Deck 2: Introduction to Health Records

Question 1

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

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

Answer 1

history of present illness.

Question 2

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

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

Answer 2

A list of conditions the patient may have based on symptoms and results of the exam

Question 3

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

A) Something a health care provider notices
B) Something that has been going on for a while now.
C) Something that runs in the family.
D) Not feeling well
E) Something a patient feels

Answer 3

Something a patient feels

Question 4

Which part of most medical notes contains information such as medical history, duration, and quality of the problem and any exacerbating or relieving factors for that problem?

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

Question 5

What is the importance of health records?

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 6

Which of the following pairs of terms are opposites?

A) acute, abrupt
B) exacerbation, symptom
C) febrile, afebrile
D) genetic, hereditary
E) lethargy, malaise

Question 7

The best definition for a review of systems is

A) a description of individual body systems in order to discover any symptoms not directly related to the main problem.
B) a record of habits such as smoking, drinking, drug abuse, and sexual practices that can impact health.
C) any significant illnesses that run in the patient's family.
D) other significant past illnesses such as high blood pressure, asthma, or diabetes.
E) the story of the patient's problem.

Question 8

A patient complains of itchy skin and has a very noticeable rash. Which of the following terms is appropriate to use to describe the rash?

A) alert
B) marked
C) objective
D) oriented
E) unremarkable

Question 9

In the patient's medical record, a note states that the patient has unremarkable symptoms. Unremarkable is a medical term used to mean that the symptoms

A) stand out.
B) get progressively worse.
C) get progressively better.
D) do not bother the patient.
E) are normal.

Question 10

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

A) All of a sudden
B) Has been going on for a while
C) Runs in the family
D) Gets progressively worse
E) Something a patient feels

Question 11

The medical term given to describe a patient's symptoms or disease as becoming more and more severe or evident each day is

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

Question 12

Which part of most medical notes contains information such as the patient's physical exam, laboratory findings, and imaging studies performed at the visit?

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

Question 13

The best definition of a systemic infection is an infection that

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 easy to treat.

Question 14

The medical term ___________ describes a patient concern that just started recently, or has a sudden onset.

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

Question 15

Which of the following statements is FALSE about the SOAP method?

A) Diagnostic work in medicine is similar to the investigative work of a detective; 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 16

Which of the following components of the health record is NOT included under the subjective section?

A) chief complaint
B) family history
C) past medical history
D) review of systems
E) social history

Question 17

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

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

Question 18

Which part of most medical notes contains information that could be a diagnosis, identification of the problem, or a differential diagnosis?

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

Question 19

During a patient examination, a medical professional may feel parts of the patient's body. This technique is called

A) auscultation.
B) diagnosing.
C) palpation.
D) palpitation.
E) percussion.

Question 20

The risk for being sick is known as

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

Question 21

All of the following terms refer to the front EXCEPT

A) antral.
B) anterior.
C) dorsal.
D) ventral.

Question 22

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 102.3^o 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."

A) Her primary care physician sent her to the emergency department for evaluation and admission.
B) It contains the history of the present illness.
C) The patient is 12 years old.
D) The patient returned to the clinic when her dysuria worsened and she became febrile.
E) The patient went to the emergency department before seeing her primary care physician.

Question 23

The medical term for the cause of a disease is

A) diagnosis.
B) etiology.
C) impression.
D) remission.
E) sequelae.

Question 24

When a person uses her left hand to reach to the right, she is showing ________________ movement.

A) bilateral
B) contralateral
C) ipsilateral
D) lateral
E) unilateral

Question 25

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

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

Question 26

If a patient's disease is classified as malignant, this means the disease is

A) dangerous.
B) getting better.
C) getting worse.
D) hidden.
E) without a known or specific cause.

Question 27

The patient's medical record noted that the patient experienced sequelae after his heart attack. This means that the patient

A) had an increased risk for sudden death.
B) developed a problem resulting from disease or injury.
C) had hidden problems.
D) had diseased tissue.
E) could develop another heart attack.

Question 28

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

A) degenerate
B) malignant
C) idiopathic
D) recurrent
E) chronic

Question 29

If a patient's infection is classified as occult, this means the infection is

A) dangerous.
B) getting better.
C) getting worse.
D) hidden.
E) without a known or specific cause.

Question 30

The medical term prophylaxis refers to

A) extremely clean, germ-free conditions.
B) observation of a patient.
C) preventive treatment.
D) telling the patient that the problem is not serious or dangerous.
E) treating the symptoms but not actually getting rid of the cause.

