Wiki Detailed or Comprehensive PE?

[clbarry8033]

I was hoping someone could help me determine how you would break this exam apart, or even if you can?

Physical Exam:
Vital Signs: Temp 36.2, pulse 82, resp. rate 24, BP 158/102, pulse ox 96%.

General: 45 yo white male, appears stated age. Well developed, well nourished. Slightly obese. Appears to be well hydrated. AAOx3. In no acute distress.

HEENT: Head atraumatic, normocephalic. Eyes: extraocular movements are intact b/l. Sclerae are clear b/l. Ears: External ears are normal. Hearing is normal. Nose: Nares are patent. No rhinorrhea. Mouth and throat: Mucous membranes are moist. Dentition is fair.

Neck: Supple

CV: Regular rate and rhythm. S1 and S2. I do not appreciate any murmurs, gallops, or rubs.

Lungs: He does have crackles noted in left base. No wheezing or rhonchi.

Abdomen: Soft. He denies tenderness with palpation. No rebound. No guarding. Bowel sounds present x4.

Extremities: No clubbing, cyanosis, or edema. Pulses are present b/l upper and lower extremities.

Skin: Warm, dry, and intact.

Neurologic: No focal deficits.

Thanks for all your help!

 

[mitchellde]

What was the reason for the visit. The only part of the exam that counts is that which is related to the medical necessity for the encounter.

 

[clbarry8033]

This was an IP Admission from the ER.

Chief Complaint: Abdominal Pain and SOB

HPI mentions Sinus congestion, x-ray concerning for cardiomegaly and possible b/l infiltrates with lymphadenopathy, and insomnia.

 

[bedforak1]

I scored a comprehensive exam