Which of the following methods are acceptable for the provider to give the physical exam? (Check all that apply.)

Call out exam findings during the visit.

Dictate exam findings all at once after the visit.

Dictate exam findings for several patients at once during downtime.

Call out exam findings during the visit.

Dictate exam findings all at once after the visit.

Dictate exam findings for several patients at once during downtime.

Expect the scribe to watch the stream and interpret exam findings without dictation.

What does the acronym PERRL stand for?

Pupils Equal, Round, and Reactive to Light

Pupils Equal, Round, Red, Light

Prostate Enlarged, Round, Reactive to Light touch

Prostate Enlarged, Round, Red, Lobes intact

What is the definition of rales?

Small clicking, bubbling, or rattling sounds in the lungs during inhalation

A high-pitched whistling sound made while breathing

Sounds that resemble snoring. Occur when air is blocked or air flow becomes rough through large airways

An uncommon sound, such as scraping or grating noise associated with an inflamed pericardium

Which is the MOST likely exam finding associated with the chief complaint, abdominal pain?

Right lower quadrant tenderness to palpation

If the provider says, "patient had a normal exam," what should you do as their scribe?

Use the provider's default normal PE template. Make no changes.

Use the provider's default normal PE template. Delete body systems which you didn't notice the provider examining.

Document the exam findings you noticed during the exam.

Which of the following could be documented in the physical exam section of the chart? (Check all that apply.)

suprapubic tenderness to palpation

Which of the following physical exam findings are CORRECTLY matched with their associated body system? (Check all that apply.)

Male GU: testes are descended bilaterally, with no tenderness or masses

Breasts: no excoriations or lesions to vulva

Which of the following contain contradictions? (Check all that apply.)

Cardiovascular: Arrhythmia, regular rate and rhythm, normal S1 and S2, no murmurs, rubs, or gallops

Respiratory: Faint crackles in left lower lobe, clear to auscultation bilaterally, no wheeze or rhonchi

Cardiovascular: Arrhythmia, regular rate and rhythm, normal S1 and S2, no murmurs, rubs, or gallops

HEENT: Ears - Cerumen partially occluding the right ear canal, TMs are intact without injection or retraction, normal light reflex; Nose - clear; Mouth - oral mucosa moist, posterior oropharynx without erythema or exudates

Breasts: nipple discharge, no masses on palpation or axillary lymph nodes

Respiratory: Faint crackles in left lower lobe, clear to auscultation bilaterally, no wheeze or rhonchi

Which of the PE body systems below is CORRECT?

General: Well appearing and in no acute distress.

HEENT: Nasal mucosa erythematous and boggy. 2+ submandibular lymphadenopathy bilaterally. PERRL, EOMI, conjunctiva clear, TMs clear bilaterally, oropharynx normal.

Lungs: Upper lung rhonchi and end expiratory wheezing

General: Well appearing and in no acute distress.

Rectal: Normal sphincter tone, no masses or tenderness.

What is the correct shorthand notation for submandibular lymphadenopathy?

There is no "correct" shorthand notation. Shorthand notation styles differ from scribe to scribe.

How should the PE template be used for this patient's note? (Check all that apply.)

Input the dictated findings into the correct body system.

Eliminate any contradictions between the template and the dictated findings.

Input the dictated findings into the correct body system.

Eliminate any contradictions between the template and the dictated findings.

Eliminate the body systems that the provider did not mention in his dictation.

Add the additional templates for Male GU and Rectal exams.

AST V3 Lecture 5 Assessment

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Quizzes Created: 13 | Total Attempts: 3,913

Questions: 30 | Attempts: 57 | Updated: May 31, 2023

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AST V3 Lecture 5 Assessment

This audio recording is based on a real physical exam dictation. Utilize shorthand when taking notes on this dictation. Your notes will not be graded.This audio recording applies to question XX-XX.

Type your notes below.

Which of the following should be included in the Physical Exam (PE)? (Check all that apply.)

Which of the following are physical exam findings? (Check all that apply.)

A primary scribe should always clarify with the provider by asking specific questions if physical exam findings are unclear.

Which of the following methods are acceptable for the provider to give the physical exam? (Check all that apply.)

What does the acronym PERRL stand for?

What is the definition of rales?

Which is the MOST likely exam finding associated with the chief complaint, abdominal pain?

Alert and oriented x3 means the patient is alert and oriented to... (Check all that apply.)

If the provider says, "patient had a normal exam," what should you do as their scribe?

If the patient complains of abdominal pain, the provider will always dictate physical exam findings for the Abdomen after the visit.

Which of the following are techniques used during the Physical Exam? (Check all that apply.)

Which of the following could be documented in the physical exam section of the chart? (Check all that apply.)

Which of the following physical exam findings are CORRECTLY matched with their associated body system? (Check all that apply.)

______________ is a technique used to assess the patient's lungs.

There is one standard PE template for all physicians and specialties.

Which of the following contain contradictions? (Check all that apply.)

Nasal congestion is a physical exam finding.

Which of the following is an abnormal vital sign?

If a patient presents with a GI complaint, which body system would you expect the provider to examine?

If a patient presents with a history of osteoarthritis, which body system would you expect the provider to examine?

Exam findings for which body systems were dictated? (Check all that apply.)

Which of the PE body systems below is CORRECT?

What is the correct shorthand notation for submandibular lymphadenopathy?

How should the PE template be used for this patient's note? (Check all that apply.)

Based on the audio recording, which of the Top 10 Chief Complaints is most likely?