Question 31

If a patient is prone, he is

A) lying on his belly.
B) lying on his back.
C) lying on his left side.
D) lying on his right side.
E) standing.

Question 32

Read this excerpt from a patient's health record. "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 a 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

A) chief complaint.
B) history of present illness.
C) past medical history.
D) personal social medical history.
E) review of systems.

Question 33

Which of the following terms is the correct opposite for the proximal part of the body?

A) distal
B) dorsum
C) ipsilateral
D) prone
E) ventral

Question 34

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

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

Question 35

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. Respiratory: clear to auscultation. No wheezes, rales, rhonchi, or crackles. Good air exchange. No increased work of breathing."

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

Question 36

All of the following statements about the term discharge are true EXCEPT

A) It can mean to send home.
B) It is included as part of the plan section in a health care note.
C) It literally means to unload.
D) It can mean that the patient has been cured.
E) It refers to a fluid coming out of a part of the body.

Question 37

Which of the following are the correct roots and definitions for the term pathogen?

A) path/o (development, nourishment) + gen (generation, cause) = pathogen (development or nourishment of the cause)
B) path/o (development, nourishment) + gen (suffering, disease) = pathogen (development or nourishment of the suffering/disease)
C) path/o (generation, cause) + gen (suffering, disease) = pathogen (generation/cause of the suffering/disease)
D) path/o (suffering, disease) + gen (development, nourishment) = pathogen (development or nourishment of the suffering/disease)
E) path/o (suffering, disease) + gen (generation, cause) = pathogen (generation/cause of the suffering/disease)

Question 38

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

A) be discharged.
B) be observed.
C) receive prophylactic medication.
D) be given reassurance.
E) receive supportive care.

Question 39

When a medical professional gives the patient a prognosis, he/she is telling the patient

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/she thinks the patient has.

Question 40

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."

A) Her anorexia was getting better.
B) She was vomiting constantly.
C) She was diagnosed with pancreatitis.
D) She did not have any epigastric tenderness.
E) She was not given intravenous fluids.

Question 41

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

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

Question 42

Read the following health record excerpt. "Miss Sweet arrived in the emergency department 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 intravenous was started and labs were sent. Chemistry profile showed hypernatremia, hypokalemia, and acidemia. The pediatric intensive care team was contacted for transfer to the Pediatric Intensive Care Unit." According to this excerpt, when Miss Sweet arrived at the emergency department, she

A) was alert and oriented to person, place and time.
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 able to answer questions.

Question 43

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

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

Question 44

The meaning of the medical termmalaise is

A) not feeling well.
B) difficulty breathing.
C) difficulty walking.
D) having a fever.
E) having severe pain.

Question 45

The correct definition for the term disposition is

A) what happened to the patient at the end of the visit.
B) the main reason for the patient's visit.
C) how the patient is feeling.
D) when the patient will be sent home.
E) none of these.

Question 46

A problem that worsens more and more each day is said to be

A) progressive.
B) acute.
C) chronic.
D) abrupt.
E) exacerbation.

Question 47

The superior vena cava is a large-diameter short vein that carries deoxygenated blood from the body to the heart. It is located in the anterior right superior mediastinum. The correct definitions of anterior and superior are

A) back, above.
B) back, below.
C) front, above.
D) front, below.

Question 48

All of the following statements about the medical term remission are true EXCEPT

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 49

The physical examination technique that involves hitting something and listening to the resulting sound or feeling the resulting vibration is called

A) percussion.
B) auscultation.
C) palpation.
D) palpitation.
E) inspection.

Question 50

The plane that divides the body into slices, front to back, is the _______plane.

A) sagittal
B) transverse
C) horizontal
D) coronal
E) midsagittal

Question 51

The umbilicus (belly button) is located on the ________ ________ part of one's body.

A) anterior, lateral
B) anterior, medial
C) dorsal, lateral
D) dorsal, medial
E) lateral, medial

Question 52

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.

A) caudal
B) dorsal
C) prone
D) proximal
E) supine

Question 53

The patient had tympanostomy tubes placed bilaterally. Which is the correct breakdown and definition of the term bilateral?

A) bi (one) + later (out to the side) + al (condition) = condition one side
B) bi (side) + later (toward the middle) + al (condition) = condition toward the middle of the side
C) bi (side) + later (toward the side) + al (pertaining to) = pertaining to toward the side
D) bi (two) + later (side) + al (pertaining to) = pertaining to two sides
E) bi (two) + lateral (toward the middle) = towards the middle of both ears

Question 54

The term used to describe a problem that developed all of a sudden is

A) chronic.
B) acute.
C) progressive.
D) exacerbation.
E) abrupt.

