Wiki components of neurological exam for headache specialist

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ollielooya

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I'm studying the 95 and 97 guidelines and need help in determining what part of this doctors's exam notes are applicable to the bullets. I'm trying to familiarize myself with this particular specialist's style, and would dearly appreciate any comments. I suspect my esteemed peer, F. Tessa Bartels will comment, but lest I pester her with my questions thought it would be appropriate to post here. Here are the PE notes: BP: 105/63, Pulse: 85, Temp: 98.F. Patient is alert and oriented with fluent speech and intact verbal comprehension. Extraocular movements are intact. Pupils are equal, round and reactive to light. Fundi are sharp with flat discs, and no papilledemia is noted(?) No postural tremor is present (musculoskeletal?). There are spasms in the trapezii (musculoskeletal?) There is tenderness in the occipitocervial junctions with radiation and increased headaches (musculoskeletal). Where does this fit?

I've calculated 6 bulleted items for 97 guidelines, but not sure, and also once I understand this, will make an attempt to understand if there will be any variations in making the application to the 95 guidelines.

Thanks for your input and comments, list members?

Suzanne Byrum
CPC-A
 
BP: 105/63, Pulse: 85, Temp: 98.F. Patient is alert and oriented with fluent speech and intact verbal comprehension. Extraocular movements are intact. Pupils are equal, round and reactive to light. Fundi are sharp with flat discs, and no papilledemia is noted(?) No postural tremor is present (musculoskeletal?). There are spasms in the trapezii (musculoskeletal?) There is tenderness in the occipitocervial junctions with radiation and increased headaches (musculoskeletal). Where does this fit?

Here's what I think based on 1997 guidelines...........


3/7 Vital Signs - 1 Bullet (Constitutional)
Alert & Oriented - 2 Bullets (Psych - though I would have liked for the provider to say .... "alert & oriented x 3..." (to time, place, person) instead of rather assuming... but for educational purposes we'll roll with it...;))
Exam of Pupils/Irises - 3 Bullets
Ophthalmoscopic Exam - 4 Bullets (Fundi = "f"arthest away.. that's how I remember so when you see this, in order to check the fundi, they have to use their ophthalmoscope. Also "papilledemia" is swelling of the optic nerve - another clue;)
Muscle Strength/Tone - 5 Bullets. Postural Tremor is when the body works against gravity - so if they sit with their arms up would be a test to see if they have a twitch. I would count this as assessment of muscle strength and tone with notation of any abnormal movements in an extremity (in your case, tremors!) and because it doesn't mention how many, I will count only one.
Your trapezius muscles are the triangular muscles in your upper back that allow you move your head and shoulders. so you now have 6 bullets for "head and neck" area for assessment of muscle strength/tone.
tenderness in the occipitocervial junctions - you would get 7 bullets now for inspection/palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions.


So, based upon 1997 guidelines, 7 bullets gives you an EXPANDED PROBLEM FOCUSED EXAM..


Hope that helps!!:)
 
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If you are using the Neurological exam...Here's my .2 cents.

*Constitutional-vitals
*Neurologic (evaluation of higher integrative functions) alert oriented x 3
*Neurologic (language)-fluent speech
*Neurologic (evaluation of higher integrative functions) fund of knowledge-intact verbal comprehension
*Neurologic-Test 3rd,4th, and 6th cranial nerves-extraocular movements are intact pupils
*Neurologic-Test 2nd cranial nerve-fundi
*Eyes-Ophthalmoscopic exam of optic discs-flat discs Papilledemia
*Musculoskeletal-Examination of gait and station-no postural tremor
*Musculoskeletal-Assesment of motor function-muscle tone-spasms
*Now...as for the occipitocervical junctions, this is located on the skull-this is sorta a gray area for a bullet. Not sure I would credit this.

I get an expanded exam.
 
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1995 guidelines

Using 1995 guidelines:

Consitutional (vital signs)
Eyes (EOMI, PERRLA)
Psych (alert & oriented)
Musculoskeletal (spasm, tremor)
Head (tenderness at occipitocervical junction w/ increased headaches)

Detailed exam.

Also, make note that he states "increased headaches" - don't know what the assessment or history looks like, but I'd take this as an "established problem, worsening" for problem points in MDM (2 points)

F Tessa Bartels, CPC, CEMC
 
Thanking you all for your guidance...

What can I say? You've all given me so much to dwell on while digging deep into this study. Now it's just getting it down to a fine point and knowing how to navigate thru the 95 and 97 guidlines and choosing the ones which work best for your particular case. Again, I ask..where would we newbies be without the help and support from you experienced coders??? Thanks for taking YOUR time to share. When I grow up, want to be just like YOU!

Suzanne
 
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