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Wiki Bullets 1997 exam

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daniel

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I'm I Breaking this down correctly?


Objective:
Physical Exam

VITAL SIGNS - B/P-124/ 102 T- 36.1 P-88 R- 18
GEN- Calm, communicative, no acute distress, obese

(2 bullets: one for vital signs, general appearance)


HEENT- PERRL, EOMI, moist membranes, no lesions, nose & ears WNL. Sclerae Anicteric.

(4 bullets: two for PERRL WNL, Sclerae Anicteric:two for moist mem-
membranes, no lesions, nose & ears WNL

NECK- Supple, no adenopathy, trachea midline, jugular venous pressure WNL. No Thyromegaly.

(2 bullets: one exam of neck, one for exam of thyroid


CHEST- fine wheezing, few R base crackles, slightly decreased L base, good effort

( 1 bullet: one for Auscultation of the lungs)


HEART- Regular rate & rhythm, no murmurs.

(2 bullets: one for Auscultation of the heart, one for pulling edema
ext exam


ABD- Soft, non-tender, non-distended, +BS, obese, no mass.

(1 bullet: Exam of abdomen

EXT- No cyanosis, clubbing, edema.

( 1 bullet: Inspection of or palpation of digits and nails. Used this section for credit in the musculoskeltal exam:


SKIN- No rashes or lesions. No induration.

(2 bullets: one bullet for Inspection of skin and subcutaneous tissue
one bullet for Palpation of the skin and subcutaneous tissue


NEURO- Alert & oriented x4, strong and symmetric, CN 2-12 WNL. nl mood and affect

(1 bullet: CN 2-12 WNL)

I pulled Alert & Oriented X4, nl mood and affect to use for Psych exam
Which have me 2 bullets.


Total of 17 bullets, 6 organs systems only met with 2 bullets within.

This is a detailed exam.

Am I on the right track.


Daniel, CPC
 
1997 exam

Okay here's what I get

VITAL SIGNS - B/P-124/ 102 T- 36.1 P-88 R- 18 (Constitutional 1 bullet)
GEN- Calm, communicative, no acute distress, obese (Constitutional 1 bullet)

HEENT- PERRL, (Eyes 1 bullet)
EOMI,(This is part of Neuro exam - see below)
moist membranes, (ENT 1 bullet)
no lesions, nose & ears WNL. ENT 1 bullet)
Sclerae Anicteric.
NECK- Supple,(Musculoskeletal - range of motion, Neck - 1 bullet)
no adenopathy,(LYMPH 1 bullet)
trachea midline, (NECK 1 bullet)
jugular venous pressure WNL. No Thyromegaly. (NECK 1 bullet)
CHEST- fine wheezing, few R base crackles, slightly decreased L base, (Respiratory 1 bullet)
good effort (Respiratory 1 bullet)
HEART- Regular rate & rhythm, no murmurs.(CV 1 bullet)
ABD- Soft, non-tender, non-distended, +BS, obese, no mass.(GI 1 bullet)
EXT- No cyanosis, clubbing, (Musculoskeletal 1 bullet)
edema. (CV 1 bullet)
SKIN- No rashes or lesions. (Skin 1 bullet)
No induration. (Skin 1 bullet)
NEURO- Alert & oriented x4, (Psych 1 bullet)
strong and symmetric, (I'm not sure what this is ... if it's muscle strength in extremities it should be spelled out - NO bullet)
CN 2-12 WNL. (Neuro 1 bullet)
nl mood and affect (Psych 1 bullet)

In summary:
Constitutional 2 bullets
Eyes 1 bullet
ENT 2 bullets
Neck 3 bullets
Respiratory 2 bullets
CV 2 bullets
GI 1 bullet
Musculoskeletal 2 bullets
Skin 2 bullets
Neuro 1 bullet
Psych 2 bullets

1997 DETAILED exam (because you need 2 bullets in EACH of 9 systems to get to comperehensive.

F Tessa Bartels, CPC, CEMC
 
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