dimanche 23 novembre 2014

Opinion on Detailed or Comp

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.






Opinion on Detailed or Comp

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