Quiz Day 5 - Comprehensive
This is a comprehensive quiz on all components of the medical chart.
Questions and Answers
- 1.
"Along with my headache, I've noticed some blood in my urine," is an example of which HPI component listed below?
- A.
Onset/Duration
- B.
Modifying Factors
- C.
Location/Radiation
- D.
Associated Symptoms
Correct Answer
D. Associated SymptomsExplanation
The statement "Along with my headache, I've noticed some blood in my urine" indicates that the person is experiencing both a headache and blood in their urine. These symptoms are associated with each other, as they are occurring together. Therefore, the correct HPI component for this statement is "Associated Symptoms."Rate this question:
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- 2.
"My temperature went down after I took some Tylenol," is an example of which HPI component listed below?
- A.
Quality
- B.
Modifying Factors
- C.
Onset/Duration
- D.
Associated Symptoms
Correct Answer
B. Modifying FactorsExplanation
The statement "My temperature went down after I took some Tylenol," indicates that the action of taking Tylenol had an effect on the person's temperature. This demonstrates a modifying factor, as the use of Tylenol modified or influenced the temperature.Rate this question:
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- 3.
In what part of the medical chart does abdominal pain belong, ROS or PE? Please write the answer below and include the associated system. (Example: PE, Musculoskeletal)
Correct Answer
ROS, Abdomen
ROS, Abdominal
ROS, abdomen
ROS, abdominal - 4.
In what part of the medical chart does murmur belong, ROS or PE? Please write the answer below and include the associated system. (Example: PE, Musculoskeletal)
Correct Answer
PE, Cardiovascular
PE, Cardiac
PE, Cardio
PE, cardiovascular
PE, cardiacExplanation
The correct answer is PE, Cardiovascular or PE, Cardiac. Murmur refers to an abnormal sound heard during the heartbeat and is related to the cardiovascular system. Therefore, it would be documented in the Physical Examination (PE) section of the medical chart, specifically under the Cardiovascular or Cardiac subsection.Rate this question:
- 5.
Which of the following medications is an antiemetic?
- A.
Dilaudid
- B.
Zofran
- C.
Toradol
- D.
Motrin
Correct Answer
B. ZofranExplanation
Zofran is the correct answer because it is an antiemetic medication. Antiemetics are drugs that are used to prevent or treat nausea and vomiting. Dilaudid, Toradol, and Motrin are not antiemetics. Dilaudid is a potent opioid pain medication, Toradol is a nonsteroidal anti-inflammatory drug (NSAID), and Motrin is also an NSAID commonly used for pain relief and reducing inflammation.Rate this question:
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- 6.
The physician dictates, "The patient had left-sided, horizontal nystagmus." This would be charted where?
- A.
In the Eyes system of the PE
- B.
In the Eyes system of the ROS
- C.
In the Skin system of the PE
- D.
None of the above
Correct Answer
A. In the Eyes system of the PEExplanation
The physician's statement "The patient had left-sided, horizontal nystagmus" indicates an abnormal eye movement, specifically nystagmus, which is characterized by involuntary eye oscillations. This information is relevant to the Eyes system of the Physical Examination (PE) because it pertains to the examination of the patient's eyes and their movements. Therefore, it would be charted in the Eyes system of the PE.Rate this question:
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- 7.
What is the perspective of physical exam and review of systems?
- A.
Physical Exam is objective, Review of Systems is subjective
- B.
Physical Exam is subjective, Review of Systems is objective
- C.
Physical Exam and Review of Systems are both subjective
- D.
Physical Exam and Review of Systems are both objective
Correct Answer
A. Physical Exam is objective, Review of Systems is subjectiveExplanation
The physical exam involves the healthcare provider directly observing and examining the patient's body, using techniques such as palpation, auscultation, and inspection. This makes it an objective assessment since it is based on measurable and observable findings. On the other hand, the review of systems relies on the patient's subjective reporting of symptoms, such as asking about their medical history, current symptoms, and any relevant past experiences. This makes it a subjective assessment as it relies on the patient's perception and interpretation of their symptoms.Rate this question:
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- 8.
True or False. A medical chart is used for the following: legal document, patient medical history, billing purposes, public record.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
A medical chart is used for various purposes, including recording a patient's medical history, documenting treatments and medications, and tracking their progress. However, it is not used as a legal document, for billing purposes, or as a public record. These functions are typically fulfilled by other documents such as consent forms, insurance claims, and government databases. Therefore, the statement that a medical chart is used for legal document, patient medical history, billing purposes, and public record is false.Rate this question:
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- 9.
True or False. The best time to ask the physician for clarification on any part of the chart is while he/she is seeing the patient.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
The best time to ask the physician for clarification on any part of the chart is not while he/she is seeing the patient. It is important to respect the physician's time with the patient and avoid interrupting the consultation. Asking for clarification outside of the patient's presence allows the physician to focus on the patient's needs and provide the best possible care.Rate this question:
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- 10.
A physician's Plan on the medical chart includes which of the following? (You may check more than one answer.)
- A.
Treatment instructions
- B.
Differential diagnosis
- C.
Physical exam
- D.
