Question

General – Visit Note

CC:     37 y.o. w/ diabetes c/o swelling of the ® foot and calf x 3d.
S:     There is no Hx of trauma, pain, SOB, or cardiac Sx. Smoker x 12 years ½ pkg q.d. Denies ETOH
consumption.
Meds: parenteral insulin q.d. NKDA.
O:     Pt. is afebrile, BP 140/84, P 72, R 16, lungs are clear; abdomen is benign w/o organomegaly;
muscle tone and strength are WNL. There is swelling of the ® calf but w/o erythema or tenderness.
A:     Edema of ® calf of unknown etiology.
P:     Schedule STAT vascular sonogram of lower extremities; pt is to keep the leg elevated x 2d then
    RTC for follow-up and test results on Thursday (or sooner if ? edema, SOB, or CP).

Questions

What is the sex of the patient? (1)

Male

Female

Where is the patient to be seen for follow-up on Thursday? (1)

Emergency room

Outpatient clinic

Inpatient hospital

What was the condition of the patient’s abdomen? (1)

Shows signs of cancer

Internal organs are enlarged

Internal organs are not enlarged

Muscle tone and strength are weak

How is the patient’s insulin administered? (1)

Orally

Sublingually

By injection

Rectally

What one word in the patient’s chart note gives you the answer to #4? (1)

What is the cause of the patient’s complaint? (1)

Unknown

Fever

Shortness of breath

Trauma

When should the sonogram be performed? (1)

Immediately

Within two days

At the time of follow-up

Only if symptoms persist

How long should the patient’s leg be kept elevated? (1)

One week

Two weeks

One day

Two days

In the context of this report, what would the abbreviation CP mean? (1)

Cerebral palsy

Cardiopulmonary

Chickenpox

Chest pain

The patient states he does not drink alcohol. This statement is (1)

true

false

What abbreviation in this report indicates that the patient is not allergic to medications? (1)

Answer 1

1. Answer ; Female.

Reason ; According to the given case history, the client is 37 year old women patient.

2. Answer ; Outpatient clinic.

Reason ; The given description tells the client to have follow up on RTC, which is not the inpatient or emergency unit, but it refers the outpatient unit.

3. Answer ; Show signs of cancer.

Reason ; On abdominal examination, the benign part is identified. There is no organomegally identified in these client.

4. Answer ; By injection.

5. Answer ; Parenteral ( one word )

6. Answer ; Unknown.

7. Answer ; Immediately.

8. Answer ; Two days.

9. Answer ; Chest pain

10. Answer ; True