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Exam 2: Introduction to Health Records

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Question 21

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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.

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Question 22

Multiple Choice

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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.

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Question 23

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A review of systems is:

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

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

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

PERRLA means :

Which of the following is FALSE about the term discharge?

The risk for being sick is known as:

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

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

A medicine administered PR is given in the:

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.

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

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

Which term refers to "before surgery"?

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 ________________.

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

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.