Prescriptions and dosage
Correct Answer(s)
A. Treatment instructions
B. Differential diagnosis
D. Prescriptions and dosageExplanation
The physician's Plan on the medical chart includes treatment instructions, which outline the recommended course of action for the patient's condition. The Plan also includes a differential diagnosis, which is a list of possible conditions that could explain the patient's symptoms. Additionally, the Plan includes prescriptions and dosage information for any medications that the physician has prescribed to the patient. These components are all important for guiding the patient's care and ensuring that they receive appropriate treatment.Rate this question:
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- 11.
Patient takes Metformin 850 MG twice a day. What chronic condition does patient most likely have?
Correct Answer(s)
Diabetes
diabetes
type 2 diabetes
diabetes mellitusExplanation
The patient most likely has diabetes, as indicated by the fact that they are taking Metformin, which is a medication commonly used to treat diabetes. The mention of "850 MG twice a day" suggests that the patient has a chronic condition that requires regular medication, further supporting the likelihood of diabetes. The terms "diabetes," "type 2 diabetes," and "diabetes mellitus" all refer to the same chronic condition.Rate this question:
- 12.
What phrase would you write if patient states he/she has no allergies?
Correct Answer(s)
No Known Allergies (NKA)
No Known Drug Allergies
NKA
No Known AllergiesExplanation
The phrase "No Known Allergies (NKA)" is the correct answer because it is a common notation used in medical records to indicate that the patient has no known allergies to any substances. Similarly, "No Known Drug Allergies" is also an acceptable phrase to document that the patient does not have any known allergies specifically to medications. The abbreviation "NKA" is often used as a shorthand notation for "No Known Allergies" in medical documentation. Therefore, all options provided in the question are valid ways to indicate that the patient has no allergies.Rate this question:
- 13.
Please answer the question following the HPI below.Patient is a 46 year-old male presenting to the clinic with complaints of back pain that began s/p falling from a ladder (1). Pain starts in the lower back and radiates through the shoulder blades and into the neck (2). Pain was further aggravated while playing tennis (3). Patient took Motrin with minor relief of pain (4). Pain is relieved slightly when patient lies on his side (5). Patient reports that pain increases when he rises from laying down, sitting, and with ambulation (6).What element(s) is/are missing? Check all that apply.
- A.
Onset/duration
- B.
Associated symptoms
- C.
Context
- D.
Quality
- E.
Chief complaint
- F.
Modifying factors
Correct Answer(s)
A. Onset/duration
B. Associated symptoms
D. QualityExplanation
The given correct answer is onset/duration, associated symptoms, and quality. The question asks for the missing element(s) in the patient's history. The patient's chief complaint is back pain that started after falling from a ladder, indicating the context of the pain. The pain radiates through the shoulder blades and into the neck, providing information about the quality of the pain. The patient also mentions that the pain is aggravated while playing tennis and relieved slightly when lying on his side, indicating modifying factors. However, the question does not provide any information about the onset/duration of the pain or any associated symptoms, making these elements missing from the patient's history.Rate this question:
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- 14.
Which of the following is NOT an example of official diagnostic results that should be found in a patient's chart?
- A.
EKG findings
- B.
Patient's vital signs for today
- C.
MRI of pelvis
- D.
Laboratory results
Correct Answer
B. Patient's vital signs for todayExplanation
The given options consist of various types of diagnostic results that are typically included in a patient's chart. However, the only option that is not an example of official diagnostic results is "Patient's vital signs for today." Vital signs, such as blood pressure, heart rate, and temperature, are important measurements for assessing a patient's current condition but are not considered diagnostic results. Diagnostic results are typically obtained from tests or procedures, such as EKG findings, MRI scans, or laboratory tests, which provide specific information about a patient's health or medical condition.Rate this question:
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- 15.
Is the following statement true or false?It is necessary for the physician to sign off on the chart notes of new patients, but not of existing patients.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
Physicians must sign off on ALL patient charts.Rate this question:
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- 16.
Atenolol is a medication most often used to treat what medical condition?
Correct Answer
Hypertension
High Blood Pressure
HTNExplanation
High blood pressure also counts as an answer.Rate this question:
- 17.
What is the correct format for a typical patient's medical chart?
- A.
Assessment/Plan, Diagnostic Studies/Ancillary Data, HPI, PMHx, PE, ROS
- B.
HPI, PMHx, ROS, PE, Diagnostic Studies/Ancillary Data, Assessment/Plan
- C.
PMHx, ROS, HPI, PE, Assessment/Plan, Diagnostic Studies/Ancillary Data
- D.
HPI, ROS, PE, PMHx, Diagnostic Studies/Ancillary Data, Assessment/Plan
Correct Answer
B. HPI, PMHx, ROS, PE, Diagnostic Studies/Ancillary Data, Assessment/PlanExplanation
The correct format for a typical patient's medical chart is to start with the History of Present Illness (HPI), followed by the Past Medical History (PMHx), Review of Systems (ROS), Physical Examination (PE), Diagnostic Studies/Ancillary Data, and finally the Assessment/Plan. This order allows healthcare providers to gather all relevant information about the patient's current condition, medical history, symptoms, physical findings, and any additional tests or studies that have been conducted, and then formulate an assessment of the patient's condition and create a plan for further treatment or management.Rate this question:
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Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.
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Current Version
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Mar 16, 2023Quiz Edited by
ProProfs Editorial Team -
Sep 03, 2014Quiz Created by
Susan
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