jojo1uf
Contributor
Is this exam Detailed if following 1995 guidelines? I think it qualifies for a EPF on both the 1995 and 1997 guidelines.
Please let me know what you think. Thanks!
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OBJECTIVE
BP (!) 172/90 | Pulse 68 | Temp 98.6 °F (37 °C) (Oral) | Resp 16 | Ht 5' 9" (1.753 m) | Wt (!) 152 kg (335 lb) | SpO2 94% | BMI 49.47 kg/m²
Physical Exam
Physical Exam
Constitutional: She is oriented to person, place, and time. Non-toxic appearance. She does not have a sickly appearance. No distress.
In wheelchair
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop.
Pulmonary/Chest: Effort normal and breath sounds normal.
Musculoskeletal: She exhibits edema. She exhibits no tenderness.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. Lesion noted. She is not diaphoretic.
Please let me know what you think. Thanks!
----------------------
OBJECTIVE
BP (!) 172/90 | Pulse 68 | Temp 98.6 °F (37 °C) (Oral) | Resp 16 | Ht 5' 9" (1.753 m) | Wt (!) 152 kg (335 lb) | SpO2 94% | BMI 49.47 kg/m²
Physical Exam
Physical Exam
Constitutional: She is oriented to person, place, and time. Non-toxic appearance. She does not have a sickly appearance. No distress.
In wheelchair
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop.
Pulmonary/Chest: Effort normal and breath sounds normal.
Musculoskeletal: She exhibits edema. She exhibits no tenderness.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. Lesion noted. She is not diaphoretic.