shanamarie
Guru
Can someone reivew, and tell me what level you get for this exam? I usually use 97 guidelines, and I'm getting detailed with that, but with 95 guidelines I think this would qualify as comprehensive. Do you agree? Thanks for any guidance!
Height: 64 in (162.6 cm)
Weight: 170 lbs (77.0 kg) (170)
Blood Pressure: 121/78 Pulse Rate: 91
General appearance: Well-developed, well-nourished, in no acute distress. There are no evident facial dysmorphisms.
Sclera and conjunctivae are clear.
Mucous membranes are moist.
Heart is regular rate and rhythm.
Respiratory effort is normal.
Lungs are clear to auscultation bilaterally.
Skin is warm and well perfused.
Neurologic exam: Awake, alert, and interactive. Cognitive processing is grossly age-appropriate. Speech is fluent without dysarthria. Pupils are equal, round, and reactive to light. Fundoscopic exam reveals flat optic discs bilaterally. Visual fields are full to confrontation. Extraocular movements are full and conjugate. Facial movements are symmetric in the upper and lower face. Hearing appears intact to conversational voice. Palate raise is symmetric and uvula is midline. Shoulder shrug is strong and symmetric. Tongue protrusion is midline with no abnormal movements. Muscle bulk and tone are normal. Muscle strength is 5/5 to confrontation in the upper and lower extremities. Deep tendon reflexes are 2+ and symmetric in the upper and lower extremities. Toes are downgoing bilaterally. Finger-nose-finger is normal without tremor, dysmetria, or ataxia. Sensation is intact to touch. Casual, heel, toe, and tandem gait are normal for age.
Height: 64 in (162.6 cm)
Weight: 170 lbs (77.0 kg) (170)
Blood Pressure: 121/78 Pulse Rate: 91
General appearance: Well-developed, well-nourished, in no acute distress. There are no evident facial dysmorphisms.
Sclera and conjunctivae are clear.
Mucous membranes are moist.
Heart is regular rate and rhythm.
Respiratory effort is normal.
Lungs are clear to auscultation bilaterally.
Skin is warm and well perfused.
Neurologic exam: Awake, alert, and interactive. Cognitive processing is grossly age-appropriate. Speech is fluent without dysarthria. Pupils are equal, round, and reactive to light. Fundoscopic exam reveals flat optic discs bilaterally. Visual fields are full to confrontation. Extraocular movements are full and conjugate. Facial movements are symmetric in the upper and lower face. Hearing appears intact to conversational voice. Palate raise is symmetric and uvula is midline. Shoulder shrug is strong and symmetric. Tongue protrusion is midline with no abnormal movements. Muscle bulk and tone are normal. Muscle strength is 5/5 to confrontation in the upper and lower extremities. Deep tendon reflexes are 2+ and symmetric in the upper and lower extremities. Toes are downgoing bilaterally. Finger-nose-finger is normal without tremor, dysmetria, or ataxia. Sensation is intact to touch. Casual, heel, toe, and tandem gait are normal for age.