abfloyd1
New
Would you say the following is a Detailed or Comprehensive exam? I'm currently in discussion with one of our physicians who is arguing that he should get more credit under Lumbar Spine and Motor Strength sections below as he examined the lower extremities. My opinion is that since he's examining the spine, the pelvis is included in the spinal body area. What is correct?
Ht 5'7", Wt 192lbs, BP 98/66 Sitting (+1)
Constitutional: General Appearance: healthy-appearing and NAD. (+1)
Psychiatric: Orientation: oriented to time, place, and person. Mood and Affect: active and alert.(+2)
Gait and Station: Appearance: limp and antalgic gait and ambulating with no assistive devices.(+1)
Cardiovascular System: Arterial Pulses Right: posterior tibialis normal and dorsalis pedis normal. Arterial Pulses Left: posterior tibialis normal and dorsalis pedis normal. (+1)
Skin: Lumbosacral Spine: normal skin. (+1)
Lumbar Spine: Inspection: no induration, ecchymosis, or swelling and normal alignment. Bony Palpation of the Lumbar Spine: no tenderness of the spinous process or the sacrum. Bony Palpation of the Right Hip: no tenderness of the iliac crest, the SI joint, or the greater trochanter. Bony Palpation of the Left Hip: tenderness of the SI joint and the greater trochanter and no tenderness of the iliac crest. Soft Tissue Palpation on the Right: tenderness of the iliolumbar region. Soft Tissue Palpation on the Left: tenderness of the paraspinal region at L 5 and the iliolumbar region. Active Range of Motion: some limitation of lumbar motion.(+2)
Motor Strength: L1 Motor Strength on the Right: hip flexion iliopsoas 5/5. L1 Motor Strength on the Left: hip flexion iliopsoas 5/5. L2-L4 Motor Strength on the Right: knee extension quadriceps 5/5. L2-L4 Motor Strength on the Left: knee extension quadriceps 5/5. L5 Motor Strength on the Right: ankle dorsiflexion tibialis anterior 5/5 and great toe extension extensor hallucis longus 5/5. L5 Motor Strength on the Left: ankle dorsiflexion tibialis anterior 5/5 and great toe extension extensor hallucis longus 5/5. S1 Motor Strength on the Right: plantar flexion gastrocnemius 5/5. S1 Motor Strength on the Left: plantar flexion gastrocnemius 5/5.(+1)
Neurological System: Ankle Reflex Right: normal (2). Ankle Reflex Left: normal (2). Knee Reflex Right: normal (2). Knee Reflex Left: normal (2). Sensation on the Right: normal distal extremities. Sensation on the Left: normal distal extremities. Special Tests on the Right: seated straight leg raising test negative. Special Tests on the Left: seated straight leg raising test negative.(+2)
Ht 5'7", Wt 192lbs, BP 98/66 Sitting (+1)
Constitutional: General Appearance: healthy-appearing and NAD. (+1)
Psychiatric: Orientation: oriented to time, place, and person. Mood and Affect: active and alert.(+2)
Gait and Station: Appearance: limp and antalgic gait and ambulating with no assistive devices.(+1)
Cardiovascular System: Arterial Pulses Right: posterior tibialis normal and dorsalis pedis normal. Arterial Pulses Left: posterior tibialis normal and dorsalis pedis normal. (+1)
Skin: Lumbosacral Spine: normal skin. (+1)
Lumbar Spine: Inspection: no induration, ecchymosis, or swelling and normal alignment. Bony Palpation of the Lumbar Spine: no tenderness of the spinous process or the sacrum. Bony Palpation of the Right Hip: no tenderness of the iliac crest, the SI joint, or the greater trochanter. Bony Palpation of the Left Hip: tenderness of the SI joint and the greater trochanter and no tenderness of the iliac crest. Soft Tissue Palpation on the Right: tenderness of the iliolumbar region. Soft Tissue Palpation on the Left: tenderness of the paraspinal region at L 5 and the iliolumbar region. Active Range of Motion: some limitation of lumbar motion.(+2)
Motor Strength: L1 Motor Strength on the Right: hip flexion iliopsoas 5/5. L1 Motor Strength on the Left: hip flexion iliopsoas 5/5. L2-L4 Motor Strength on the Right: knee extension quadriceps 5/5. L2-L4 Motor Strength on the Left: knee extension quadriceps 5/5. L5 Motor Strength on the Right: ankle dorsiflexion tibialis anterior 5/5 and great toe extension extensor hallucis longus 5/5. L5 Motor Strength on the Left: ankle dorsiflexion tibialis anterior 5/5 and great toe extension extensor hallucis longus 5/5. S1 Motor Strength on the Right: plantar flexion gastrocnemius 5/5. S1 Motor Strength on the Left: plantar flexion gastrocnemius 5/5.(+1)
Neurological System: Ankle Reflex Right: normal (2). Ankle Reflex Left: normal (2). Knee Reflex Right: normal (2). Knee Reflex Left: normal (2). Sensation on the Right: normal distal extremities. Sensation on the Left: normal distal extremities. Special Tests on the Right: seated straight leg raising test negative. Special Tests on the Left: seated straight leg raising test negative.(+2)