Clinical Flashcards
(229 cards)
1
Q
ABC
A
Airway, breathing, circulation
2
Q
AD
A
Right ear (auris dexter)
3
Q
AK
A
Above the knee
4
Q
Ama
A
Autonomic nervous system
5
Q
A&P
A
Anterior, posterior
Auscultation, percussion
6
Q
AS
A
Left ear (auris sinister)
7
Q
AU
A
Both ears (aures unitas)
8
Q
A&W
A
Alive and well
9
Q
BK
A
Below knee
10
Q
BM
A
Bowel movement
11
Q
BP, B/P
A
Blood pressure
12
Q
BRAT
A
Bananas, rice, applesauce, toast diet
13
Q
C
A
Celsius
14
Q
CA
A
Cancer
15
Q
CC, cc
A
Chief complaint
16
Q
CNS
A
Central nervous system
17
Q
C/O
A
Complains of
18
Q
CXR
A
Chest xray
19
Q
D&C
A
Dilation and curettage
20
Q
DNR
A
Do not resuscitate
21
Q
Dx
A
Diagnosis
22
Q
EMS
A
Emergency medical service
23
Q
ENT
A
Ears, nose, throat
24
Q
Eq
A
Equivalent
25
ER
Emergency room
26
F
Fahrenheit
27
FH
Family history
28
F/u
Follow up
29
FUO
Fever of underdetermined origin
30
FYI
For your information
31
GI
Gastrointestinal
32
HBP
High blood pressure
33
HEENT
Head, ear, eye, nose, throat
34
H&P
History and physical
35
HR
Heart rate
36
HRT
Hormone replacement therapy
37
Hx
History
38
ICU
Intensive care unit
39
I&D
Incision and drainage
40
L&A
Light and accommodation
41
LBP
Lowe blood pressure
42
LMP
Last menstrual period
43
L&W
Living and well
44
MA
Mental age
45
N/O
No complaints
46
OD
Right eye (oculus dexter)
47
OS
Left eye (oculus sinister)
48
OU
Each eye (oculus uterque)
49
PE, ex
Physical examination
50
PERRLA
Pupils equal/round/reactive to light and accommodation
51
PH
Past history
52
PNS
Peripheral nervous system
53
WNL
Within normal limits
54
VS
Vital signs
55
UTI
Urinary tract infection
56
Tx
Treatment
57
TPR
Temperature, pulse, respiration
58
TIA
Transient ischemic attack
59
Sx
Symptoms
60
SOB
Shortness of breath
61
SID
Sudden infant death
62
SH
Social history
63
ROS
Review of system
64
ROM
Range of motion
65
REM
Rapid eye movement
66
Px
Prognosis
67
PT
Physical therapy
68
Asepsis
- State of being free from pathogen
- technique is use of measure that prevent contact with disease causing contaminants
- elimination of infection is general goal of asepsis
69
Medical asepsis
- maintain cleanliness, prevent spread of all pathogenic microorganisms, by good hygiene practice.
- dermal patch application, oral/rectal tympanic temp measurement, venipuncture (thoroughly clean skin puncture site, hand washing, gloves), cerumen removal, proctoscopy, blood pressure measurement, eye irrigation or instillation
70
Medical aseptic Hand washing
- keep hands lower than forearm
| - with water running, dry hands with clear/dry paper towel, turn off faucet using clean/dry papertowel
71
Surgical asepsis hand washing
- use sterile scrub brush
- wash hand / forearms
- hold hand higher than elbow
- use sterile towel instead of paper towel
72
Surgical asepsis
- Exclusion of all microorganism
- most or all sterile invasive procedure: include venipuncture, parenteral administration, also used when gloving, setting up and maintain sterile tray
- venipuncture / parenteral administration, suture removal, dressing change, urinary catheter insertion, minor laceration closure, minor laceration closure, sterile solution pouring, local infection incision and drainage, culture collection
73
Guideline for surgical asepsis
-1 inch border around sterile field considered contaminated
-hold sterile items above waist
-always face sterile field, never reach over field
-if must leave field, place sterile towel over it
-never cough/ sneeze over sterile field
-sterile object comes in contact with unsterile item, cannot be used
-if in doubt, do not use
-if field has bee broken, start all over with set up
-for venipuncture / parenteral administration
—must use and maintain sterile equipment for invasive procedure
—any introduction of sterile item in patient must always be performed with no-touch technique
—skin should not be touched in area of insertion after skin cleaned
—sterile device must not touch no sterile service
74
Antiseptic
- used to cleanse infective agent from human skin and wound
- alcohol wipes, sponges, cotton tip
- prepare skin by using outward circular motion from incision site 2-5 minutes
75
Sanitization
- cleaning of debris, blood, pathogenic microorganism from instrument, equipment, examine room
- use of disinfectant or detergent solution with non metal brush
- first step before disinfecting and sterilization
76
Disinfection
- reduction of number of pathogenic microorganism on objects or in materials so they pose no threat of disease
- use of chemicals on instruments, equipment, countertops
- chemical: glutaraldehyde (cidex), chemical germicides, household bleach (sodium hypochlorite)
77
Sterilization
-destroy all microorganism by dry heat, steam heat, chemical or gases
78
Gas heat sterilization
For late equipment, used in hosptials
79
Dry heat sterilization
For instruments prone to corrosion
80
Chemical sterilization
For heat-sensitive equipment
