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Exam 2: Introduction to Health Records

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Question 41

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In the following health record, the patient's disposition is noted. 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. 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 visit.
D) when the patient will be sent home.
E) none of these.

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Question 42

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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

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Question 43

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

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

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

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

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

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:

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

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

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:

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

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

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

If a person's head were divided on the coronal plane, which of the following is NOT true?

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

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.

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?

What is the correct definition for the abbreviation RR?

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.