Question 1

The story of the patient's problem is known as the
A) chief complaint.
B) family history.
C) history of present illness.
D) review of history.
E) social history.

Accepted Answer

The "history of present illness" is the detailed account of the patient's current problem, including the onset, duration, and characteristics of symptoms.

Question 2

Which of the following statements is the best definition for differential diagnosis?
A) A list of conditions the patient may have based on symptoms and results of the exam
B) A problem that results from a disease or injury
C) Another way of saying assessment
D) The cause of a disease
E) What the health care professional thinks the patient has

Accepted Answer

Differential diagnosis refers to the process of distinguishing a particular disease or condition from others that present with similar clinical features. It involves creating a list of potential conditions that could be causing the patient's symptoms and then narrowing it down through further testing and examination.

Question 3

Which of the following is the correct definition for the term symptom?
A) Something a health care provider notices
B) Something that has been going on for a while now.
C) Something that runs in the family.
D) Not feeling well
E) Something a patient feels

Accepted Answer

A symptom is a subjective experience reported by the patient, such as pain or fatigue, which cannot be directly observed by others.

Question 4

Which part of most medical notes contains information such as medical history, duration, and quality of the problem and any exacerbating or relieving factors for that problem?
A) subjective
B) objective
C) assessment
D) plan
E) none of these

Accepted Answer

The subjective part of medical notes includes the patient's medical history, the duration and quality of the problem, and any exacerbating or relieving factors, as it is based on the patient's personal experience and description of their symptoms.

Question 5

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.

Accepted Answer

Health records contain important information about a patient's health history, including medical conditions, allergies, medications, and previous procedures. This information is crucial for providing effective patient care and developing treatment plans. Health records also provide a roadmap for future treatment and help healthcare providers make informed decisions about the best course of action for a patient.

Question 6

Which of the following pairs of terms are opposites?
A) acute, abrupt
B) exacerbation, symptom
C) febrile, afebrile
D) genetic, hereditary
E) lethargy, malaise

Accepted Answer

Febrile means having a fever, while afebrile means not having a fever, making them opposites.

Question 7

The best definition for 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 such as 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 such as high blood pressure, asthma, or diabetes.
E) the story of the patient's problem.

Accepted Answer

A review of systems is a systematic approach to evaluating each body system to identify any symptoms that may not be directly related to the patient's chief complaint.

Question 8

A patient complains of itchy skin and has a very noticeable rash. Which of the following terms is appropriate to use to describe the rash?
A) alert
B) marked
C) objective
D) oriented
E) unremarkable

Accepted Answer

The term "marked" is appropriate to use to describe a rash that is very noticeable.

Question 9

In the patient's medical record, a note states that the patient has unremarkable symptoms. Unremarkable is a medical term used to mean that the symptoms
A) stand out.
B) get progressively worse.
C) get progressively better.
D) do not bother the patient.
E) are normal.

Accepted Answer

In medical terminology, "unremarkable" means that the symptoms are normal or not unusual, indicating nothing of concern.

Question 10

Which of the following is the correct definition for the term chronic?
A) All of a sudden
B) Has been going on for a while
C) Runs in the family
D) Gets progressively worse
E) Something a patient feels

Accepted Answer

Chronic refers to a condition or disease that persists for a long time or is constantly recurring.

Question 11

The medical term given to describe a patient's symptoms or disease as becoming more and more severe or evident each day is
A) abrupt.
B) acute.
C) genetic.
D) malaise.
E) progressive.

Accepted Answer

The term "progressive" is used in medicine to describe a condition or symptoms that become more severe or evident over time.

Question 12

Which part of most medical notes contains information such as the patient's physical exam, laboratory findings, and imaging studies performed at the visit?
A) subjective
B) objective
C) assessment
D) plan
E) none of these

Accepted Answer

The "objective" section of medical notes typically includes information from the physical exam, laboratory findings, and imaging studies.

Question 13

The best definition of a systemic infection is an infection that
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 easy to treat.

Accepted Answer

A systemic infection is one that affects the entire body, rather than being localized to one area.

Question 14

The medical term ___________ describes a patient concern that just started recently, or has a sudden onset.
A) acute
B) chronic
C) febrile
D) lethargic
E) noncontributory

Accepted Answer

The term "acute" is used in medicine to describe a condition that has a sudden onset or is of short duration.

Question 15

Which of the following statements is FALSE about the SOAP method?
A) Diagnostic work in medicine is similar to the investigative work of a detective; 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.

Accepted Answer

The SOAP method begins with collecting data (Subjective and Objective) and then moves to analysis (Assessment) and planning (Plan), not the other way around.

Question 16

Which of the following components of the health record is NOT included under the subjective section?
A) chief complaint
B) family history
C) past medical history
D) review of systems
E) social history

Accepted Answer

The review of systems is typically considered part of the objective section, as it involves a systematic inquiry about symptoms related to different body systems.

Question 17

The part of the medical record that outlines a course of action consistent with a health care provider's assessment is the ________.
A) subjective
B) objective
C) assessment
D) plan
E) none of these

Accepted Answer

The "plan" section of a medical record outlines the course of action or treatment plan that is consistent with the healthcare provider's assessment.

Question 18

Which part of most medical notes contains information that could be a diagnosis, identification of the problem, or a differential diagnosis?
A) subjective
B) objective
C) assessment
D) plan
E) none of these

Accepted Answer

The assessment section of medical notes typically contains the diagnosis, identification of the problem, or a differential diagnosis.

Question 19

During a patient examination, a medical professional may feel parts of the patient's body. This technique is called
A) auscultation.
B) diagnosing.
C) palpation.
D) palpitation.
E) percussion.

Accepted Answer

Palpation is the technique where a medical professional uses their hands to feel parts of a patient's body to assess size, shape, firmness, or location of certain structures.

Question 20

The risk for being sick is known as
A) malignant.
B) morbidity.
C) mortality.
D) prognosis.
E) remission.

Accepted Answer

Morbidity refers to the risk or incidence of illness or disease within a population. A is incorrect as malignant refers to a type of cancer, not the risk for being sick. C is incorrect as mortality refers to the number of deaths within a population. D is incorrect as prognosis refers to the predicted outcome or course of a disease or condition. E is incorrect as remission refers to a period when symptoms of a disease have improved or disappeared.

Quiz 2: Introduction to Health Records

The story of the patient's problem is known as the

Which of the following statements is the best definition for differential diagnosis?

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

Which part of most medical notes contains information such as medical history, duration, and quality of the problem and any exacerbating or relieving factors for that problem?

What is the importance of health records?

Which of the following pairs of terms are opposites?

The best definition for a review of systems is

A patient complains of itchy skin and has a very noticeable rash. Which of the following terms is appropriate to use to describe the rash?

In the patient's medical record, a note states that the patient has unremarkable symptoms. Unremarkable is a medical term used to mean that the symptoms

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

The medical term given to describe a patient's symptoms or disease as becoming more and more severe or evident each day is

Which part of most medical notes contains information such as the patient's physical exam, laboratory findings, and imaging studies performed at the visit?

The best definition of a systemic infection is an infection that

The medical term ___________ describes a patient concern that just started recently, or has a sudden onset.

Which of the following statements is FALSE about the SOAP method?

Which of the following components of the health record is NOT included under the subjective section?

The part of the medical record that outlines a course of action consistent with a health care provider's assessment is the ________.

Which part of most medical notes contains information that could be a diagnosis, identification of the problem, or a differential diagnosis?

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

The risk for being sick is known as