BP: 105/63, Pulse: 85, Temp: 98.F. Patient is alert and oriented with fluent speech and intact verbal comprehension. Extraocular movements are intact. Pupils are equal, round and reactive to light. Fundi are sharp with flat discs, and no papilledemia is noted(?) No postural tremor is present (musculoskeletal?). There are spasms in the trapezii (musculoskeletal?) There is tenderness in the occipitocervial junctions with radiation and increased headaches (musculoskeletal). Where does this fit?
Here's what I think based on 1997 guidelines...........
3/7 Vital Signs - 1 Bullet (Constitutional)
Alert & Oriented - 2 Bullets (Psych - though I would have liked for the provider to say .... "alert & oriented x 3..." (to time, place, person) instead of rather assuming... but for educational purposes we'll roll with it...)
Exam of Pupils/Irises - 3 Bullets
Ophthalmoscopic Exam - 4 Bullets (Fundi = "f"arthest away.. that's how I remember so when you see this, in order to check the fundi, they have to use their ophthalmoscope. Also "papilledemia" is swelling of the optic nerve - another clue
Muscle Strength/Tone - 5 Bullets. Postural Tremor is when the body works against gravity - so if they sit with their arms up would be a test to see if they have a twitch. I would count this as assessment of muscle strength and tone with notation of any abnormal movements in an extremity (in your case, tremors!) and because it doesn't mention how many, I will count only one.
Your trapezius muscles are the triangular muscles in your upper back that allow you move your head and shoulders. so you now have 6 bullets for "head and neck" area for assessment of muscle strength/tone.
tenderness in the occipitocervial junctions - you would get 7 bullets now for inspection/palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions.
So, based upon 1997 guidelines, 7 bullets gives you an EXPANDED PROBLEM FOCUSED EXAM..
Hope that helps!!
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