Test Questions & Answers Introduction to Health Records Ch.2

Acquiring Medical Language, 2e (Jones)

Chapter 2 Introduction to Health Records

1) 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.

2) The first part of most medical notes that includes such information as medical history, duration and quality of the problem, and any exacerbating or relieving factors for that problem is known as the ________ part.

A) subjective.

B) objective.

C) assessment.

D) plan.

E) none of these.

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

A) Subjective

B) Objective

C) Assessment

D) Plan

E) None of these

4) 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.

A) subjective

B) objective

C) assessment

D) plan

E) none of these

5) The course of action consistent with a health care provider's assessment is known as a(n):

A) subjective.

B) objective.

C) assessment.

D) plan.

E) none of these.

6) Which of the following is FALSE about the SOAP method?

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.

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

A) chief complaint.

B) family history.

C) history of present illness.

D) review of history.

E) social history.

8) 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 like 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, like high blood pressure, asthma, or diabetes.

E) the story of the patient's problem.

9) Which section of the health record is NOT included in the subjective section?

A) Chief complaint

B) Family history

C) Past medical history

D) Review of systems

E) Social history

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

A) Clinic note

B) Consult note

C) Emergency department note

D) Pathology report

E) Prescription

11) Which of the following notes is usually authored by a specialist and provides an expert opinion on a more challenging problem?

A) Admission summary

B) Clinic note

C) Consult note

D) Daily hospital/progress note

E) Emergency department note

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

A) Admission summary

B) Clinic note

C) Daily hospital/progress note

D) Discharge summary

E) Emergency department note

13) 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?

A) Admission summary

B) Clinic note

C) Daily hospital/progress note

D) Discharge summary

E) Emergency department note

14) Which of the following pairs of terms are opposites?

A) Acute, abrupt

B) Exacerbation, symptom

C) Febrile, afebrile

D) Genetic, hereditary

E) Lethargic, malaise

15) A patient concern that just started recently, or is a sudden onset, severe symptom, is called:

A) acute.

B) chronic.

C) febrile.

D) lethargic.

E) noncontributory.

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

A) abrupt.

B) acute.

C) genetic.

D) malaise.

E) progressive.

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

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

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

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

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

A) Auscultation

B) Marked

C) Objective

D) Oriented

E) Unremarkable

20) A patient has unremarkable symptoms. Unremarkable is a medical term used to mean:

A) it stands out.

B) normal.

C) responsive.

D) unresponsive.

E) none of these.

21) During a patient exam, a medical professional may feel parts of the patient's body. This is called:

A) auscultation.

B) diagnosing.

C) palpation.

D) palpitation.

E) percussion.

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

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

23) The risk for being sick is known as:

A) malignant.

B) morbidity.

C) mortality.

D) prognosis.

E) idiopathic

24) A systemic infection by definition:

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.

25) The term pathogen comes from combining the roots path/o and gen/o. Which are the correct root and term definitions?

A) path/o (development, nourishment) + gen/o (generation, cause) = pathogen (development or nourishment of the cause)

B) path/o (development, nourishment) + gen/o (suffering, disease) = pathogen (development or nourishment of the suffering/disease)

C) path/o (generation, cause) + gen/o (suffering, disease) = pathogen (generation/cause of the suffering/disease)

D) path/o (suffering, disease) + gen/o (development, nourishment) = pathogen (development or nourishment of the suffering/disease)

E) path/o (suffering, disease) + gen/o (generation, cause) = pathogen (generation/cause of the suffering/disease)

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

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) the treatment plan.

27) Which of the following is FALSE about the term discharge?

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.

28) 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.

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

A) discharge.

B) observation.

C) consultation

D) reassurance.

E) supportive care.

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

A) Auscultation

B) Family medical history

C) Past surgical history

D) Reassurance

E) Sequelae

31) Which is the correct opposite for the proximal part of the body?

A) Distal

B) Dorsum

C) Ipsilateral

D) Prone

E) Ventral

32) Which of the following does NOT refer to "the front"?

A) Antral

B) Anterior

C) Dorsal

D) Ventral

E) They all refer to "the front."

33) If a patient is prone, he is:

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.

34) 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

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

A) coronal

B) ipsilateral

C) sagittal

D) supine

E) transverse

36) Which of the following is NOT an abbreviation that refers to a health care facility or department?

A) CTA

B) ECU

C) ER

D) OR

E) PACU

37) A PACU is a(n):

A) care unit for cardiac patients.

B) intensive care unit for children.

