I am new at this we have a pain managment doc and I am not sure how to code this exam?
General: Affect demonstrated is notable for mild to moderate discomfort.
Skin exam reveals no open lesion.
Brief vascular evaluation notes no swelling, redness or heat of the distal limbs.
Peripheral pulses are present and symmetric bilaterally.
Musculoskeletal:
Gait is antalgic. The patient does use a four wheeled walker to ambulate. Her gait is notable for poor dynamic balance.
In the appendicular skeleton, effusion, ligament laxity and synovitis are absent.
Spinal curvature evaluation notes no a reduced cervical lordosis. Neck range is decreased in flexion, extension, right rotation, right lateral bending. Spurling sign is negative. Lhermitte's sign is negative.
Muscle stretch reflexes are present and symmetric throughout. In muscle segments C5 through T1 and L2 through S1, she did have weakness with right dorsiflexion She does have a history of foot drop. Tandem gait was done with hand held assistance.
Focal sensory deficits are absent. Nerve root tension signs are absent.
Lumbar range of motion is adequate. Painful arc of motion is present to the neck.
Muscle exam notes no atrophy, fasciculation or dystonia. Deep palpation tenderness was present to the right cervical paraspinal musculature and right trapezius. Hoffman's sign is positive. Clonus is negative. Waddell's signs are 0/5.
I need all the help I can get!!!
Thank you!!!
General: Affect demonstrated is notable for mild to moderate discomfort.
Skin exam reveals no open lesion.
Brief vascular evaluation notes no swelling, redness or heat of the distal limbs.
Peripheral pulses are present and symmetric bilaterally.
Musculoskeletal:
Gait is antalgic. The patient does use a four wheeled walker to ambulate. Her gait is notable for poor dynamic balance.
In the appendicular skeleton, effusion, ligament laxity and synovitis are absent.
Spinal curvature evaluation notes no a reduced cervical lordosis. Neck range is decreased in flexion, extension, right rotation, right lateral bending. Spurling sign is negative. Lhermitte's sign is negative.
Muscle stretch reflexes are present and symmetric throughout. In muscle segments C5 through T1 and L2 through S1, she did have weakness with right dorsiflexion She does have a history of foot drop. Tandem gait was done with hand held assistance.
Focal sensory deficits are absent. Nerve root tension signs are absent.
Lumbar range of motion is adequate. Painful arc of motion is present to the neck.
Muscle exam notes no atrophy, fasciculation or dystonia. Deep palpation tenderness was present to the right cervical paraspinal musculature and right trapezius. Hoffman's sign is positive. Clonus is negative. Waddell's signs are 0/5.
I need all the help I can get!!!
Thank you!!!
what level exam is this ?
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