Question 55

If a body part is located inferior to another body part, its position is

A) above the other body part.
B) on the side of the other body part.
C) in front of the other body part.
D) below the other body part.
E) behind the other body part.

Question 56

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

A) chief complaint.
B) social history.
C) family history.
D) review of systems.
E) past medical history.

Question 57

A patient has a rash on the top of both hands. Which of the following is the correct medical term for the location of the rash?

A) bilateral, dorsum
B) bilateral, palmar
C) bilateral, plantar
D) unilateral, dorsum
E) unilateral, palmar

Question 58

The physical examination technique that involves listening with a stethoscope is called

A) percussion.
B) auscultation.
C) palpation.
D) palpitation.
E) inspection.

Question 59

A synonym for the term hereditary is

A) progressive.
B) chronic.
C) non-contributory.
D) genetic.
E) idiopathic.

Question 60

The medical term that means a condition suddenly gets worse is

A) remission.
B) progressive.
C) exacerbation.
D) malaise.
E) chronic.

Question 61

The medical term that means the cause of the disease is

A) idiopathic.
B) prognosis.
C) etiology.
D) remission.
E) diagnosis.

Question 62

A patient who is alert and oriented x 3 can

A) answer questions and is aware of who he or she is.
B) answer questions and is aware of the current time or date.
C) answer questions and is aware of where he or she is.
D) All the answers are correct.
E) None of the answers are correct.

Question 63

The medical term that means what the health care professional thinks the patient has is

A) idiopathic.
B) prognosis.
C) etiology.
D) remission.
E) diagnosis.

Question 64

A _________refers to diseased tissue.

A) pathogen
B) benign
C) lesion
D) malignant
E) sequelae

Question 65

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?

A) abrupt
B) noncontributory
C) contributory
D) unremarkable
E) remarkable

Question 66

An infant died of sudden infant death syndrome (SIDS). The physician told the parents that the cause of the infant's death was idiopathic. This means that

A) the infant died from a hereditary condition.
B) the infant died from a localized infection.
C) the cause of the infant's death is pending.
D) the cause of the infant's death is unknown.
E) the infant had a hidden heart defect.

Question 67

A synonym for the word assessment is

A) etiology.
B) prognosis.
C) remission.
D) impression.
E) differential diagnosis.

Question 68

The medical term that means toward the bottom and comes from the Latin meaning tail is

A) cranial.
B) proximal.
C) inferior.
D) caudal.
E) antral.

Question 69

The prefix in the term unilateral means

A) same.
B) both.
C) one.
D) opposite.
E) half.

Question 70

A patient is scheduled for palliative treatment. This means that the patient

A) will be cured of the disease.
B) will receive chemotherapy.
C) will be scheduled for surgery.
D) will have the symptoms treated without getting rid of the disease.
E) will receive preventative treatment.

Question 71

If a body part is located inferior to another body part, its position is

A) above the other body part.
B) on the side of the other body part.
C) in front of the other body part.
D) below the other body part.
E) behind the other body part.

Question 72

A patient with bilateral plantar warts has lesions on the

A) palm of one hand.
B) palm of both hands.
C) sole of one foot.
D) soles of both feet.
E) top of both feet.

Question 73

The medical term that refers to the risk for dying is

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

Question 74

The definition for the medical term sterile is

A) preventative treatment.
B) extremely clean, germ-free environment.
C) treating the symptoms.
D) free of blood-borne pathogens.
E) contaminated.

Question 75

The medical term that means pertaining to the same side is

A) bilateral.
B) unilateral.
C) contralateral.
D) ipsilateral.
E) monolateral.

Question 76

A tumor is labeled as benign. This means that

A) the tumor is safe, not cancerous.
B) the tumor is cancerous.
C) the tumor has spread.
D) the tumor is localized.
E) the diagnosis of the tumor is pending.

Question 77

The body plane that divides the body from top to bottom is the ________plane.

A) transverse
B) coronal
C) sagittal
D) midsaggital

Question 78

Significant past illnesses such as high blood pressure, diabetes, or asthma would be documented in which section of the health record?

A) social history
B) chief complaint
C) review of systems
D) past surgical history
E) past medical history

Question 79

A synonym for the term posterior is

A) antral.
B) dorsal.
C) medial.
D) caudal.
E) inferior.

Question 80

If a patient's lab results are pending, this means that

A) the patient's blood sample wasn't any good and had to be re-drawn.
B) the patient is waiting to have his blood drawn.
C) the health care provider is waiting for the results.
D) the lab tests will be done in the morning.
E) the blood sample has been sent to another lab for testing.