Question 1

A discharge summary will often have information regarding the recommended f/u, or ________ for the patient.

Accepted Answer

A)  future ultrasounds 
B)  future ultrasonographies 
C)  future uses 
D)  following ultrasounds 
E)  follow up 
A)  future ultrasounds 
B)  future ultrasonographies 
C)  future uses 
D)  following ultrasounds 
E)  follow up E

Question 2

During a patient exam, a medical professional may feel parts of the patient's body. This is called:

Accepted Answer

A)  auscultation. 
B)  diagnosing. 
C)  palpation. 
D)  palpitation. 
E)  percussion. 
A)  auscultation. 
B)  diagnosing. 
C)  palpation. 
D)  palpitation. 
E)  percussion. C

Question 3

In the following prescription, which line gives the patient instructions? Amoxicillin 400 mg/5ml
Sig) 5 ml PO BID x 10days
Dispense 100ml
Refills: None
Brand name medically necessary

Accepted Answer

A)  Amoxicillin 400 mg/5ml 
B)  Sig. 5 ml PO BID x 10 days 
C)  Dispense 100ml 
D)  Refills: None 
E)  Brand name medically necessary 
A)  Amoxicillin 400 mg/5ml 
B)  Sig. 5 ml PO BID x 10 days 
C)  Dispense 100ml 
D)  Refills: None 
E)  Brand name medically necessary B

Question 4

Which of the following terms is part of a patient's assessment?

Accepted Answer

A)  Auscultation 
B)  Family medical history 
C)  Past surgical history 
D)  Reassurance 
E)  Sequelae 
A)  Auscultation 
B)  Family medical history 
C)  Past surgical history 
D)  Reassurance 
E)  Sequelae

Question 5

The superior vena cava is a large-diameter, yet short, vein that carries deoxygenated blood from the body to the heart. It is located in the anterior right superior mediastinum. The correct definitions of anterior and superior are:

Accepted Answer

A)  back, above. 
B)  back, below. 
C)  front, above. 
D)  front, below. 
A)  back, above. 
B)  back, below. 
C)  front, above. 
D)  front, below.

Question 6

Which of the abbreviations would be a correct reflection of the following Emergency Department note? Physical Exam
Vital Signs: Temperature: 102.3; Heart Rate: 90; Respiratory Rate: 20;BP: 112/84.
General: Well-developed and nourished, in mild discomfort. Alert andoriented x 3.

Accepted Answer

A)  Vital Signs: T: 90; HR: 90; RRR; BP: 112/84 General: WDWN, in mild discomfort. A&Ox3 
B)  Vital Signs: T: 102.3; HR: 90; RR: 20; BP: 112/84 General: WDWN, in mild discomfort. A&Ox3 
C)  Vital Signs: T: 102.3; HR: 90; RR: 20; BP: 112/84 General: WW, in mild discomfort. A&Ox3 
D)  Vital Signs: T: 102.3; HtR: 90; RR: 20; BldPres: 112/84 General: WW, in mild discomfort. A&Ox3 
E)  Vital Signs: Temp: 102.3; HtR: 90; RR: 20; BP: 112/84 General: WW, in mild discomfort. Al&Orx3 
A)  Vital Signs: T: 90; HR: 90; RRR; BP: 112/84 General: WDWN, in mild discomfort. A&Ox3 
B)  Vital Signs: T: 102.3; HR: 90; RR: 20; BP: 112/84 General: WDWN, in mild discomfort. A&Ox3 
C)  Vital Signs: T: 102.3; HR: 90; RR: 20; BP: 112/84 General: WW, in mild discomfort. A&Ox3 
D)  Vital Signs: T: 102.3; HtR: 90; RR: 20; BldPres: 112/84 General: WW, in mild discomfort. A&Ox3 
E)  Vital Signs: Temp: 102.3; HtR: 90; RR: 20; BP: 112/84 General: WW, in mild discomfort. Al&Orx3

Question 7

Which of the following is the correct definition for the term chronic?