C) intensive care unit for patients.

D) postanesthesia care unit.

E) recovery room following an operation.

38) Which term refers to "before surgery"?

A) L&D

B) OR

C) PACU

D) Post-op

E) Pre-op

39) A patient usually has surgery in a(n):

A) ED.

B) ICU.

C) OR.

D) PACU.

E) SICU.

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

A) Subjective

B) Objective

C) Assessment

D) Plan

E) None of these

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

A) BP

B) Hx

C) T

D) VS

E) Wt

42) What is the correct definition for the abbreviation RR?

A) Radiology report

B) Rapid rate

C) Recurrent reason

D) Respiratory rate

E) Responsive remission

43) The amount of fluids a patient has taken in and produced is abbreviated:

A) BMI.

B) H&P.

C) HPI.

D) I/O.

E) PERRLA.

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

A) H&P

B) HPI

C) h/o

D) PMHx

E) CTA

45) Interpret the following abbreviations: "The Pt is 5y/o."

A) The patient is 5 years old.

B) The patient is 5 years under observation.

C) The prescription is 5 years old.

D) The prescription is 5 years under observation.

E) None of these.

46) PCP refers to the:

A) past care provider.

B) primary care provider.

C) past complaint or problem.

D) present complaint or problem.

E) primary complaint or problem.

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

A) future ultrasounds

B) future ultrasonographies

C) future uses

D) following ultrasounds

E) follow up

48) PERRLA means:

A) pathogen is emerging, responsive, and responsive to adversity.

B) patient is equalized, recovering, responsive, and adjusting.

C) physical exam has been reported, responded to, and accepted by insurance.

D) pupils are equal, round, and reactive to light and accommodation.

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

A) CTA, RRR

B) CTA, SOB

C) NAD, WDWN

D) PERRLA, A&O

E) WNL

50) NOS and NEC are:

A) abbreviations used for symptoms and exam findings.

B) catchalls for diagnoses that do not quite fit any specific cause.

C) mean "not otherwise specified" or "not elsewhere classified."

D) all of these.

E) none of these.

51) Which of the following is true about the abbreviation CTA?

A) Means "clear to auscultation"

B) Describes normal-sounding lungs

C) Is an abbreviation used by medical professionals after listening (auscultation = "listen")

D) All of these

E) None of these

52) 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?

A) BP NAD

B) BP NEC

C) BP RRR

D) BP WDWN

E) BP WNL

53) 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:

A) A&O.

B) PERRLA.

C) NAD.

D) ROS.

E) WDWN.

54) Which of the following pairs of abbreviations are opposites?

A) IM, IV

B) IV, CVL

C) NPO, PR

D) PO, NPO

E) SC, IM

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

A) signa care = signa (label) + care = carefully labeled

B) subcutaneous = sub (above) + cutane/o (skin) = above the skin

C) subcutaneous = sub (beneath) + cutane/o (skin) = beneath the skin

D) subcutaneous = sub (through) + cutane/o (muscle) = through the muscle

E) supportive care (abbreviation comes from regularly used English words)

56) A medicine administered PR is given in the:

A) lungs (respirated).

B) mouth.

C) rectum.

D) skin.

E) vein.

57) Which is the correct abbreviation for a medicine administered "as desired"?

A) Ad lib

B) IM

C) NPO

D) PICC

E) PO

58) A medication prescribed BID is taken:

A) once a day.

B) twice a day.

C) three times a day.

D) before meals.

E) after meals.

59) Which abbreviation does NOT describe the time of day in which a prescription should be taken?

A) AC

B) PC

C) AM

D) QHS

E) TID

60) The prescriber uses which of the following abbreviations if a medication is to be taken before meals?

A) AC

B) PC

C) prn

D) QHS

E) TID

61) Which of the following abbreviations would most likely be found in the "plan" portion of a health record?

A) Dx

B) PERRLA

C) QHS

D) ROS

E) RRR

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

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

63) The following is an excerpt from a patient's medical record. 

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.

According to this information, which is NOT true about the patient?

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.

64) 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.

A) Subjective

B) Objective

C) Assessment

D) Plan

E) Prescription

65) 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:

A) review of systems.

B) past surgical history.

C) patient history.

D) prescription plans.

E) treatment plan.

66) 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?

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.

67) 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

A) Amoxicillin 400 mg/5ml

B) Sig. 5 ml PO BID x 10 days

C) Dispense 100ml

D) Refills: None

E) Brand name medically necessary

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

A) DDx

B) Idiopathic

C) Mortality

D) Occult

E) WDWN

69) If a patient's infection is classified as occult, it is:

A) dangerous.

