A: This is a scenario that someone got from the E/M university – and I believe that’s an online coding site – and would like to know why only one bullet was credited for the cardiovascular system. Again, this is E/M, this is Laureen’s baby, but I’m going to do my best to answer the question.
This is the scenario that they were given – again, normally we don’t go in and answer questions from other sites. We like to say “What did you think,” then we can maybe explain why you’re on track or why you’re off track to help build you up, but not… Just in case this is somebody’s E/M university and I’m not familiar with what they are, but in the event that this is a test, then I don’t want to be answering it for you. [Laughs]
Let’s get to it. We have vital signs, we have general appearance and then it goes down doing… this portion shows the body system. This is a full report, mind you, they’ve just taken this one section of the report. The lungs are clear to auscultation. I went ahead and highlight this because I think this is where the question is coming from and I thought I’ll do a little education on…. The CV means cardiovascular, the RRR stands for regular rate and rhythm. Nobody ever spells any of that stuff out. If you can make an abbreviation, they will do it. No MRGs means murmur, rubs or gallops. And again, these are sounds and things that the physician would listen to, so this is part of the physical exam not the review of systems, but the physical exam of the patient. Normal carotid upstroke and amplitude without bruits – which is the sound that they’re getting in the arteries.
The abdomen – again, most of this stuff is… she was asking specifically about cardio, but abdomen is soft, non-tender, no masses or HSM. Extremities: No peripheral edema or digital cyanosis (which means her fingers aren’t swollen and they don’t have blue fingernails). Skin: No rash, lesions or ulcers. Skin is good. Psych: Alert and oriented to person, place and time. Sometimes they’ll say: alert, oriented x3 (which means person, place and time).
So, they went through and said they got a bullet for the vital signs, the appearance, the examination of neck, auscultation of lungs. Again, the bullet for auscultation of the heart and then one bullet for auscultation of the carotid arteries, examination of the abdomen, and it goes on to all these different things.