Question 1

A patient complains of itchy skin and has a very noticeable rash.What is an appropriate medical term to describe the rash?

Accepted Answer

A) Alert 
B) Marked 
C) Objective 
D) Oriented 
E) Unremarkable 
A) Alert 
B) Marked 
C) Objective 
D) Oriented 
E) Unremarkable B

Question 2

The story of the patient's problem is known as:

Accepted Answer

A) chief complaint. 
B) family history. 
C) history of present illness. 
D) review of history. 
E) social history. 
A) chief complaint. 
B) family history. 
C) history of present illness. 
D) review of history. 
E) social history. C

Question 3

As part of a patient's treatment plan, she was admitted to the hospital for observation.This means :

Accepted Answer

A) the patient needs to be admitted to the hospital to undergo further tests before she can be diagnosed. 
B) the patient will be discharged with a prescription. 
C) the patient will be in the hospital so that medical professionals can watch, or keep an eye on, her. 
D) the patient will be sent home to see if the symptoms get better on their own. 
E) the patient's symptoms resolved after her hospital stay. 
A) the patient needs to be admitted to the hospital to undergo further tests before she can be diagnosed. 
B) the patient will be discharged with a prescription. 
C) the patient will be in the hospital so that medical professionals can watch, or keep an eye on, her. 
D) the patient will be sent home to see if the symptoms get better on their own. 
E) the patient's symptoms resolved after her hospital stay. C

Question 4

Which of the following is FALSE about the SOAP method?

Accepted Answer

A) Diagnostic work in medicine is very similar to the investigative work of a detective; thus the SOAP method begins with an analysis and ends with collecting data to confirm the diagnosis. 
B) Most medical notes share a consistent pattern in their organization and layout that reflects the SOAP thought process. 
C) SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. 
D) SOAP reflects a general thought process used by most medical professionals. 
E) The SOAP method is repeated in every health care visit across all disciplines of medicine. 
A) Diagnostic work in medicine is very similar to the investigative work of a detective; thus the SOAP method begins with an analysis and ends with collecting data to confirm the diagnosis. 
B) Most medical notes share a consistent pattern in their organization and layout that reflects the SOAP thought process. 
C) SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. 
D) SOAP reflects a general thought process used by most medical professionals. 
E) The SOAP method is repeated in every health care visit across all disciplines of medicine.

Question 5

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 
E) Vital Signs: Temp: 102.3; HtR: 90; RR: 20; BP: 112/84 
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 
E) Vital Signs: Temp: 102.3; HtR: 90; RR: 20; BP: 112/84

Question 6

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

Question 7

The following excerpt would most accurately be classified as which kind of health care record? Dear Dr.Childs,
Thank you for referring Mr.Samuels to my office.I saw him on March 3, 2015.Mr.Samuels has a 4-month history of increasing pain in his right distal femur.He first noticed pain after being kicked in the leg at a soccer game and was evaluated in your office 3 weeks later for persistent pain.There was a soft tissue mass in his distal femur that was tender to touch.

Accepted Answer

A) Consult note 
B) Operative report 
C) Pathology report 
D) Prescription 
E) Discharge summary 
A) Consult note 
B) Operative report 
C) Pathology report 
D) Prescription 
E) Discharge summary

Question 8

After a car accident, the medical professional asks the patient questions about her name, location, and the date.The patient is able to accurately answer all of the questions.The patient can be classified as :

Accepted Answer

A) A&O. 
B) PERRLA. 
C) NAD. 
D) ROS. 
E) WDWN. 
A) A&O. 
B) PERRLA. 
C) NAD. 
D) ROS. 
E) WDWN.

Question 9

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

Accepted Answer

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

Question 10

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 11

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 12

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 13

Which part of the SOAP method most accurately describes the following excerpt from a patient's clinic note? T: 99.0; HR: 60; RR: 20; BP: 112/70.
General: Pleasant, responsive.No acute distress.
HEENT: PERRLA.Mucous membranes moist and pink.
Resp: CTA.No wheezes, rales, rhonchi, or crackles.Good air exchange.No increased work of breathing.

