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Please help with this xam what level would you code and why???

Cora Posted Fri 20th of May, 2011 18:03:55 PM

Physical exam: The patient is a well-developed well-nourished female in no acute distress. She is alert and oriented x3 and very cooperative throughout the exam. Examination of the right elbow demonstrates no erythema or ecchymosis. She does have a loss of 2° of terminal extension. Flexion is good. She has good range of motion with pronation and supination. She does have pain with resisted wrist extension and resisted supination. She has good grip strength, however she does have pain on the lateral although with this. She is somewhat tender over the lateral epicondyle. She is nontender over the medial epicondyle. She has no pain with resisted wrist flexion and resisted pronation. She is neurovascularly intact distally.

SuperCoder Answered Sat 21st of May, 2011 17:36:15 PM

At least six elements identified by a bullet: Expanded Problem Focused
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Constitutional: well-developed well-nourished
cardio: right elbow demonstrates no erythema or ecchymosis
Musculo:
1- Flexion is good. She has good range of motion with pronation and supination.
2- She does have pain with resisted wrist extension and resisted supination.
3- She has good grip strength, however she does have pain on the lateral although with this.
4- She is somewhat tender over the lateral epicondyle. She is nontender over the medial epicondyle.
Neuro: She is neurovascularly intact distally.

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