CPCA Reading Comprehension 2 — Questions and Answers
Question 1: An operative note states: 'The patient was placed in the supine position. A 4 cm incision was made in the right lower quadrant. The appendix was identified, ligated, and excised.' Which term best describes the position documented?
- Prone
- Supine (Correct answer)
- Lateral decubitus
- Lithotomy
Correct answer: Supine
Supine means the patient is lying face-up on their back, as stated explicitly in the operative note.
Question 2: A discharge summary reads: 'Patient presented with acute onset dyspnea, diaphoresis, and chest pain radiating to the left arm. EKG showed ST elevation in leads II, III, and aVF.' Which condition is most consistent with these findings?
- Pulmonary embolism
- Unstable angina
- Inferior myocardial infarction (Correct answer)
- Aortic dissection
Correct answer: Inferior myocardial infarction
ST elevation in leads II, III, and aVF indicates an inferior MI, as these leads reflect the inferior wall of the heart.
Question 3: A progress note reads: 'The wound measures 3.5 cm in length with serous drainage and mild erythema at the margins. No induration or crepitus noted.' The coder must identify the wound condition. What does 'serous drainage' indicate?
- Purulent infection requiring antibiotics
- Clear or slightly yellow fluid, typically non-infectious (Correct answer)
- Bleeding from wound edges
- Necrotic tissue formation
Correct answer: Clear or slightly yellow fluid, typically non-infectious
Serous drainage is thin, watery, and clear or slightly yellow, which is generally a normal part of wound healing.
Question 4: A physician documents: 'Patient is a 68-year-old male with PMH significant for HTN, T2DM, and COPD presenting with exacerbation of his underlying pulmonary condition.' What does 'PMH' stand for in clinical documentation?
- Primary Medical History
- Past Medical History (Correct answer)
- Preventive Medicine History
- Pharmacological Management History
Correct answer: Past Medical History
PMH is a standard medical abbreviation for Past Medical History, listing prior diagnoses and conditions.
Question 5: An anesthesia record states: 'General anesthesia administered via endotracheal intubation. Total anesthesia time: 2 hours 15 minutes. Patient remained hemodynamically stable throughout.' What does 'hemodynamically stable' mean in this context?
- The patient's blood levels were normal
- The patient's heart rate, blood pressure, and circulation were maintained within acceptable ranges (Correct answer)
- The patient did not experience any allergic reactions
- The patient's respiratory rate was within normal limits
Correct answer: The patient's heart rate, blood pressure, and circulation were maintained within acceptable ranges
Hemodynamically stable means the cardiovascular system (heart rate, blood pressure, blood flow) remained within safe parameters during the procedure.
Question 6: A pathology report reads: 'Gross examination reveals a 2.3 cm firm, irregular mass with ill-defined borders. Microscopic examination shows pleomorphic cells with frequent mitotic figures.' What does 'pleomorphic' suggest about the cells?
- The cells are uniform in size and shape
- The cells vary widely in size and shape, suggesting malignancy (Correct answer)
- The cells show signs of normal differentiation
- The cells are arranged in glandular patterns
Correct answer: The cells vary widely in size and shape, suggesting malignancy
Pleomorphic cells vary in size and shape, which is a hallmark of malignant (cancerous) tissue.
Question 7: A consultation note reads: 'After reviewing the patient's imaging and lab values, and in consideration of the patient's comorbidities, I concur with the referring physician's assessment and recommend conservative management at this time.' Who is the 'referring physician' in this context?
- The specialist writing the consultation note
- The physician who sent the patient to the specialist for evaluation (Correct answer)
- The patient's insurance-designated primary provider
- The physician who initially diagnosed the condition years ago
Correct answer: The physician who sent the patient to the specialist for evaluation
The referring physician is the provider who sent (referred) the patient to the specialist for a consultation.
CPCA Reading Comprehension 2
An operative note states: 'The patient was placed in the supine position.
A 4 cm incision was made in the right lower quadrant.
The appendix was identified, ligated, and excised.' Which term best describes the position documented?