CPCA Reading Comprehension 2

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?

Accepted Answer

Supine

Answer

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?

Accepted Answer

Inferior myocardial infarction

Answer

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?

Accepted Answer

Clear or slightly yellow fluid, typically non-infectious

Answer

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?

Accepted Answer

Past Medical History

Answer

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?

Accepted Answer

The patient's heart rate, blood pressure, and circulation were maintained within acceptable ranges

Answer

Hemodynamically stable means the cardiovascular system (heart rate, blood pressure, blood flow) remained within safe parameters during the procedure.

CPCA Exam Practice Test

CPCA Exam Practice Test

CPCA Reading Comprehension 2