Question 1

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

Accepted Answer

The chief complaint is the primary reason for the patient's visit, describing the symptoms or concerns that prompted them to seek medical attention.

Question 2

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

Accepted Answer

Miss Sweet was described as lethargic but responsive, indicating she looked sick but was still able to respond to questions.

Question 3

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

Accepted Answer

Observation in a hospital setting means that medical professionals are monitoring the patient to assess her condition and determine the next steps in her treatment.

Question 4

The meaning of the medical termmalaise is

Accepted Answer

Malaise refers to a general feeling of discomfort, illness, or unease, often without a specific cause, which aligns with the description of "not feeling well."

Question 5

The correct definition for the term disposition is

Accepted Answer

Disposition refers to what happened to the patient at the end of the visit, such as whether they were admitted, discharged, or transferred.

Question 6

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

Accepted Answer

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

Question 7

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

Accepted Answer

"Anterior" refers to the front, and "superior" refers to above.

Question 8

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

Accepted Answer

Remission means that the signs and symptoms of a disease are reduced or disappear, but it does not necessarily mean the illness has been cured.

Question 9

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

Accepted Answer

Percussion involves hitting something and listening to the resulting sound or feeling the resulting vibration.

Question 10

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

Accepted Answer

The coronal plane, also known as the frontal plane, divides the body into anterior (front) and posterior (back) sections.

Question 11

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

Accepted Answer

The umbilicus is located on the anterior (front) and medial (middle) part of the body.

Question 12

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.

Accepted Answer

The supine position is when a person lies on their back, facing upwards.

Question 13

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

Accepted Answer

The term "bilateral" is broken down into "bi" meaning two, "later" meaning side, and "al" meaning pertaining to, so it means pertaining to two sides.

Question 14

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

Accepted Answer

The answer of The term used to describe a problem...

Question 15

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

Accepted Answer

"Inferior" refers to a position below another body part in anatomical terms.

Question 16

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

Accepted Answer

The social history section of a medical record includes information about a patient's lifestyle and habits, such as smoking, alcohol use, drug abuse, and sexual practices.

Question 17

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?

Accepted Answer

The correct medical term for the location of the rash is "bilateral, dorsum" because the rash is on the top (dorsal side) of both hands (bilateral).

Question 18

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

Accepted Answer

Auscultation is the physical examination technique that involves listening with a stethoscope.

Question 19

A synonym for the term hereditary is

Accepted Answer

The term "hereditary" refers to traits or conditions that are passed from parents to offspring through genes, making "genetic" the correct synonym.

Question 20

The medical term that means a condition suddenly gets worse is

Accepted Answer

Exacerbation refers to the worsening or increase in severity of a disease or its symptoms.

Quiz 2: Introduction to Health Records