shanamarie
Guru
Hello, looking to see if I can get a second opinion on this exam based on 95 guidelines. Does this qualify as a comprehensive exam? I'm specifically questioning the general exam (no vitals), and HEENT.
Physical Exam:
General Examination: The patient is well nourished and well developed, in no acute distress.
Psych: normal affect, good eye contact, well groomed
HEENT: Atraumatic, normocephalic. Mallampati 3-4, neck circumference _ inches. There is no scalloping of the tongue. There is no flattened dentition.
Musculoskeletal: normal range of motion in the neck with flexion/extension, rotation and lateral movements
Pulm: no observed labored breathing, wheezing or use of accessory muscles during conversation
Extremities are without rashes, lesions
Neurologic Examination: Alert and oriented x 3. Speech showed normal fluency, syntax and comprehension. Attention and concentration are normal.
Cranial nerves II-XII: EOMI, eyes are conjugate. Face is symmetric. Hearing is intact normal conversational tones. No dysarthria.
Motor: No face, voice or upper extremity tremor. Normal for rapid finger tapping bilaterally.
Strength: Moves arms symmetrically
Sensation: sensation is intact throughout to light touch.
Cerebellum: coordination is normal for finger to nose, rapid alternating movement, no truncal or appendicular ataxia
Gait: The patient can stand from a chair independently. Normal gait as best I can tell. No ataxia
Physical Exam:
General Examination: The patient is well nourished and well developed, in no acute distress.
Psych: normal affect, good eye contact, well groomed
HEENT: Atraumatic, normocephalic. Mallampati 3-4, neck circumference _ inches. There is no scalloping of the tongue. There is no flattened dentition.
Musculoskeletal: normal range of motion in the neck with flexion/extension, rotation and lateral movements
Pulm: no observed labored breathing, wheezing or use of accessory muscles during conversation
Extremities are without rashes, lesions
Neurologic Examination: Alert and oriented x 3. Speech showed normal fluency, syntax and comprehension. Attention and concentration are normal.
Cranial nerves II-XII: EOMI, eyes are conjugate. Face is symmetric. Hearing is intact normal conversational tones. No dysarthria.
Motor: No face, voice or upper extremity tremor. Normal for rapid finger tapping bilaterally.
Strength: Moves arms symmetrically
Sensation: sensation is intact throughout to light touch.
Cerebellum: coordination is normal for finger to nose, rapid alternating movement, no truncal or appendicular ataxia
Gait: The patient can stand from a chair independently. Normal gait as best I can tell. No ataxia