1. A patient is admitted to the hospital with chest pain and

shortness of breath. The physician orders an

electrocardiogram (ECG) and a cardiac enzyme test. The

ECG report shows ST segment elevation in leads V1-V4,

indicating an acute anterior myocardial infarction (MI).

The cardiac enzyme test shows elevated levels of troponin

and creatine kinase-MB, confirming the diagnosis of MI.

The physician documents the diagnosis as "acute anterior

MI" in the discharge summary. Which of the following

statements is true about this documentation?

a) It is accurate and complete, as it reflects the findings of

the diagnostic tests and the location of the MI.

b) It is inaccurate and incomplete, as it does not specify the

cause of the MI, such as coronary artery disease or

atherosclerosis.

c) It is accurate but incomplete, as it does not include the

severity of the MI, such as mild, moderate, or severe.

d) It is inaccurate but complete, as it includes the location

of the MI but not the correct terminology, such as acute

coronary syndrome or ST-elevation MI.

Answer: A. The documentation is accurate and complete,

as it reflects the findings of the diagnostic tests and the

location of the MI. The cause and severity of the MI are not

essential elements of the diagnosis, as they can be inferred

from the clinical presentation and the test results.

2. A patient is admitted to the hospital with a history of

chronic obstructive pulmonary disease (COPD) and