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Wiki Opinion on Detailed or Comp

jifnif

Expert
Messages
265
Location
Pottstown/Philadelphia
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I was wondering if anyone wouldnt mind giving a lend on how you would score this exam by 95 guidelines. :)

Physical Exam
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished
Morbid obesity
HENT:
Head: Normocephalic.
Eyes: EOM are normal.
Neck: Neck supple.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds
No murmur heard.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes
Abdominal: Soft. Bowel sounds are normal. She exhibits no distension and no mass. There is no tenderness. There is no rebound and no guarding.
Exam limited by body habitus
Musculoskeletal: Normal range of motion.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry.
Psychiatric: She has a normal mood and affect.
 
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