Exam 2: Introduction to Health Records

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?

The following is an excerpt from a consult note. PMHx: CAD with PTCA in 20xx.Hypertension.Hypertriglyceridemia. Medications: Beta blocker, nitroglycerin prn, ASA, antilipidemic agent. Allergies: Penicillin. FHx: Brother deceased from an MI at 69 years of age. SHx: Patient does not smoke.He drinks 1-2 beers per week.Denies illicit drug use.He is married with two grown children and three grandchildren. This information is most accurately classified as:

Your belly button is located on the ________________ part of your body.

According to the following discharge summary, Ms.Cloud began complaining of ophthalmalgia. 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. Which is the correct definition of the suffix -algia?

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

When a patient is examined by a medical professional, which of the following would NOT be part of the physical examination?

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

Which of the following pairs of abbreviations are opposites?

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, Miss Sweet was transferred to the:

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

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 102.3^o 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.

A PACU is a(n):

Which of the following pairs of terms are opposites?

A CC is usually included on which part of the health care record?

Which of the following is true about the abbreviation CTA?

The following excerpt most likely comes from what time of health record? 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.

Prophylaxis refers to:

PCP refers to the: