chapter 1

What does this documentation represent? CC: Jaundice.

Chief complaint

What option is true regarding pathophysiology?

It enables us to understand what occurs in a healthy body in normal life and what goes wrong when someone becomes ill

What statement is true regarding a chief complaint?

It is a description of why the patient is presenting for healthcare services

Medical treatment can be divided into how many categories?

Three

The term hemic specifically refers to what bodily fluid?

blood

Which one is NOT a serous membrane?

synovial

What space contains the spinal cord?

vertebral canal

What type of documentation is the following? Const: Appears obese. No signs of apparent distress present. Musculo: Walks with a normal gait.

A general and musculoskeletal exam

What does the abbreviation ROM stand for in the following documentation and what type of document is this? Extremities: No clubbing, cyanosis, or edema. Right shoulder is tender. No obvious deformation. Decreased ROM in abduction and extension.

A physical exam including the range of motion

What type of documentation is the following and what instrument was required? Respiration rate is normal. No wheezing. Auscultate good airflow. Lungs are clear bilaterally. CV: Rate is regular. Rhythm is regular. No heart murmur appreciated.

A physician exam requiring a stethoscope

What section is missing from the below documentation? SUBJECTIVE: The patient is a male being seen for lumbar back pain. The symptoms have been gradual in onset with a severity of 6/10 in pain score. This lumbar back pain is also associated with headaches. Both sides are affected equally. He has had no history of surgery. OBJECTIVE: On exam, he has diffuse lower lumbar back pain and headache. PLAN: The patient will need a lumbar AP and lateral plain film for further evaluation. Patient to return to office after obtaining further studies or if symptoms get worse.

Assessment

What type of information is provided in the following documentation? INDICATION: This patient was seen in the surgery clinic after an admission for his second bout of sigmoid diverticulitis. A CAT scan showed a segment of colon approximately 15 to 20 cm from the anal verge with inflammation and diverticulum. The patient was cooled off on antibiotics, and sent to the clinic where barium enema was done with diverticulum and spasm of sigmoid colon and scattered diverticuli in the area of the previous episode. The patient was seen in the clinic and booked for laparoscopic sigmoid colectomy.

Brief history outlining the reasons for the procedure

What type of documentation is the following? CV: Denies chest pain and palpitations.

Cardiovascular system review

Which service is not specific to a medical specialty or one body system or anatomical area?

Evaluation and management

What does the abbreviation HEENT refer to in the following documentation and what type of document is it?

Head, eyes, ears, nose, throat; physical examination

Which organ system houses white blood cells?

Lymphatic system

What information is missing from the below document? OPERATIVE NOTE PATIENT: AGE:47 This is a commercial payer (follow Medicare rules if 65 and older). DOS: 1/1/20XX PREOPERATIVE DIAGNOSIS: Family history of colon cancer and multiple colon polyps. POSTOPERATIVE DIAGNOSIS: Normal colon. OPERATIVE PROCEDURE: Screening colonoscopy with conscious sedation. Time 19 min. SURGEON: Analgesia/sedation given. Patient status during sedation was attended constantly and was cooperative. Vitals were stable monitored.

Name of the surgeon

What is this type of the medical record? PROCEDURE: CT HEAD WITHOUT CONTRAST COMPARISON: None. INDICATIONS: Status-post fall with loss of consciousness. TECHNIQUE: Noncontrast head CT was performed with axial 5 mm reformations. FINDINGS: There is a small extra-axial fluid collection on the right side. It overlies the right parietal hemisphere. It is moderately dense. The pattern suggests a small subdural hematoma. It is perhaps 7-8 mm in greatest thickness. There is effacement of the sulcal markings in the right parietal lobe. The ventricles are still in the midline. No signs of any intraaxial hemorrhage. At the base of the brain, the cisterns are still open. On the bone window settings, no definite skull fracture is seen on that side. CONCLUSION: SMALL RIGHT SIDED SUBDURAL HEMATOMA WITH MILD MASS EFFECT.

Radiology report

Which type of treatment requires an antibiotic?

curative

How many sections is the abdomen divided into?

four

Which organ is not part of the digestive system?

larynx

Which system controls the body's response to internal and external changes?

nervous system

What medical specialty treats diseases of the bones, joints, and muscles?

orthopedics

What is the term for study of the development process of a disease?

pathogenesis

What is the term for creating sounds from tapping on body areas to examine body organs and body cavities?

percussion