Wiki Physical examiantion - PF or Comprehensive

[shruthi]

Hi,

Kindly suggest your opinion about the below mentioned physical examination, if this can be considered as complete examination of single organ system.

Neurologic:
Mental status: Affect – Normal and appropriate
Speech – Normal
Thought content/perception – Normal
Cognitive function – Normal
Cranial Nerves: Eye Movements – pupil equal, round, reacts to light, accommodation and extraocular movements intact. II optic – Visual fields – Normal. III Oculomotor – Normal bilaterally. IV Trochlear – Bilateral – Normal. V Trigeminal – Normal Bilaterally. VI Abducens – Bilateral – Normal. VII Facial – Normal bilaterally. VIII Acoustic – Left – Hearing normal and (Hearing tested by whispered voice). Right – Hearing normal. IX Glossopharyngeal/X Vagus – Normal. XI Accessory – Normal bilaterally. XII Hypoglossal – Left Normal, right Normal.
Sensory – Light touch – Intact-Globally. Pain – Intact –Globally. Temperature – Intact –Globally. Vibration – Intact-Globally. Tactile Location – Intact – Globally. Proprioception – Bilateral – Normal. Motor – Bulk and Contour –Normal. Tone – Normal. Strength – 5/5 normal muscle strength – All muscles. General assessment of reflexes – DTRs+2 and symmetric bilaterally.
Coordination –Romberg sigh negative. No impairment of finger to nose or impairment of rapid alternating movements.
Gait –Normal.

As per my knowledge this can considered as comprehensive physical examination.

Thanks,
Shruthi.

 

[sullivak]

If you are using 97 guidelines, it would not count as Comprehensive, but rather, as a Detailed Neurological specialty exam. It's missing vitals and general appearance; opthalmoscopic exam of optic discs; cardiovascular bullet; orientation to time, place, and person; Recent and Remote memory; Attention Span and concentration; and Fund of Knowledge.

In 95 guidelines, however, I would count this as a comprehensive neurological exam, because I see it as a comprehensive single system review. However, since 95 guidelines is not specific as to what is meant by a "complete examination of a single organ system", this is very subjective.

Hope that helps!

 

[shruthi]

If you are using 97 guidelines, it would not count as Comprehensive, but rather, as a Detailed Neurological specialty exam. It's missing vitals and general appearance; opthalmoscopic exam of optic discs; cardiovascular bullet; orientation to time, place, and person; Recent and Remote memory; Attention Span and concentration; and Fund of Knowledge.

In 95 guidelines, however, I would count this as a comprehensive neurological exam, because I see it as a comprehensive single system review. However, since 95 guidelines is not specific as to what is meant by a "complete examination of a single organ system", this is very subjective.

Hope that helps!

Thanks for your help.

We are using 1995 guidelines. But am not finding any document which states how many elements or components should be there to consider - complete examination of a single organ system.
Can anyone help me out in this.


Thanks,
Shruthi.