Accepted Answer

A)  All of a sudden 
B)  It has been going on for a while now. 
C)  It runs in the family. 
D)  Not feeling well 
E)  Something a patient feels 
A)  All of a sudden 
B)  It has been going on for a while now. 
C)  It runs in the family. 
D)  Not feeling well 
E)  Something a patient feels

Question 8

The patient had "tubes placed bilaterally." PMHx
Johnny's history is significant for tympanostomy tubes placed bilaterally when he was 2 years old. One tube left a persistent perforation in the tympanic membrane, so he had tympanoplasty at 3 years of age. He has not had any episodes of otitis media in the past 2 years.
Which is the correct breakdown and definition of the term bilateral?

Accepted Answer

A)  bi (one) + lateral (out to the side) = one side 
B)  bi (side) + lateral (toward the middle) = toward the middle of the side 
C)  bi (side) + lateral (toward the side) = toward the side 
D)  bi (two) + lateral (out to the side) = both sides 
E)  bi (two) + lateral (toward the middle) = in the middle 
A)  bi (one) + lateral (out to the side) = one side 
B)  bi (side) + lateral (toward the middle) = toward the middle of the side 
C)  bi (side) + lateral (toward the side) = toward the side 
D)  bi (two) + lateral (out to the side) = both sides 
E)  bi (two) + lateral (toward the middle) = in the middle

Question 9

Which of the following health records describes when and why a patient was admitted to the hospital, documents his/her stay in the hospital, and indicates the type of follow-up the patient will have?

Accepted Answer

A)  Admission summary 
B)  Clinic note 
C)  Daily hospital/progress note 
D)  Discharge summary 
E)  Emergency department note 
A)  Admission summary 
B)  Clinic note 
C)  Daily hospital/progress note 
D)  Discharge summary 
E)  Emergency department note

Question 10

According to the following discharge summary, which of the following statements is NOT true? Hospital Course
On postop day 2, Ms. Cloud began complaining of increasing right ophthalmalgia. She was noted to be febrile to 102.2. Exam revealed conjunctival infection and edema. She was presumed to have postoperative endophthalmitis. Vitrectomy was performed under sterile conditions, and samples were sent to lab for culture. She was given intravitreal antibiotics. Over the next couple of days, her fever curve trended down and her WBC count improved. Cultures came back positive for S. epidermidis. Infectious disease was consulted; they recommended two weeks of IV therapy. A PICC line was placed and she was discharged with care instructions.

Accepted Answer

A)  A peripherally inserted central catheter was inserted. 
B)  Ms. Cloud complained of increasing right ophthalmalgia 2 days before her surgery. 
C)  Ms. Cloud developed a fever while in the hospital. 
D)  Ms. Cloud was presumed to have endophthalmitis after her operation. 
E)  The vitrectomy was performed under extremely clean, germ-free conditions. 
A)  A peripherally inserted central catheter was inserted. 
B)  Ms. Cloud complained of increasing right ophthalmalgia 2 days before her surgery. 
C)  Ms. Cloud developed a fever while in the hospital. 
D)  Ms. Cloud was presumed to have endophthalmitis after her operation. 
E)  The vitrectomy was performed under extremely clean, germ-free conditions.

Question 11

In order to treat the symptoms and make the patient feel better, a medical professional may recommend:

Accepted Answer

A)  discharge. 
B)  observation. 
C)  consultation 
D)  reassurance. 
E)  supportive care. 
A)  discharge. 
B)  observation. 
C)  consultation 
D)  reassurance. 
E)  supportive care.

Question 12

Which section of the health record is NOT included in the subjective section?

