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grandmacora

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I am using the 95 guidlines how many body areas and organ systems do you see? Which ones are they?

Physical exam: The patient is a well-developed well-nourished male in no acute distress. Examination of the left shoulder demonstrates external rotation to 55°, internal rotation to T10 abduction to 160°. He has slight weakness with external rotation at 5 minus/5. He is 4+/5 strength with abduction testing and is very sore superiorly over the a.c. joint with this. He is tender to direct palpation over the a.c. joint. There is some fullness to the biceps muscle belly, but no obvious Popeye deformity. Impingement signs are positive.

Height 6'2", weight 275 pounds, BP 142/84, Pulse 68 BPM

Thanks so much
 
Can you explain how you came to a detailed exam? All I see is maybe one system, musculoskeletal, and just one body area with extremity? Thanks
 
This is a [PROBLEM FOCUSED exam. The left shoulder,vitals and physical appearance is all I find. Am I missing something
 
As an EM student I see one body area based on 95 guidelines, but trying to determine if shoulder would be considered part of the back OR part of the extremity (anatomical consideration?) Leaning towards the back at this point.

For body systems: 2
Constitutional
Musculoskeletal
According to the guidelines would this not be “an extended examination of the affected body area(s) and other symptomatic OR related organ system(s) = DETAILED?

--OR—
Since this is the L. shoulder exam of the musculoskeletal system would this be considered a “LIMITED EXAM” of the affected body area or ORGAN SYSTEM and other symptomatic or related organ system(2) = EXPANDED.

Still learning, and still want to know…
---Suzanne E. Byrum CPC
 
For the body systems
I have constitutional
and YES and extended exam of the musculoskeltal

an extended exam is not defined in the documentation guidelines but should included documentation of examination of multiple components of the system or examination in multiple ways (inspection, auscultation, palpation, percussion.

Components: Range of Motion, Strength/Tone, Palpation, not to mention the Impingement testing.

Physical exam: The patient is a well-developed well-nourished male in no acute distress. Examination of the left shoulder demonstrates external rotation to 55°, internal rotation to T10 abduction to 160°. He has slight weakness with external rotation at 5 minus/5. He is 4+/5 strength with abduction testing and is very sore superiorly over the a.c. joint with this. He is tender to direct palpation over the a.c. joint. There is some fullness to the biceps muscle belly, but no obvious Popeye deformity. Impingement signs are positive.

Height 6'2", weight 275 pounds, BP 142/84, Pulse 68 BPM
 
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detailed exam level

I would agree that this is a detailed exam. The provider does an extended exam of the MS system.

Hope that helps!
 
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