Jinx75
Networker
Here is the documentation from my provider's office note, please tell me using both 95 and 97 guidelines what level physical exam you get (PF, EXPF, DTLD or Comp)
General examination:
General appearance:well developed, well nourished, in no acute distress.
Head:normocephalic, atraumatic
Neck: no cervical lymphadenopathy, carotid pulse normal, no thyroid nodules, no thyromegaly.
Lungs: normal volumes
Abdomen:nondistended
Skin: warm and dry, no suspicious lesions.
Vascular: no jugular venous distention, extremities warm and well perfused, no cyanosis, no edema.
Neurological:
Mental status:the patient is awake and alert.
Cranial nervesEERL/EOMI, face symmetric. Tongue midline. Speech fluent.
Sensory:Sensation is grossly intact to light touch throughout.
Gait and station:w/in normal limits.
Cervical Spine/Neck:
C SPINE EXAM:No palpable abnormality, mild paraspinal tenderness, no paravertebral spasm, no percussion
tenderness. Normal flexion/extension/axial rotation.
Motor Strength:
Deltoid bilateral 5/5.
Biceps bilateral 5/5.
Triceps bilateral 5/5.
Wrist extensor bilateral 5/5.
Grip bilateral 5/5.
Interossii bilateral 5/5.
Opponens pollicis bilateral 5/5.
Finger extention bilateral 5/5.
Reflexes:
Biceps bilateral 2+
Triceps bilateral 2+
Radial bilateral 2+
Hoffman's Absent
Tone Normal
General examination:
General appearance:well developed, well nourished, in no acute distress.
Head:normocephalic, atraumatic
Neck: no cervical lymphadenopathy, carotid pulse normal, no thyroid nodules, no thyromegaly.
Lungs: normal volumes
Abdomen:nondistended
Skin: warm and dry, no suspicious lesions.
Vascular: no jugular venous distention, extremities warm and well perfused, no cyanosis, no edema.
Neurological:
Mental status:the patient is awake and alert.
Cranial nervesEERL/EOMI, face symmetric. Tongue midline. Speech fluent.
Sensory:Sensation is grossly intact to light touch throughout.
Gait and station:w/in normal limits.
Cervical Spine/Neck:
C SPINE EXAM:No palpable abnormality, mild paraspinal tenderness, no paravertebral spasm, no percussion
tenderness. Normal flexion/extension/axial rotation.
Motor Strength:
Deltoid bilateral 5/5.
Biceps bilateral 5/5.
Triceps bilateral 5/5.
Wrist extensor bilateral 5/5.
Grip bilateral 5/5.
Interossii bilateral 5/5.
Opponens pollicis bilateral 5/5.
Finger extention bilateral 5/5.
Reflexes:
Biceps bilateral 2+
Triceps bilateral 2+
Radial bilateral 2+
Hoffman's Absent
Tone Normal