Accepted Answer

A)  Chief complaint 
B)  Family history 
C)  Past medical history 
D)  Review of systems 
E)  Social history 
A)  Chief complaint 
B)  Family history 
C)  Past medical history 
D)  Review of systems 
E)  Social history

Question 13

A patient usually has surgery in a(n):

Accepted Answer

A)  ED. 
B)  ICU. 
C)  OR. 
D)  PACU. 
E)  SICU. 
A)  ED. 
B)  ICU. 
C)  OR. 
D)  PACU. 
E)  SICU.

Question 14

The cause is also called the:

Accepted Answer

A)  diagnosis. 
B)  etiology. 
C)  impression. 
D)  remission. 
E)  sequelae. 
A)  diagnosis. 
B)  etiology. 
C)  impression. 
D)  remission. 
E)  sequelae.

Question 15

The prescriber uses which of the following abbreviations if a medication is to be taken before meals?

Accepted Answer

A)  AC 
B)  PC 
C)  prn 
D)  QHS 
E)  TID 
A)  AC 
B)  PC 
C)  prn 
D)  QHS 
E)  TID

Question 16

If a patient is prone, he is:

Accepted Answer

A)  lying down on his belly. 
B)  lying down on his back. 
C)  lying down on his left side. 
D)  lying down on his right side. 
E)  standing. 
A)  lying down on his belly. 
B)  lying down on his back. 
C)  lying down on his left side. 
D)  lying down on his right side. 
E)  standing.

Question 17

Read this excerpt from a patient's health record. PMHx
Johnny's history is significant for tympanostomy tubes placed bilaterally when he was 2 years old. One tube left a persistent perforation in the tympanic membrane, so he had tympanoplasty at 3 years of age. He has not had any episodes of otitis media in the past 2 years.
This is the patient's:

Accepted Answer

A)  chief complaint. 
B)  history of present illness. 
C)  past medical history. 
D)  personal social medical history. 
E)  review of systems. 
A)  chief complaint. 
B)  history of present illness. 
C)  past medical history. 
D)  personal social medical history. 
E)  review of systems.

Question 18

The following excerpt is from which portion of the discharge summary? Labs
Admission labs: UA: Pyuria: .20 wbcs; Hematuria: 3 1 blood; Albuminuria: 1 1 protein.
Urine culture: E. coli.
Blood culture: E. coli.
Discharge labs: UA normal. Urine culture normal.
Imaging
VCUG: No vesicoureteral reflux noted.
RUS: No hydronephrosis noted. Normal.
Spiral CT of kidneys on day 3 of admission revealed perinephric abscess formation of the left kidney.

Accepted Answer

A)  Subjective 
B)  Objective 
C)  Assessment 
D)  Plan 
E)  Prescription 
A)  Subjective 
B)  Objective 
C)  Assessment 
D)  Plan 
E)  Prescription

Question 19

In the following health record, the patient's disposition is noted. Emergency Department Course:
Elizabeth arrived in the ED lethargic but responsive. Given her history and vomiting, we were concerned about diabetic ketoacidosis. The patient's finger stick blood sugar test result of 320 confirmed hyperglycemia, and a urinalysis revealed both glucosuria and ketonuria. An IV was started and labs were sent for review. Chemistry profile showed hypernatremia, hypokalemia, and acidemia. The pediatric intensive care team was contacted for patient transfer to the PICU.
Disposition: Transfer to PICU.
The correct definition for disposition in this context is:

Accepted Answer

A)  how the patient is feeling. 
B)  the main reason for the patient's visit. 
C)  what happened to the patient at the end of the ED visit. 
D)  when the patient will be sent home. 
E)  none of these. 
A)  how the patient is feeling. 
B)  the main reason for the patient's visit. 
C)  what happened to the patient at the end of the ED visit. 
D)  when the patient will be sent home. 
E)  none of these.

Question 20

Which of the following does NOT refer to "the front"?

Accepted Answer

A)  Antral 
B)  Anterior 
C)  Dorsal 
D)  Ventral 
E)  They all refer to "the front." 
A)  Antral 
B)  Anterior 
C)  Dorsal 
D)  Ventral 
E)  They all refer to "the front."

