Question Exam detailed or comprehensive?

shanamarie

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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.
 

Chelle-Lynn

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Based on the 95 guidelines for the exam portion, this does level out to a Comprehensive for exam:

Constitutional
Eye
ENT
Cardio
Resp
Neuro
Skin
Musculo
 

RGT

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Based on 1995 guidelines for physical exam, it is qualifying for Comprehensive exam:
8 Organ system documented-
Constitutional/General
Eye
ENT
Cardiology
Respiratory
Skin
Neuro
Musculo
 

shanamarie

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Eagan
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Based on the 95 guidelines for the exam portion, this does level out to a Comprehensive for exam:

Constitutional
Eye
ENT
Cardio
Resp
Neuro
Skin
Musculo
Thank you for your response. I really appreciate it! Would you also consider this "cognitive processing is grossly age-appropriate " for psych or neuro?
 

shanamarie

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Eagan
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Based on 1995 guidelines for physical exam, it is qualifying for Comprehensive exam:
8 Organ system documented-
Constitutional/General
Eye
ENT
Cardiology
Respiratory
Skin
Neuro
Musculo
Thank you for your response. I really appreciate it! Would you also consider this "cognitive processing is grossly age-appropriate " for psych or neuro?
 

RGT

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Thank you for your response. I really appreciate it! Would you also consider this "cognitive processing is grossly age-appropriate " for psych or neuro?
I will consider Cognitive processing is grossly age-appropriate and speech is fluent in Psychiatry OS.
 

RGT

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Thank you for your response. I really appreciate it! Would you also consider this "cognitive processing is grossly age-appropriate " for psych or neuro?
Pls review the attached 1997 physical exam CMS guidelines. On page no. 38- they have mentioned the detailed exam for Psychiatry where Cognitive and Speech is mentioned in Pysch exam. Hope the attached file will be helpful for you. Thanks !
 

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