Chapter 1 - Introduction Medical Terminology & Anatomy

Question 1

What does the suffix -tripsy mean?

Answer 1

Correct:
Crushing
The suffix -tripsy means crushing. For example, lithotripsy is the crushing of calculi (stones).

Question 2

What is the outer layer of the meninges?

Answer 2

Correct Answer:
Dura mater
The meninges from outer layer to inside layer are dura mater, arachnoid mater, and pia mater.

Question 3

What is the membrane that covers the interior walls of the organs and tubes opening to the outside of the body?

Answer 3

Correct Answer:
Mucous membranes
Mucous membranes line the interior walls of the organs and tubes opening to the outside of the body, such as those of the digestive, respiratory, urinary, and reproductive systems. These membranes are lined with epithelium and are involved in absorption and secretion.

Question 4

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

Answer 4

Correct Answer:
Nervous system
The nervous system controls how the body responds to internal and external changes. This includes the brain, sensory receptors, spinal cord, and nerves.

Question 5

What is the term for the study of cells including the formation?

Answer 5

Correct Answer:
Cytology
Cytology is the study of cells including the formation, structure, and function of cells.

Question 6

What statement is true regarding a chief complaint?

Answer 6

Correct Answer:
It is a description of why the patient is presenting for healthcare services.
The chief complaint is a description of why the patient is presenting for healthcare services. It can also be referred to as the reason for the patient visit.

Question 7

Which organ system houses white blood cells?

Answer 7

Correct Answer:
Lymphatic system
The lymphatic system is the body’s immune system, which houses white blood cells (lymphocytes), the main warriors of the immune system

Question 8

What is a stethoscope used for?

Answer 8

Correct Answer:
To listen to heart and lungs sounds
A stethoscope may be used to listen to the heart and lung sounds. Percussion is creating sounds from tapping on body areas to examine body organs and body cavities. The vibrations of the sounds help identify abnormalities

Question 9

What is palpation?

Answer 9

Correct Answer:
Examination of the body by touch
Palpation refers to examination of the body by touch. Body parts are palpated to look for organ size or condition, or for tenderness.

Question 10

What cavities are included in the ventral cavity?

Answer 10

Correct Answer:
Thoracic, abdominal, and pelvic cavities
The ventral cavity contains thoracic, abdominal, and pelvic cavities

Question 11

Which membrane is composed of epithelium?

Answer 11

Correct Answer:
Mucous membranes
Mucous membranes line the interior walls of the organs and tubes opening to the outside of the body, such as those of the digestive, respiratory, urinary, and reproductive systems. These membranes are lined with epithelium and are involved in absorption and secretion. The mucous membrane is composed of epithelium overlaying a layer of connective tissue called lamina propria. In some instances, the lamina propria rests on a third layer of smooth muscle cells. Not every mucous membrane secretes mucus.

Question 12

Which component of a medical record provides a brief history outlining the reasons for the procedure?

Answer 12

Correct Answer:
Indication
The indication typically gives a brief history outlining the reasons for the procedure (medical necessity).

Question 13

How many types of membranes are found in the body?

Answer 13

Correct Answer:
Five
There are five types of membranes: mucous membranes, serous membranes, synovial membranes, meninges, and the cutaneous membrane. Membranes line the internal spaces of organs and tubes opening to the outside, and line body cavities.

Question 14

What type of membrane secretes the synovial fluid?

Answer 14

Correct Answer:
Synovial membranes
Synovial membranes line the joint cavities and are composed of connective tissue. They secrete synovial fluid into the joint cavity; this lubricates the ends of bones, so they can move freely.

Question 15

Which one is NOT a serous membrane?

Answer 15

Correct Answer:
Synovial
The serous membranes are named according to their organ associations. The lungs are covered by pleura and the heart is covered by pericardium. The serous layer also lines the abdominal cavity and is known as the peritoneum. Serous membranes line cavities, including the thoracic cavity and internal organs. They consist of a layer of simple squamous epithelium overlaying a layer of loose connective tissue. Serous membranes support internal organs and compartmentalize the large cavities to hinder spread of infection.

Question 16

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.

Answer 16

Correct Answer:
A physical exam including the range of motion
This is a musculoskeletal system examination of the extremities. The physician observes and palpates the extremities, then checks the range of motion (ROM).

Question 17

What type of documentation is the following?

CV: Denies chest pain and palpitations.

Answer 17

Correct Answer:
Cardiovascular system review
This is an example of a cardiovascular system review. In this review, the patient provides information about their symptoms and what, if anything, they have done to relieve the symptoms.

Question 18

What does this documentation represent?
CC: Jaundice.

Answer 18

Correct Answer:
Chief complaint
CC is the abbreviation used for chief complaint. Based on the chief complaint, the clinical staff will ask questions about the occurrence and progression of the injury. This line of questioning is to gather information to prepare the provider for what type of condition is they are addressing

Question 19

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.

Answer 19

Correct Answer:
Brief history outlining the reasons for the procedure
The given documentation is the indication section of the report. The indication typically gives a brief history outlining the reasons for the procedure (medical necessity).

Question 20

What type of documentation is the following?

Const: Appears obese. No signs of apparent distress present.
Musculo: Walks with a normal gait.

Answer 20

Correct Answer:
A general and musculoskeletal exam
This is the example of a physical exam. Once the provider gathers the historical information, they will complete a physical exam. As the provider entered the room and gathered information on the history of the condition, they were observing the appearance of the patient.

Question 21

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.

Answer 21

Correct Answer:
A physician exam requiring a stethoscope
This is documentation of a physician exam requiring a stethoscope to listen to (auscultate) the lungs and heart. The provider is checking the respiratory effort (how hard it is for the patient to breath and how fast the patient is breathing), the rate and rhythm of the patient’s heart rate, and any abnormal sounds in the heart or lungs

Question 22

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.

Answer 22

Correct Answer:
Assessment
The most common format used in the medical records is the SOAP format that is Subjective, Objective, Assessment and Plan. In this documentation, you can notice that assessment section is missing.

Question 23

4 out of 4 points
What does the abbreviation HEENT refer to in the following documentation and what type of document is it?

HEIGHT: 5’4
WEIGHT: 165 pounds
GENERAL: Very pleasant African American female in no acute distress.
HEENT: Negative
LUNGS: Clear to auscultation bilaterally.
CVS: Regular rate and rhythm.
ABDOMEN: Soft, obese, and nontender.
EXTREMITIES: The left foot is wrapped. There is a 1+ common femoral artery pulse with a nonpalpable left common femoral artery pulse.
NEUROLOGIC: Cranial nerves II-XII are grossly intact. Alert and oriented times three.

Answer 23

Correct Answer:
Head, eyes, ears, nose, throat; physical examination
HEENT refers to head, eyes, ears, nose, and throat. Physical examination is performed by the healthcare provider through a series of assessments and observations, focused on the symptoms described by the patient, that include palpation, auscultation, etc.