A discharge summary will often have information regarding the recommended f/u, or ________ for the patient.

During a patient exam, a medical professional may feel parts of the patient's body. This is called:

In the following prescription, which line gives the patient instructions? Amoxicillin 400 mg/5ml Sig) 5 ml PO BID x 10days Dispense 100ml Refills: None Brand name medically necessary

Which of the following terms is part of a patient's assessment?

The superior vena cava is a large-diameter, yet short, vein that carries deoxygenated blood from the body to the heart. It is located in the anterior right superior mediastinum. The correct definitions of anterior and superior are:

Which of the abbreviations would be a correct reflection of the following Emergency Department note? Physical Exam Vital Signs: Temperature: 102.3; Heart Rate: 90; Respiratory Rate: 20;BP: 112/84. General: Well-developed and nourished, in mild discomfort. Alert andoriented x 3.

Which of the following is the correct definition for the term chronic?

Which of the following health records describes when and why a patient was admitted to the hospital, documents his/her stay in the hospital, and indicates the type of follow-up the patient will have?

In order to treat the symptoms and make the patient feel better, a medical professional may recommend:

Which section of the health record is NOT included in the subjective section?

A patient usually has surgery in a(n):

The cause is also called the:

The prescriber uses which of the following abbreviations if a medication is to be taken before meals?

If a patient is prone, he is:

Which of the following does NOT refer to "the front"?

Introduction to Medical Language

The Integumentary System Dermatology

The Musculoskeletal System Orthopedics

The Nervous System Neurology and Psychiatry

The Sensory System Ophthalmology and Otolaryngology

The Endocrine System Endocrinology

The Blood and Lymphatic Systems Hematology and Immunology

The Cardiovascular System Cardiology

The Respiratory System Pulmonology

The Gastrointestinal System Gastroenterology

The Urinary and Male Reproductive Systems Urology

The Female Reproductive System Gynecology, Obstetrics, and Neonatology

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Exam 2: Introduction to Health Records

A discharge summary will often have information regarding the recommended f/u, or ________ for the patient.

During a patient exam, a medical professional may feel parts of the patient's body. This is called:

In the following prescription, which line gives the patient instructions? Amoxicillin 400 mg/5ml Sig) 5 ml PO BID x 10days Dispense 100ml Refills: None Brand name medically necessary

Which of the following terms is part of a patient's assessment?

The superior vena cava is a large-diameter, yet short, vein that carries deoxygenated blood from the body to the heart. It is located in the anterior right superior mediastinum. The correct definitions of anterior and superior are:

Which of the abbreviations would be a correct reflection of the following Emergency Department note? Physical Exam Vital Signs: Temperature: 102.3; Heart Rate: 90; Respiratory Rate: 20;BP: 112/84. General: Well-developed and nourished, in mild discomfort. Alert andoriented x 3.

Which of the following is the correct definition for the term chronic?

Which of the following health records describes when and why a patient was admitted to the hospital, documents his/her stay in the hospital, and indicates the type of follow-up the patient will have?

In order to treat the symptoms and make the patient feel better, a medical professional may recommend:

Which section of the health record is NOT included in the subjective section?

A patient usually has surgery in a(n):

The cause is also called the:

The prescriber uses which of the following abbreviations if a medication is to be taken before meals?

If a patient is prone, he is:

Which of the following does NOT refer to "the front"?

Introduction to Medical Language

The Integumentary System Dermatology

The Musculoskeletal System Orthopedics

The Nervous System Neurology and Psychiatry

The Sensory System Ophthalmology and Otolaryngology

The Endocrine System Endocrinology

The Blood and Lymphatic Systems Hematology and Immunology

The Cardiovascular System Cardiology

The Respiratory System Pulmonology

The Gastrointestinal System Gastroenterology

The Urinary and Male Reproductive Systems Urology

The Female Reproductive System Gynecology, Obstetrics, and Neonatology

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