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Assign the level of examination based on the documentation in the following scenario:

- Temperature: 98 degrees F
- Pulse: 86
- Respirations: 16
- Blood Pressure: 150/65

General: Patient is a well-nourished female who is wearing corrective lenses and appears to be somewhat uncomfortable.

HEENT (Head, Eyes, Ears, Nose, Throat):
- Head: Normocephalic, atraumatic
- Eyes: Clear. Pupils equally round and reactive to light and accommodation. Discs sharp bilaterally.
- Ears: Tympanic membranes pearly white bilaterally. Negative fluid.

Neck:
- Trachea midline, supple, no adenopathy.
- Cervical spine shows no swelling, bruising, or erythema.
- Tenderness to palpation in the sternocleidomastoid muscle.
- C-spine itself is nontender to palpation.

Answer :

Final answer:

The level of examination in the provided scenario includes a problem-focused or expanded problem-focused physical examination, depending on the evaluation guidelines. The detailed assessments in the examples involve careful consideration of the patient's symptoms and a selection of examinations tailored to diagnose conditions such as pneumonia and neurological issues.

Explanation:

When assigning the level of examination based on the provided documentation, it is important to consider various elements of the patient evaluation. The scenario provided includes a detailed physical examination covering vital signs, HEENT (Head, Eyes, Ears, Nose, Throat), and a musculoskeletal assessment indicating tenderness in the sternocleidomastoid muscle without any other issues. Such an examination could be considered a problem-focused or expanded problem-focused examination depending on the specific guidelines being used for evaluation, such as those set by the Centers for Medicare & Medicaid Services (CMS) in the United States for billing and documentation purposes.

Looking at the other provided scenarios, each represents a complex clinical situation requiring specific and systemic physical examinations. For example, Barbara's examination suggesting pneumonia shows that a careful and thorough assessment of the heart, lungs, blood oxygen level, and the collection of a sputum sample is essential for diagnosis. The treatment plan with the use of a pulse oximeter, stethoscope, and ordering of a chest radiograph reflects an in-depth examination and diagnostic process. Similarly, for the patient experiencing sensory deficits suggesting a neurologic issue, the examination performed includes sensory exams, assessment of muscular strength, and coordination exercises, which are appropriate for neurological evaluation.

Lastly, the clinical focus on Olivia indicates the need for a complete immune response and infection assessment, looking at lymph node swelling, spleen size, and conducting blood tests to diagnose the underlying condition. All these cases reflect tailored examination levels based on the patient's presenting symptoms and clinical findings.

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