXTREMITIES: no cyanosis, no clubbing, no edema. PERIPHERAL PULSES: symmetrical bilateral.
Assessments
1. Insulin dependent diabetes mellitus - 250.01 (Primary)
2. HTN - 401.9
3. Hyperlipidemia - 272.4
4. Gastritis - 535.50
5. Obese - 278.00
Would like some other opinions:
General Examination:
GENERAL APPEARANCE: alert and oriented x 3, no acute distress, well nourished. NECK: no thyromegaly, no lymphadenopathy, non-tender. HEART: regular rate and rhythm, normal S1S2, no murmurs, click or rubs. LUNGS: clear to auscultation bilaterally, no wheezes/rhonchi/rales, regular breathing rate and effort. ABDOMEN: soft, Nontender/Nondistended, bowel sounds present. EXTREMITIES: no cyanosis, no clubbing, no edema. PERIPHERAL PULSES: symmetrical bilateral.
Assessments
1. Insulin dependent diabetes mellitus - 250.01 (Primary)
2. HTN - 401.9
3. Hyperlipidemia - 272.4
4. Gastritis - 535.50
5. Obese - 278.00