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Provider Exam

Date: Apr 26, 2021

Question:

Would the below exam info qualify as "comprehensive" under either 95 or 97 guidelines for an initial hospital visit?

Patient name is a 86 y.o. female who is in no acute distress 

Vitals:

03/30/21 2249 03/31/21 0020 03/31/21 0254 03/31/21 0714

BP: 101/60   112/69 106/66

Pulse: 106 116 115 114

Resp: 18   17 16

Temp: 97.5 °F (36.4 °C) 97.3 °F (36.3 °C) 97.5 °F (36.4 °C)

SpO2: 95%   96% 97%

Weight: 150 lb 4.8 oz (68.2 kg)  

 

Body mass index is 27.49 kg/m².

HEENT Normocephalic and atraumatic. Normal nose, normal oral mucosa.

Neck: Supple without masses or tenderness.

CARDIOVASCULAR: Regular, S1S2, murmur

RESPIRATORY: Clear to auscultation bilaterally with no adventitious sounds.

GASTROINTESTINAL: Soft, Non tender.

EXTREMITIES: No edema appreciated.

NEURO: Patient oriented X3. Speech is clear. Affect is appropriate.

INTEGUMENTARY: Incision not viewed.

I don't count it as comprehensive but others do. Please advise. Thank you.

Question ID : 15379
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