Exam 2: Introduction to Health Records

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A physician informed the patient that he has six months to live following a diagnosis of pancreatic cancer. This is called a

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B

The medical term prophylaxis refers to

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C

In order for the medical professional to perform a physical examination, he asked the patient to lie on his back. This is called the ________________position.

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E

A _________infection is an infection that stays in a certain part of the body.

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A patient who is alert and oriented x 3 can

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A _____________symptom is one that a patient has again and again.

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The prefix in the term unilateral means

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The following is an excerpt from a patient's discharge summary. Which of the following is NOT true about this excerpt? "Miss Susan Nesbit is a 12-year-old female who first visited her primary care provider for dysuria. A urinalysis was ordered, but the patient could not urinate in the office. She took the urinalysis cup home but did not return with the sample. The next day, Susan's dysuria worsened. She developed a fever of 102.3o F, 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."

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If a patient is prone, he is

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A (n)_________ scan of the body divides the body in slices from right to left.

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In a patient's medical record, which term would be used to indicate that something is not related to the specific problem the patient is experiencing?

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The medical term that means the cause of the disease is

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The best definition of a systemic infection is an infection that

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The left hemisphere controls movement on the right side of your body. This is called __________control.

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The part of the medical record that outlines a course of action consistent with a health care provider's assessment is the ________.

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According to the following discharge summary, which of the following statements is true about this patient? "Mrs. Roxana Collach presented to the emergency department 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 emergency department 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 intravenous fluids."

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In a medical record, the main reason for the patient's visit is the

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The findings from the techniques of auscultation, percussion, and palpation would be found in which part of the patient's medical record?

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The medical term that means pertaining to the same side is

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The section of the medical record containing information related to a patient's habits such as smoking, alcohol use, drug abuse and sexual practices would be found in the

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