B) getting better.

C) getting worse.

D) hidden.

E) without a known or specific cause.

70) If a patient's infection is classified as malignant, it is:

A) dangerous.

B) getting better.

C) getting worse.

D) hidden.

E) without a known or specific cause.

71) The cause is also called the:

A) diagnosis.

B) etiology.

C) impression.

D) remission.

E) sequelae.

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

A) degenerate.

B) localized.

C) malignant.

D) recurrent.

E) systemic.

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

A) degenerate; malignant.

B) recurrent; degenerate.

C) recurrent; idiopathic.

D) idiopathic; malignant.

E) malignant; recurrent.

74) According to the following discharge summary, which is true about this patient? 

HPI 

Mrs. Roxana Collach presented to the ED 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 ED 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 IVF.

A) Her anorexia was getting better.

B) She did not have a fever when she arrived.

C) She did not have any epigastric tenderness.

D) She was diagnosed with pancreatitis.

E) She was not given intravenous fluids.

75) 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.

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.

76) 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.

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 

General: WW, in mild discomfort. A&Ox3

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

General: WW, in mild discomfort. Al&Orx3

77) From which portion of a consult note is the following excerpt? 

Reason for Consult: urinary retention 

HPI: Mr. Johnson is a 57-year-old male with a 2-month history of difficulty voiding. He reports urgency and frequency. He has had increasing problems with a weakurinary stream. The symptoms have progressed to include mild abdominal discomfortand erectile dysfunction. He denies any incontinence, hematuria, balanorrhea, orchiodynia, or trauma. He has not tried any medicines at this point. 

PMHx: Hypercholesterolemia-currently controlled with diet. Positive history of gonococcalurethritis 3 years previously. No history of urolithiasis.

A) Subjective

B) Objective

C) Assessment

D) Plan

E) Prescription

78) Which is a correct interpretation of the following portion of a physical exam? 

CV: RRR without murmur, gallops, or rubs. 

Resp: CTA bilaterally.

A) Heart has a regular rate and rhythm; lungs are clear on both sides.

B) Heart has a regular rate and rhythm; right lung is clear.

C) Heart rate is normal; lungs are cloudy on both sides.

D) Heart rate is slightly elevated; lungs are clear on both sides.

E) Heart rhythm is normal; left lung is cloudy.

79) 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 102.3o 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) Her PCP sent her to the ED for evaluation and admission.

B) It contains the history of the present illness.

C) The patient is 12 y/o.

D) The patient returned to the clinic when her dysuria worsened and she became febrile.

E) The patient went to the ED before seeing her PCP.

80) The following excerpt is from which portion of the discharge summary? 

Labs 

Admission labs: UA: Pyuria: .20 wbcs; Hematuria: 3 1 blood; Albuminuria: 1 1 protein. 

Urine culture: E. coli. 

Blood culture: E. coli. 

Discharge labs: UA normal. Urine culture normal. 

Imaging 

VCUG: No vesicoureteral reflux noted. 

RUS: No hydronephrosis noted. Normal. 

Spiral CT of kidneys on day 3 of admission revealed perinephric abscess formation of the left kidney.

A) Subjective

B) Objective

C) Assessment

D) Plan

E) Prescription

81) 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, 2017. 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.

A) Consult note

B) Operative report

C) Pathology report

D) Prescription

E) Discharge summary

82) According to the following discharge summary, which of the following statements is NOT true? 

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.

A) A peripherally inserted central catheter was inserted.

B) Ms. Cloud complained of increasing right ophthalmalgia 2 days before her surgery.

C) Ms. Cloud developed a fever while in the hospital.

D) Ms. Cloud was presumed to have endophthalmitis after her operation.

E) The vitrectomy was performed under extremely clean, germ-free conditions.

83) 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?

A) Cause

B) Hernia

C) Medical science

D) Pain

E) Specialist

84) 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:

A) chief complaint.

B) history of present illness.

C) past medical history.

D) personal social medical history.

E) review of systems.

85) The patient had "tubes placed bilaterally." 

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. 

Which is the correct breakdown and definition of the term bilateral?

A) bi (one) + lateral (out to the side) = one side

B) bi (side) + lateral (toward the middle) = toward the middle of the side

C) bi (side) + lateral (toward the side) = toward the side

D) bi (two) + lateral (out to the side) = both sides

E) bi (two) + lateral (toward the middle) = in the middle

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

ED Course: 

Elizabeth 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 for review. Chemistry profile showed hypernatremia, hypokalemia, and acidemia. The pediatric intensive care team was contacted for patient transfer to the PICU. 

