Study Guide Exam And Actual Answers.
The Admission H&P (history and physical exam) starts with a medical history to provide the
chronology of a patient's care, including procedures and examinations performed by various
health providers during the life of the patient. The physical exam provides a baseline of the
patient's current physical condition.
The current (chief) complaint documents worsening belly pain accompanied by nausea and
vomiting as described by the patient. Nausea and belly pain are _____, which represent
subjective evidence of disease that is evaluated or measured by the patient. Jonathan reported
one episode of _____. - Answer symptoms; non-bloody emesis
There is a wide variety of shortened forms of words or phrases used in medical records. This
means that a health professional needs to learn the accepted shortened formats used in their
healthcare organization. Your list of medical terms includes the list of accepted shortened forms
for this course.
Some shortened forms in the case study include: HEENT (head, eyes, ears, nose, throat); NKDA
(no known drug allergies); RRR, no m/g/r (regular rate and rhythm, no murmurs/grunts/rubs
auscultated); WBC (white blood count).
These are examples of _____ that are a shorthand way to record long and complex medical
terms.
This patient's pain localized to which area of the abdomen? (You will be learning about
anatomic reference systems in Chapter 2.) - Answer abbreviations; right lower quadrant (RLQ)
The physician conducts the examination and orders tests which provide objective evidence of
the disease that can be evaluated. This is a sign of the condition. Select all the sign(s) from the
list below that were reported in the medical record, even if the patient did not have them.
[Check all the apply.] - Answer cyanosis
edema
101.4 temperature
The physician documents that the patient has acute appendicitis because this condition has
a/an _______________________. - Answer rapid onset and a severe course with a relatively
short duration
The physical examination of the abdomen, laboratory data, and diagnostic studies are the
methods to determine which one of several diseases can be producing the signs and symptoms