hpi, Exam, mdm question

daniel

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Using the 1995 guidelines, what level of exam do you get.


51 yr. old female with hx of psychosis & s/p repair of an incarcerated hernia 8 mons. prior

cc -presently constipated. Takes mineral oil 4 tablsp.
Appetite good
Allergies: PCN, erythromycin.
Meds. Klonipin, seroquel, advair, albuterol, calcium.


Ex: B/P110/70, p-80, resp., 16 ht.5.5, wt 122. A&O x3
Heart – S1+S2, no murmurs
Lungs – clear
Abdomen –R hernia repair noted, BS +, abdomen flat.


PLAN: Constipation – Lactulose - once daily/ prn,
and instructed to increase fluid intake



Thank You in advance
Daniel
CPC
 
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