Which of the number of diagnosis and/or management option (established problem, stable or improving; established problem, worsening; new problem without workup; new problem with workup) do you find the easiest to understand? Please explain why this specific number of diagnosis and/or management option makes sense to you.
What will be an ideal response?
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Q. 2) The documented findings Lungs clear to auscultation bilaterally. Bradycardic, regular rhythm, distant heart sounds support one element identified by a bullet in the Respiratory system/body area, which has a shaded border AND one element identified by a bullet in the Cardiovascular system/body area, which also has a shaded border.
Please read the documentation below and answer the related questions regarding the cardiovascular single organ system physical examination.
Vital signs: Temp 37.2 BP 112/61 RR 14 BP 112/61 SaO2 99 at room air
General: Alert, thin male seated in hospital gurney, no acute distress.
NEURO: Cranial nerves II-XII intact. Alert, oriented times 3.
HEENT: PERRL, EOMI. Sclera non-icteric. Mucus membranes moist. Neck supple, no adenopathy.
CHEST: Lungs clear to auscultation bilaterally. Bradycardic, regular rhythm, distant heart sounds. Well-healed sternotomy scar noted.
ABD: Soft, non-tender, non-distended. No masses palpable. Bowel sounds present.
EXT: Warm, well perfused, no edema
Indicate whether this statement is true or false.
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Q. 3) The documented findings . Abdomen soft, non-tender upon palpation. Normal bowel sounds present support one element identified by a bullet in the Gastrointestinal (Abdomen) system/body area, which has an unshaded border.
Please read the documentation below and answer the related questions regarding the ear, nose and throat single organ system physical examination.
PE: Temp 98.2 HR 28, RR 16, BP 115/71
Patient alert and well groomed, but clearly agitated, with flushed face but in no acute distress. Eyes clear without jaundice, EOMI intact, PERRLA. No nasal congestion noted. Oral examination reveals sour odor and copious amounts of salivation present along gumline and beneath tongue. Otherwise, oral mucosa intact. Oropharynx red but no inflammation or exudates noted along tonsils or adenoids. Neck soft without masses and non-tender, although patient reports radiating pressure upon palpation of submaxillary lymph glands with significant pain upon swallowing during exam. Lungs clear to auscultation and percussion. Abdomen soft, non-tender upon palpation. Normal bowel sounds present. Patient displays appropriate judgment, insight and recall, but is very anxious her painful throat and her father's poor response to treatment. Patient alert, oriented x3. Cranial nerves intact. Extremities warm, well-perfused without rash or indurations.
Indicate whether this statement is true or false.
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Q. 4) The documented findings PERRL, EOMI. Sclera non-icteric support one element identified by a bullet in the Eye system/body area, which has an unshaded border.
Please read the documentation below and answer the related questions regarding the cardiovascular single organ system physical examination.
Vital signs: Temp 37.2 BP 112/61 RR 14 BP 112/61 SaO2 99 at room air
General: Alert, thin male seated in hospital gurney, no acute distress.
NEURO: Cranial nerves II-XII intact. Alert, oriented times 3.
HEENT: PERRL, EOMI. Sclera non-icteric. Mucus membranes moist. Neck supple, no adenopathy.
CHEST: Lungs clear to auscultation bilaterally. Bradycardic, regular rhythm, distant heart sounds. Well-healed sternotomy scar noted.
ABD: Soft, non-tender, non-distended. No masses palpable. Bowel sounds present.
EXT: Warm, well perfused, no edema
Indicate whether this statement is true or false.
(
Q. 5) The documented findings Oral examination reveals sour odor and copious amounts of salivation present along gumline and beneath tongue. Otherwise, oral mucosa intact. Oropharynx red but no inflammation or exudates noted along tonsils or adenoids. Supports one element identified by a bullet in the ears, nose, mouth, and throat system/body area, which has a shaded border.
Please read the documentation below and answer the related questions regarding the ear, nose and throat single organ system physical examination.
PE: Temp 98.2 HR 28, RR 16, BP 115/71
Patient alert and well groomed, but clearly agitated, with flushed face but in no acute distress. Eyes clear without jaundice, EOMI intact, PERRLA. No nasal congestion noted. Oral examination reveals sour odor and copious amounts of salivation present along gumline and beneath tongue. Otherwise, oral mucosa intact. Oropharynx red but no inflammation or exudates noted along tonsils or adenoids. Neck soft without masses and non-tender, although patient reports radiating pressure upon palpation of submaxillary lymph glands with significant pain upon swallowing during exam. Lungs clear to auscultation and percussion. Abdomen soft, non-tender upon palpation. Normal bowel sounds present. Patient displays appropriate judgment, insight and recall, but is very anxious her painful throat and her father's poor response to treatment. Patient alert, oriented x3. Cranial nerves intact. Extremities warm, well-perfused without rash or indurations.
Indicate whether this statement is true or false.
(
Q. 6) The documented findings Eyes clear without jaundice, EOMI intact, PERRLA. Support one element identified by a bullet in the Eye system/body area, which has a shaded border.
Please read the documentation below and answer the related questions regarding the ear, nose and throat single organ system physical examination.
PE: Temp 98.2 HR 28, RR 16, BP 115/71
Patient alert and well groomed, but clearly agitated, with flushed face but in no acute distress. Eyes clear without jaundice, EOMI intact, PERRLA. No nasal congestion noted. Oral examination reveals sour odor and copious amounts of salivation present along gumline and beneath tongue. Otherwise, oral mucosa intact. Oropharynx red but no inflammation or exudates noted along tonsils or adenoids. Neck soft without masses and non-tender, although patient reports radiating pressure upon palpation of submaxillary lymph glands with significant pain upon swallowing during exam. Lungs clear to auscultation and percussion. Abdomen soft, non-tender upon palpation. Normal bowel sounds present. Patient displays appropriate judgment, insight and recall, but is very anxious her painful throat and her father's poor response to treatment. Patient alert, oriented x3. Cranial nerves intact. Extremities warm, well-perfused without rash or indurations.
Indicate whether this statement is true or false.
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Q. 7) What does the word supine mean?
A. The dark border outlining a specific system/body area in the single organ system physical examination
B. The nostril
C. Lying on the back
D. The section of the throat that contains the voicebox
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Q. 8) Which of the following statements best completes the sentence, The higher level of anatomic specificity in the single organ system physical examination
A. should be utilized when reviewing documentation of any E/M service visit regardless of the healthcare setting
B. may prove very helpful when reviewing documentation of an E/M service visit performed in a specialist's setting
C. is very daunting and should never be referenced regardless of the healthcare setting
D. is very general and was the first documentation guidelines drafted in 1995
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Q. 9) What are the requirements for a comprehensive type single organ system physical examination?
A. Documentation of every element identified by a bullet within a shaded border and at least one element within each unshaded border
B. Documentation of eight or more organ systems or body areas
C. Documentation of every element identified by a bullet
D. Documentation of at least two elements identified by a bullet in at least nine system/body areas
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Q. 10) Which of the following statements best completes the statement, The shaded border indicates that
A. those specific elements identified by a bullet have no bearing on the single organ system being examined
B. those specific elements identified by a bullet reveal very important clinical evidence about the single organ system being examined
C. those specific elements identified by a bullet are the only elements that should be examined regardless of the nature of the presenting problem
D. any positive findings for any of those specific elements identified by a bullet should warrant immediate medical attention
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