Question Comprehensive Exam?

shanamarie

Networker
Messages
60
Location
Eagan
Best answers
0
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
 

twizzle

True Blue
Messages
1,265
Location
Sarasota FL
Best answers
0
The general exam is acceptable because it includes general appearance and the fact the patient is well nourished, and the HEENT includes exam of the tongue and the dentition as well as hearing. Eyes are conjugate could be used for the eye exam.
 

shanamarie

Networker
Messages
60
Location
Eagan
Best answers
0
The general exam is acceptable because it includes general appearance and the fact the patient is well nourished, and the HEENT includes exam of the tongue and the dentition as well as hearing. Eyes are conjugate could be used for the eye exam.
Thankyou! So you would agree that this supports a comprehensive exam?
 
Top