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Wiki Exam

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KaylaRieken

True Blue
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Waukee, IA
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GENERAL: Alert and pleasant female who appears in no acute distress.
SKIN: No rash or lesions
NEUROLOGIC: Exam is grossly intact.
HEENT: Head is normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
Neck: Supple
RESPIRATORY: Breathing is unlabored.
EXTREMETIES: She moves all extremities without difficulty.


How many organ systems are here for a 95?
 
For organ systems based on 95 guidelines I come up with the following:

Eye = Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
Neuro = Exam is grossly intact
Repira = Breathing is unlabored
Musco = Head is normocephalic, atraumatic.Neck: Supple. She moves all extremities without difficulty
Skin = No rash or lesions
Psych = Alert and pleasant female who appears in no acute distress.

Note, some will see the psych as constitutional...it is one of those either/or....however in the case the total would still be 6 systems.
 
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