Assign level of examination based on the documentation

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Reference no: EM133701948

Question

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 looks to be somewhat uncomfortable. HEENT: Head examination is 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. She has tenderness to palpation in the sternocleidomastoid muscle. C-spine itself is nontender to palpation.

Reference no: EM133701948

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