SHIBA425
Guest
I am looking for all viewpoints I can get when it comes to determining if "cyanosis" should always be counted as part of the "skin" exam or as part of the "cardiopulmonary" exam.
For example:
51 y-o-f with shourtness of breath and cough. underwent bronchoscopy 2 weeks ago which showed diffuse nodularity throughout the tracheobronchial tree with endobronchail metastasis verified by biopsy. She is on oxygen.
Here is the documented exam:
VITALS: TEMP-98.8, BP 120/72, PULSE 73, RESPIRATIONS18, &O2 SAT is 94% on two liters.
HEAD & NECK: No accessory pulmonary muscle use.
LUNGS: Essentially clear
HEART: Regular, slightly tachycardic
ABDOMEN: Soft and nontender. No hepatosplenomegaly. No CVA tenderness or bladder distension.
EXTREMITIES: No focal bony tenderness or joint swelling. No clubbing, cyanosis or edema.
NEUROLOGICAL: the patient is intact
The question is......Count it as skin or count it under cariopulmonary?
I have asked a few physicians and they say it can really be both, so if that is true where do I count it?
Thank you for any assistance.
For example:
51 y-o-f with shourtness of breath and cough. underwent bronchoscopy 2 weeks ago which showed diffuse nodularity throughout the tracheobronchial tree with endobronchail metastasis verified by biopsy. She is on oxygen.
Here is the documented exam:
VITALS: TEMP-98.8, BP 120/72, PULSE 73, RESPIRATIONS18, &O2 SAT is 94% on two liters.
HEAD & NECK: No accessory pulmonary muscle use.
LUNGS: Essentially clear
HEART: Regular, slightly tachycardic
ABDOMEN: Soft and nontender. No hepatosplenomegaly. No CVA tenderness or bladder distension.
EXTREMITIES: No focal bony tenderness or joint swelling. No clubbing, cyanosis or edema.
NEUROLOGICAL: the patient is intact
The question is......Count it as skin or count it under cariopulmonary?
I have asked a few physicians and they say it can really be both, so if that is true where do I count it?
Thank you for any assistance.