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physical exam help - hb

Posted: Dec 07, 2010

I am typing a new doc that does not dictate the headings in his physical exam, however i am required to add them in. I am horrible sometimes at determining the headings so i am hoping to get some input on this file.

A moderate hematoma persists over the proximal anterior tibial area which is somewhat fluctuant but not tender. Lumbar flexion is 60 degrees. Lumbar extension is 20 degrees. Lateral flexion is decreased to the left as compared to the right. The leg signs are negative. Deep tendon reflexes are equal and within normal limits bilaterally in the lower extremities. There is somatic dysfunction greatest at the left sacroiliac area in T2-L2 on the right.

What heading or headings would this fall under?

physical exam help-hb - ILMT

[ In Reply To ..]
I believe everything you have typed would fall under a physical exam. I would put Physical Examination above what you have typed.

let me specify - hb

[ In Reply To ..]
Yes they are dictated under physical exam, but i have to add subheadings. Would this fall under Musculoskeletal?

yes, musculoskeletal would be an appropriate subheading for what you have. - anon

[ In Reply To ..]
nm

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