Question 1

A scan of the body divides the body in slices from left to right.

Accepted Answer

A)  coronal 
B)  ipsilateral 
C)  sagittal 
D)  supine 
E)  transverse 
A)  coronal 
B)  ipsilateral 
C)  sagittal 
D)  supine 
E)  transverse

Question 2

PCP refers to the:

Accepted Answer

A)  past care provider. 
B)  primary care provider. 
C)  past complaint or problem. 
D)  present complaint or problem. 
E)  primary complaint or problem. 
A)  past care provider. 
B)  primary care provider. 
C)  past complaint or problem. 
D)  present complaint or problem. 
E)  primary complaint or problem.

Question 3

A patient concern that just started recently, or is a sudden onset, severe symptom, is called:

Accepted Answer

A)  acute. 
B)  chronic. 
C)  febrile. 
D)  lethargic. 
E)  noncontributory. 
A)  acute. 
B)  chronic. 
C)  febrile. 
D)  lethargic. 
E)  noncontributory.

Question 4

What is the importance of health records?

Accepted Answer

A)  They contain information crucial to patient care. 
B)  They contain roadmaps to a patient's health history. 
C)  They provide a clearer picture of the best route to take in future treatment of the patient. 
D)  All of these. 
E)  None of these. 
A)  They contain information crucial to patient care. 
B)  They contain roadmaps to a patient's health history. 
C)  They provide a clearer picture of the best route to take in future treatment of the patient. 
D)  All of these. 
E)  None of these.

Question 5

Which of the following is NOT true about the medical term remission?

Accepted Answer

A)  It is a term that a medical professional might use in the assessment part of the health record. 
B)  It means the illness has been cured. 
C)  It means "to get better or improve." 
D)  It is most often used when discussing cancer. 
E)  None of these. 
A)  It is a term that a medical professional might use in the assessment part of the health record. 
B)  It means the illness has been cured. 
C)  It means "to get better or improve." 
D)  It is most often used when discussing cancer. 
E)  None of these.

Question 6

The following is an excerpt from a patient's discharge summary. Which of the following is NOT true about this excerpt? HPI
Miss Susan Nesbit is a 12-year-old female who first visited her primary care provider for dysuria. A UA was ordered, but the patient could not urinate in the office. She took the UA cup home but did not return with the sample. The next day, Susan's dysuria worsened, and she developed a fever of 102.3o F, as well as vomiting and hematuria, so she returned to the clinic. A urinalysis performed in the office revealed significant pyuria, hematuria, and albuminuria. Since Susan was not able to keep any fluids down, her primary care provider sent her to the emergency department for evaluation for admission.

Accepted Answer

A)  Her PCP sent her to the ED for evaluation and admission. 
B)  It contains the history of the present illness. 
C)  The patient is 12 y/o. 
D)  The patient returned to the clinic when her dysuria worsened and she became febrile. 
E)  The patient went to the ED before seeing her PCP. 
A)  Her PCP sent her to the ED for evaluation and admission. 
B)  It contains the history of the present illness. 
C)  The patient is 12 y/o. 
D)  The patient returned to the clinic when her dysuria worsened and she became febrile. 
E)  The patient went to the ED before seeing her PCP.

Question 7

Which term refers to toward the bottom?

Accepted Answer

A)  Cranial 
B)  Caudal 
C)  Dorsal 
D)  All of these. 
E)  None of these. 
A)  Cranial 
B)  Caudal 
C)  Dorsal 
D)  All of these. 
E)  None of these.

Question 8

According to the following discharge summary, which is true about this patient? HPI
Mrs) Roxana Collach presented to the ED with a 2-day history of increasing epigastric pain. She described the pain as constant and dull with radiation to her back. She also had progressive anorexia. She denied nausea, emesis, or diarrhea. She was febrile in the ED and had marked epigastric tenderness on exam with guarding. Her abdomen was slightly distended and she was mildly jaundiced. Her elevated amylase and lipase confirmed the suspicion of acute pancreatitis. She was admitted for pain control and IVF.

Accepted Answer

A)  Her anorexia was getting better. 
B)  She did not have a fever when she arrived. 
C)  She did not have any epigastric tenderness. 
D)  She was diagnosed with pancreatitis. 
E)  She was not given intravenous fluids. 
A)  Her anorexia was getting better. 
B)  She did not have a fever when she arrived. 
C)  She did not have any epigastric tenderness. 
D)  She was diagnosed with pancreatitis. 
E)  She was not given intravenous fluids.

Question 9

If a patient's symptoms or disease is becoming more and more severe, evident, etc. each day, it is known as:

Accepted Answer

A)  abrupt. 
B)  acute. 
C)  genetic. 
D)  malaise. 
E)  progressive. 
A)  abrupt. 
B)  acute. 
C)  genetic. 
D)  malaise. 
E)  progressive.

Question 10

After a health care provider has gathered information from the patient and performed any necessary investigations, the health care provider then formulates a(n) ________, which could be a diagnosis, identification of the problem, or a differential diagnosis.

Accepted Answer

A)  subjective 
B)  objective 
C)  assessment 
D)  plan 
E)  none of these 
A)  subjective 
B)  objective 
C)  assessment 
D)  plan 
E)  none of these

Question 11

Which is the correct abbreviation for a medicine administered "as desired"?

Accepted Answer

A)  Ad lib 
B)  IM 
C)  NPO 
D)  PICC 
E)  PO 
A)  Ad lib 
B)  IM 
C)  NPO 
D)  PICC 
E)  PO

Question 12

Which of the following health records would NOT include a plan?

