Question 1

Which of the following would NOT describe a patient with a normal physical exam?

Accepted Answer

A) CTA, RRR 
B) CTA, SOB 
C) NAD, WDWN 
D) PERRLA, A&O 
E) WNL 
A) CTA, RRR 
B) CTA, SOB 
C) NAD, WDWN 
D) PERRLA, A&O 
E) WNL

Question 2

Which of the following health care notes is NOT usually authored in a hospital?

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 3

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 4

When a medical professional gives a prognosis, he is indicating:

Accepted Answer

A) the chances for things getting better or worse. 
B) the organism that causes the problem. 
C) the risk for being sick. 
D) the risk for dying. 
E) what he thinks the patient has. 
A) the chances for things getting better or worse. 
B) the organism that causes the problem. 
C) the risk for being sick. 
D) the risk for dying. 
E) what he thinks the patient has.

Question 5

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 6

The following is an excerpt from a patient's medical record.According to this information, which is NOT true about the patient? T: 98.5; 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) The patient is afebrile. 
B) The patient is alert. 
C) The patient's eyes are not reacting to light. 
D) The patient's heart rate is 60. 
E) The patient's respiratory rate is 20. 
A) The patient is afebrile. 
B) The patient is alert. 
C) The patient's eyes are not reacting to light. 
D) The patient's heart rate is 60. 
E) The patient's respiratory rate is 20.

Question 7

Which of the following abbreviations and terms is NOT associated with the assessment in the SOAP method?

Accepted Answer

A) DDx 
B) Idiopathic 
C) Mortality 
D) Occult 
E) WDWN 
A) DDx 
B) Idiopathic 
C) Mortality 
D) Occult 
E) WDWN

Question 8

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 9

Information such as the patient's physical exam, any laboratory findings, and imaging studies performed at the visit would be contained in which part of the diagnostic process?

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 10

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

Question 11

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 12

A systemic infection by definition:

Accepted Answer

A) stays in a certain part of the body. 
B) infects all or most of the body. 
C) is a dangerous problem. 
D) is a problem resulting from disease or injury. 
E) is the organism that caused the problem. 
A) stays in a certain part of the body. 
B) infects all or most of the body. 
C) is a dangerous problem. 
D) is a problem resulting from disease or injury. 
E) is the organism that caused the problem.

Question 13

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 14

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

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 15

Which of the following is an accurate breakdown of the abbreviation IM?

Accepted Answer

A) instrumental = the essential portions of a patient's health record 
B) intermedical = inter (between) + medic/o (medicine) + al (pertaining to) = information shared between medical professionals 
C) intramicrobial = intra (in, inside) + micro (small) + bial (pertaining to) = pertaining to the small microorganisms for which a prescription is dedicated 
D) intramuscular = intra (in, inside) + muscul/o (muscle) + ar (pertaining to) = inside a muscle 
E) None of these 
A) instrumental = the essential portions of a patient's health record 
B) intermedical = inter (between) + medic/o (medicine) + al (pertaining to) = information shared between medical professionals 
C) intramicrobial = intra (in, inside) + micro (small) + bial (pertaining to) = pertaining to the small microorganisms for which a prescription is dedicated 
D) intramuscular = intra (in, inside) + muscul/o (muscle) + ar (pertaining to) = inside a muscle 
E) None of these

Question 16

A symptom that a patient has again and that continues to get worse is called:

Accepted Answer

A) degenerate; malignant. 
B) recurrent; degenerate. 
C) recurrent; idiopathic. 
D) idiopathic; malignant. 
E) malignant; recurrent. 
A) degenerate; malignant. 
B) recurrent; degenerate. 
C) recurrent; idiopathic. 
D) idiopathic; malignant. 
E) malignant; recurrent.

Question 17

A medication prescribed BID is taken:

Accepted Answer

A) once a day. 
B) twice a day. 
C) three times a day. 
D) before meals. 
E) after meals. 
A) once a day. 
B) twice a day. 
C) three times a day. 
D) before meals. 
E) after meals.

Question 18

A patient was given a prescription with the following information: "Sig.5 mL PO BID x 10 days." Which is the most accurate description of the patient prescription?

Accepted Answer

A) The medication will be taken as needed for ten days. 
B) The medication will be taken by mouth once a day for ten days. 
C) The medication will be taken by mouth twice a day for ten days. 
D) The medication will be taken intravenously for ten days. 
E) The medication will be taken subcutaneously for ten days. 
A) The medication will be taken as needed for ten days. 
B) The medication will be taken by mouth once a day for ten days. 
C) The medication will be taken by mouth twice a day for ten days. 
D) The medication will be taken intravenously for ten days. 
E) The medication will be taken subcutaneously for ten days.

Question 19

NOS and NEC are:

Accepted Answer

A) abbreviations used for symptoms and exam findings. 
B) catchalls for diagnoses that don't quite fit any specific cause. 
C) mean "not otherwise specified" or "not elsewhere classified." 
D) all of these. 
E) none of these. 
A) abbreviations used for symptoms and exam findings. 
B) catchalls for diagnoses that don't quite fit any specific cause. 
C) mean "not otherwise specified" or "not elsewhere classified." 
D) all of these. 
E) none of these.

Question 20

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.

Which of the following would NOT describe a patient with a normal physical exam?

Which of the following health care notes is NOT usually authored in a hospital?

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

When a medical professional gives a prognosis, he is indicating:

Which of the following abbreviations and terms is NOT associated with the assessment in the SOAP method?

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?

Information such as the patient's physical exam, any laboratory findings, and imaging studies performed at the visit would be contained in which part of the diagnostic process?

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

The cause is also called the:

A systemic infection by definition:

What is the importance of health records?

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

Which of the following is an accurate breakdown of the abbreviation IM?

A symptom that a patient has again and that continues to get worse is called:

A medication prescribed BID is taken:

A patient was given a prescription with the following information: "Sig.5 mL PO BID x 10 days." Which is the most accurate description of the patient prescription?

NOS and NEC are:

A patient usually has surgery in a(n):

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

Which of the following would NOT describe a patient with a normal physical exam?

Which of the following health care notes is NOT usually authored in a hospital?

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

When a medical professional gives a prognosis, he is indicating:

Which of the following abbreviations and terms is NOT associated with the assessment in the SOAP method?

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?

Information such as the patient's physical exam, any laboratory findings, and imaging studies performed at the visit would be contained in which part of the diagnostic process?

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

The cause is also called the:

A systemic infection by definition:

What is the importance of health records?

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

Which of the following is an accurate breakdown of the abbreviation IM?

A symptom that a patient has again and that continues to get worse is called:

A medication prescribed BID is taken:

A patient was given a prescription with the following information: "Sig.5 mL PO BID x 10 days." Which is the most accurate description of the patient prescription?

NOS and NEC are:

A patient usually has surgery in a(n):

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