Disposition: Transfer to PICU.

A) Clinic note

B) Emergency department note

C) Operative report

D) Pathology report

E) Radiology report

87) In the following health record, the patient's disposition is noted. 

Emergency Department Course: 

Elizabeth 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 for review. Chemistry profile showed hypernatremia, hypokalemia, and acidemia. The pediatric intensive care team was contacted for patient transfer to the PICU. 

Disposition: Transfer to PICU. 

The correct definition for disposition in this context is:

A) how the patient is feeling.

B) the main reason for the patient's visit.

C) what happened to the patient at the end of the ED visit.

D) when the patient will be sent home.

E) none of these.

88) Read the following health record excerpt. 

Emergency Department Course: 

Elizabeth 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 for review. Chemistry profile showed hypernatremia, hypokalemia, and acidemia. The pediatric intensive care team was contacted for patient transfer to the PICU. 

Disposition: Transfer to PICU. 

According to this excerpt, when Elizabeth arrived at the ED, she was:

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.

89) Read the following health record excerpt: 

Emergency Department Course: 

Elizabeth 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 for review. Chemistry profile showed hypernatremia, hypokalemia, and acidemia. The pediatric intensive care team was contacted for patient transfer to the PICU. 

Disposition: Transfer to PICU. 

According to this excerpt, Elizabeth was transferred to the:

A) emergency department.

B) laboratory.

C) pathology.

D) pediatric intensive care unit.

E) postanesthesia care unit.

90) In order for the medical professional to perform a physical examination, he asked the patient to lie down on his back. The patient is lying ________.

A) caudally

B) dorsum

C) prone

D) proximally

E) supine

91) Your belly button is located on the ________ part of your body.

A) anterior, lateral

B) anterior, medial

C) dorsal, lateral

D) dorsal, medial

E) lateral, medial

92) The inferior vena cava is also known as the posterior vena cava. From the terms inferior and posterior, one can say that this vein is ________ the heart on the ________ side.

A) above, back

B) above, front

C) below, back

D) below, front

93) The superior vena cava is a large-diameter, yet 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.

94) A patient has a rash on the top of both of his hands. Which is the correct medical term for the rash's location?

A) Bilateral, dorsum

B) Bilateral, palmar

C) Bilateral, plantar

D) Unilateral, dorsum

E) Unilateral, palmar

95) If a person's head were divided on the coronal plane, which of the following is TRUE?

A) The division would be from front to back, and therefore both eyes could be seen on the same plane.

B) The division would be from front to back, and therefore only one eye would be seen at a time.

C) The division would be from left to right, and therefore both eyes could be seen on the same plane.

D) The division would be from left to right, and therefore only one eye would be seen at a time.

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

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.

97) 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?

A) Mrs. Collach could eat a low-protein, low-fat diet when she was first admitted to the hospital.

B) Mrs. Collach spent some time in the intensive care unit.

C) Mrs. Collach was given palliative care throughout her hospital stay.

D) Mrs. Collach was given a low-protein, low-fat diet before her operation.

E) Mrs. Collach was not allowed to have anything by mouth and was given intravenous fluids when she was first admitted to the hospital.

98) 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?

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.

99) The following is a portion of a patient's consult note: 

Past Medical History: Noncontributory. 

Past Surgical History: Balanoplastyfor hypospadias at age 1. 

Social History: Doug lives with his parents and older sister. He is going into kindergarten in the fall. 

Family History: Paternal grandfather with polycystic kidney disease. 

According to the doctor who authored this note, which of the following is true?

A) The patient has never had any surgeries

B) The patient has polycystic kidney disease.

C) The patient is 10 y/o.

D) The patient's PMHx is not related to this specific problem.

E) There is not enough information to draw any conclusions.

100) Which of the following is NOT true about the medical term remission?

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.

101) Which term refers to toward the bottom?

A) Cranial

B) Caudal

C) Dorsal

D) All of these.

E) None of these.

102) A Dietician is someone that?

A) Prepares meals for patients

B) Delivers food to patients

C) Is specially trained in exercise plans.

D) Is specially trained in evaluating the nutritional status of a patient and developing an appropriate diet plan.

103) Which of the following is not part of the health record?

A) Family history

B) Past employment history

C) Past surgical history

D) Chief complaint

E) History of present illness