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Bullets 1997 exam

  1. #1
    Default Bullets 1997 exam
    Medical Coding Books
    I'm I Breaking this down correctly?


    Objective:
    Physical Exam

    VITAL SIGNS - B/P-124/ 102 T- 36.1 P-88 R- 18
    GEN- Calm, communicative, no acute distress, obese

    (2 bullets: one for vital signs, general appearance)


    HEENT- PERRL, EOMI, moist membranes, no lesions, nose & ears WNL. Sclerae Anicteric.

    (4 bullets: two for PERRL WNL, Sclerae Anicteric:two for moist mem-
    membranes, no lesions, nose & ears WNL

    NECK- Supple, no adenopathy, trachea midline, jugular venous pressure WNL. No Thyromegaly.

    (2 bullets: one exam of neck, one for exam of thyroid


    CHEST- fine wheezing, few R base crackles, slightly decreased L base, good effort

    ( 1 bullet: one for Auscultation of the lungs)


    HEART- Regular rate & rhythm, no murmurs.

    (2 bullets: one for Auscultation of the heart, one for pulling edema
    ext exam


    ABD- Soft, non-tender, non-distended, +BS, obese, no mass.

    (1 bullet: Exam of abdomen

    EXT- No cyanosis, clubbing, edema.

    ( 1 bullet: Inspection of or palpation of digits and nails. Used this section for credit in the musculoskeltal exam:


    SKIN- No rashes or lesions. No induration.

    (2 bullets: one bullet for Inspection of skin and subcutaneous tissue
    one bullet for Palpation of the skin and subcutaneous tissue


    NEURO- Alert & oriented x4, strong and symmetric, CN 2-12 WNL. nl mood and affect

    (1 bullet: CN 2-12 WNL)

    I pulled Alert & Oriented X4, nl mood and affect to use for Psych exam
    Which have me 2 bullets.


    Total of 17 bullets, 6 organs systems only met with 2 bullets within.

    This is a detailed exam.

    Am I on the right track.


    Daniel, CPC

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default 1997 exam
    Okay here's what I get

    VITAL SIGNS - B/P-124/ 102 T- 36.1 P-88 R- 18 (Constitutional 1 bullet)
    GEN- Calm, communicative, no acute distress, obese (Constitutional 1 bullet)

    HEENT- PERRL, (Eyes 1 bullet)
    EOMI,(This is part of Neuro exam - see below)
    moist membranes, (ENT 1 bullet)
    no lesions, nose & ears WNL. ENT 1 bullet)
    Sclerae Anicteric.
    NECK- Supple,(Musculoskeletal - range of motion, Neck - 1 bullet)
    no adenopathy,(LYMPH 1 bullet)
    trachea midline, (NECK 1 bullet)
    jugular venous pressure WNL. No Thyromegaly. (NECK 1 bullet)
    CHEST- fine wheezing, few R base crackles, slightly decreased L base, (Respiratory 1 bullet)
    good effort (Respiratory 1 bullet)
    HEART- Regular rate & rhythm, no murmurs.(CV 1 bullet)
    ABD- Soft, non-tender, non-distended, +BS, obese, no mass.(GI 1 bullet)
    EXT- No cyanosis, clubbing, (Musculoskeletal 1 bullet)
    edema. (CV 1 bullet)
    SKIN- No rashes or lesions. (Skin 1 bullet)
    No induration. (Skin 1 bullet)
    NEURO- Alert & oriented x4, (Psych 1 bullet)
    strong and symmetric, (I'm not sure what this is ... if it's muscle strength in extremities it should be spelled out - NO bullet)
    CN 2-12 WNL. (Neuro 1 bullet)
    nl mood and affect (Psych 1 bullet)

    In summary:
    Constitutional 2 bullets
    Eyes 1 bullet
    ENT 2 bullets
    Neck 3 bullets
    Respiratory 2 bullets
    CV 2 bullets
    GI 1 bullet
    Musculoskeletal 2 bullets
    Skin 2 bullets
    Neuro 1 bullet
    Psych 2 bullets


    1997 DETAILED exam (because you need 2 bullets in EACH of 9 systems to get to comperehensive.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default
    Thank You.

    Happy to see I'm not way off, but still have alot of homework to do.


    Daniel, CPC

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