Accepted Answer

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

Question 14

Read the following health record excerpt. Emergency Department Course:
Miss Sweet 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.Chemistry profile showed hypernatremia, hypokalemia, and acidemia.The pediatric intensive care team was contacted for transfer to the PICU.
Disposition: Transfer to PICU.
According to this excerpt, when Miss Sweet 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 15

Read the following discharge summary: Hospital Course
Mrs)Collach was admitted to the medical service.She was placed on NPO status and given IVF and analgesics.An ultrasound revealed gallstones in the common bile duct as the etiology for Mrs.Collach's pancreatitis.Surgery was consulted.On hospital day 2, Mrs.Collach was taken to the OR for laparoscopic choledocholithectomy and cholecystectomy.She tolerated the procedure well.She began a postoperative refeeding plan with a low-protein, low-fat diet.She tolerated advancing the diet, and 2 days after her surgery, her pain had improved enough that she was discharged home.
According to this summary, which of the following is true?

Accepted Answer

A) The ultrasound results are pending. 
B) The ultrasound revealed gallstones, and the cause of the pancreatitis is occult. 
C) The ultrasound revealed gallstones as the cause of Mrs.Collach's pancreas pain. 
D) The ultrasound revealed gallstones, but they were noncontributory. 
E) The ultrasound revealed the common bile duct has lesions. 
A) The ultrasound results are pending. 
B) The ultrasound revealed gallstones, and the cause of the pancreatitis is occult. 
C) The ultrasound revealed gallstones as the cause of Mrs.Collach's pancreas pain. 
D) The ultrasound revealed gallstones, but they were noncontributory. 
E) The ultrasound revealed the common bile duct has lesions.

Question 16

Which of the following is the best definition for differential diagnosis?

Accepted Answer

A) A list of conditions the patient may have based on the symptoms exhibited and the results of the exam 
B) A problem resulting from a disease or injury 
C) Another way of saying assessment 
D) The cause 
E) What the health care professional thinks the patient has 
A) A list of conditions the patient may have based on the symptoms exhibited and the results of the exam 
B) A problem resulting from a disease or injury 
C) Another way of saying assessment 
D) The cause 
E) What the health care professional thinks the patient has

Question 17

According to the following discharge summary, which of the following is NOT true about this patient? Discharge Physical Examination
Temp: 98.6; RR: 24; HR: 86; BP: 100/64.
Gen: WDWN.Alert.
CV: RRR.
Resp: CTA.
GI: Abdomen soft, nondistended, mild tenderness to palpation over the surgical incisions.Three small horizontal surgical wounds in her abdomen.Wounds clean, dry, and intact.
Activity
No restrictions.

Accepted Answer

A) The patient does not have a fever. 
B) The patient experiences mild tenderness when her surgical incisions are touched. 
C) The patient's heart is beating rapidly. 
D) The patient looks well-developed and well-nourished. 
E) The patient's lungs sound clear. 
A) The patient does not have a fever. 
B) The patient experiences mild tenderness when her surgical incisions are touched. 
C) The patient's heart is beating rapidly. 
D) The patient looks well-developed and well-nourished. 
E) The patient's lungs sound clear.

Question 18

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 19

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

Question 20

If an infection stays in a certain part of the body, it is:

Accepted Answer

A) degenerate. 
B) localized. 
C) malignant. 
D) recurrent. 
E) systemic. 
A) degenerate. 
B) localized. 
C) malignant. 
D) recurrent. 
E) systemic.

A patient complains of itchy skin and has a very noticeable rash.What is an appropriate medical term to describe the rash?

The story of the patient's problem is known as:

As part of a patient's treatment plan, she was admitted to the hospital for observation.This means :

Which of the following is FALSE about the SOAP method?

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.

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?

After a car accident, the medical professional asks the patient questions about her name, location, and the date.The patient is able to accurately answer all of the questions.The patient can be classified as :

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

If a patient is prone, he is:

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

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

Which of the following is the best definition for differential diagnosis?

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

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

If an infection stays in a certain part of the body, it is:

Introduction to Medical Language

The Integumentary System-Dermatology

The Musculoskeletal System-Orthopedics

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Exam 2: Introduction to Health Records

A patient complains of itchy skin and has a very noticeable rash.What is an appropriate medical term to describe the rash?

The story of the patient's problem is known as:

As part of a patient's treatment plan, she was admitted to the hospital for observation.This means :

Which of the following is FALSE about the SOAP method?

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.

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?

After a car accident, the medical professional asks the patient questions about her name, location, and the date.The patient is able to accurately answer all of the questions.The patient can be classified as :

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

If a patient is prone, he is:

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

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

Which of the following is the best definition for differential diagnosis?

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

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

If an infection stays in a certain part of the body, it is:

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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