Accepted Answer

A)  Clinic note 
B)  Consult note 
C)  Emergency department note 
D)  Pathology report 
E)  Prescription 
A)  Clinic note 
B)  Consult note 
C)  Emergency department note 
D)  Pathology report 
E)  Prescription

Question 13

Which of the following abbreviations is NOT part of a patient's history (either medical history or history of the illness)?

Accepted Answer

A)  H&P 
B)  HPI 
C)  h/o 
D)  PMHx 
E)  CTA 
A)  H&P 
B)  HPI 
C)  h/o 
D)  PMHx 
E)  CTA

Question 14

Which abbreviation does NOT describe the time of day in which a prescription should be taken?

Accepted Answer

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

Question 15

The risk for being sick is known as:

Accepted Answer

A)  malignant. 
B)  morbidity. 
C)  mortality. 
D)  prognosis. 
E)  idiopathic 
A)  malignant. 
B)  morbidity. 
C)  mortality. 
D)  prognosis. 
E)  idiopathic

Question 16

The following is a portion of a patient's consult note: Past Medical History: Noncontributory.
Past Surgical History: Balanoplastyfor hypospadias at age 1.
Social History: Doug lives with his parents and older sister. He is going into kindergarten in the fall.
Family History: Paternal grandfather with polycystic kidney disease.
According to the doctor who authored this note, which of the following is true?

Accepted Answer

A)  The patient has never had any surgeries 
B)  The patient has polycystic kidney disease. 
C)  The patient is 10 y/o. 
D)  The patient's PMHx is not related to this specific problem. 
E)  There is not enough information to draw any conclusions. 
A)  The patient has never had any surgeries 
B)  The patient has polycystic kidney disease. 
C)  The patient is 10 y/o. 
D)  The patient's PMHx is not related to this specific problem. 
E)  There is not enough information to draw any conclusions.

Question 17

What is the correct definition for the abbreviation RR?

Accepted Answer

A)  Radiology report 
B)  Rapid rate 
C)  Recurrent reason 
D)  Respiratory rate 
E)  Responsive remission 
A)  Radiology report 
B)  Rapid rate 
C)  Recurrent reason 
D)  Respiratory rate 
E)  Responsive remission

Question 18

Read the following health record excerpt. 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.
According to this excerpt, when Elizabeth arrived at the ED, she was:

Accepted Answer

A)  A&O x3. 
B)  did not look very sick and was able to answer questions and interact with health care professionals. 
C)  did not look very sick but acted very sick. 
D)  looked sick and was unable to answer questions or interact with health care professionals. 
E)  looked sick but was alert. 
A)  A&O x3. 
B)  did not look very sick and was able to answer questions and interact with health care professionals. 
C)  did not look very sick but acted very sick. 
D)  looked sick and was unable to answer questions or interact with health care professionals. 
E)  looked sick but was alert.

Question 19

Which of the following notes is usually authored by a specialist and provides an expert opinion on a more challenging problem?

Accepted Answer

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

Question 20

The normal blood pressure range is 90/60 to 140/90. A patient's blood pressure has been documented at 120/80. Which of the following abbreviations describes the patient's blood pressure?

Accepted Answer

A)  BP NAD 
B)  BP NEC 
C)  BP RRR 
D)  BP WDWN 
E)  BP WNL 
A)  BP NAD 
B)  BP NEC 
C)  BP RRR 
D)  BP WDWN 
E)  BP WNL

A scan of the body divides the body in slices from left to right.

PCP refers to the:

A patient concern that just started recently, or is a sudden onset, severe symptom, is called:

What is the importance of health records?

Which of the following is NOT true about the medical term remission?

Which term refers to toward the bottom?

If a patient's symptoms or disease is becoming more and more severe, evident, etc. each day, it is known as:

After a health care provider has gathered information from the patient and performed any necessary investigations, the health care provider then formulates a(n) ________, which could be a diagnosis, identification of the problem, or a differential diagnosis.

Which is the correct abbreviation for a medicine administered "as desired"?

Which of the following health records would NOT include a plan?

Which of the following abbreviations is NOT part of a patient's history (either medical history or history of the illness)?

Which abbreviation does NOT describe the time of day in which a prescription should be taken?

The risk for being sick is known as:

What is the correct definition for the abbreviation RR?

Which of the following notes is usually authored by a specialist and provides an expert opinion on a more challenging problem?

The normal blood pressure range is 90/60 to 140/90. A patient's blood pressure has been documented at 120/80. Which of the following abbreviations describes the patient's blood pressure?

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Exam 2: Introduction to Health Records

A scan of the body divides the body in slices from left to right.

PCP refers to the:

A patient concern that just started recently, or is a sudden onset, severe symptom, is called:

What is the importance of health records?

Which of the following is NOT true about the medical term remission?

Which term refers to toward the bottom?

If a patient's symptoms or disease is becoming more and more severe, evident, etc. each day, it is known as:

After a health care provider has gathered information from the patient and performed any necessary investigations, the health care provider then formulates a(n) ________, which could be a diagnosis, identification of the problem, or a differential diagnosis.

Which is the correct abbreviation for a medicine administered "as desired"?

Which of the following health records would NOT include a plan?

Which of the following abbreviations is NOT part of a patient's history (either medical history or history of the illness)?

Which abbreviation does NOT describe the time of day in which a prescription should be taken?

The risk for being sick is known as:

What is the correct definition for the abbreviation RR?

Which of the following notes is usually authored by a specialist and provides an expert opinion on a more challenging problem?

The normal blood pressure range is 90/60 to 140/90. A patient's blood pressure has been documented at 120/80. Which of the following abbreviations describes the patient's blood pressure?

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

Filters