81
Steam heat sterilization
- Autoclave, for heat and moisture stable instruments and equipment
- most common method in medical office
- procedure: operate with distilled water, wrap instruments, steam temp must be 250-254 F, sterilize for 20-40 minutes, begin timing when indicators show the recommended temp and pressure, maximum shelf life for sterile pack is 30 days
82
History
Keep history of each patient medical treatment
-must be thorough to provide foundation for all current and future care of patient by practice
-area covered in patient history:
—presenting problem: reason for visit
—sign: observed, test results, exam resulted
—symptoms: patient provide information, child given opportunity to express symptoms in own word
—past and present disease
—medical problems
—medication, include over the counter
—pregnancy and births
—allergy and other peculiarities
—past surgery and injury
—social history: alcohol, drugs, sexual orientation
—mental health: past and present
—family history: cause of death, disease
83
Vital statistic
Vital signs plus menus ration (height and weight)
- useful in assessing present health of patient, patient progress, diagnosis, variation from normal ranges of individual
- tracking for patient illness
84
Vital signs
Measure vital sign to determine how well patient body is functioning
-include temperature, pulse, respiration and BP
85
Temperature
-average: 98.6 (F) or 37 (C)
86
Pyrexia
Medical term for fever
87
Febrile
Describes a patient with fever
88
Low body temperature causes
-blood loss, fainting, dehydration, fasting, central nervous system injury
89
Oral temperature
- under tongue in mouth
- 98.6 (F)
- 36.8 (C)
90
Rectal
Rectum
- 100 (R) (F)
- 37.8 (R) (C)
91
Axillary
In armpit area (least accurate)
- 97.6 (A) (F)
- 36.4 (A) (C)
92
Tympanic
Eardrum (quick and easy)
- adult: pull ear up and back
- child: pull ear down and back
- 100 (T) (F)
- 37.8 (T) (C)
93
Pulse
- indicator of heart and blood vessel function
- indirect measure of cardiac output
- regular rhythm, rate, easy to palpate
- apply gentle pressure on artery against bone at side, do not use thumb to measure
- on infants require stethoscope
- rate equal to number of heartbeat felt in a minute
- rhythm regular recurrent expansion and contraction of artery
- volume is strength, force of pulse
- adult: 60-100
- children: 70-120
94
Temporal pulse
Over temporal bone on side of face
95
Carotid pulse
Front of neck, next to trachea
96
Apical
Lower left corner of heart, require stethoscope, used for infants
97
Brachial pulse
Within bend of elbow
98
Radial pulse
On thumb side of inner wrist
99
Femoral pulse
Groin
100
Popliteal pulse
Posterior of knee
| -used to check for circulation
101
Dorsalis pedis pulse
Top of foot, medically
| -used to check for circulation
102
Arrhythmia
Irregular heartbeat
103
Bradycardia
Slow, regular beat: less than 60 bpm
104
Bruit
Sound made by blockage in carotid artery
105
Extrasystole
An extra beat, heart contraction, which interrupts normal regular rhythm of heart
106
Pulse oximetry
- Measure percentage of oxygenated hemoglobin
- 95% or higher is normal
- used to access pulmonary function of patient with pneumonia, bronchitis, emphysema, asthma
107
Pulse pressure
Difference between systolic and diastolic reading
- give tone of arterial wall
- higher than 50 or lower than 30mm Hg is abnormal
108
Tachycardia
Rapid, regular beat, greater than 90 bpm
109
Respiration
Act of breathing
- works with heart and circulation to remove waste product, provide nourishment to body cells
- adult: 12-20 breath per minute
- children 18-30 breath per minute
- ratio of respiration to pulse rate is 1 breath to 4 pulse beats, evenly space, moderate depth, quiet
110
Dyspnea
Difficult or painful breathing
111
Eupnea
Normal breathing
112
Exhalation
Lung deflate, diaphragm rise to assist lung
113
Hyperpnea
Rapid, deep breathing
114
Inspiration
Inhalation, lungs fill, diaphragm move down to allow expansion
115
Tachypnea
Rapid breathing
116
Blood pressure
Arterial pressure measurement
- assessing health of patient heart and blood vessels
- measure force of blood against artery wall
- measured in millimeter of mercury (mm Hg)
- common site: brachial artery-inside elbow of arm
- left arm gives slightly higher reading
- do not press thumb on stethoscope bell, thumb has a pulse
- rises with age due to elasticity in blood vessels
- first sound systolic
- second sound diastolic
117
Systolic
Pressure produced on artery vessel as left ventricle contracts, sends blood into artery.
Normal is less than 120 mm Hg
118
Diastolic
Relaxation phase of heart left ventricle refills with blood
| Normal is less than 80 mm Hg
119
Korotkoff’s sound
Sounds between 1st and last sound
120
Sphygmomanometer
Device used to measure BP
-dial: register pressure
-cuff: regulate flow of blood through blood vessel
-pressure bulb: used to pump air into cuff
—inflate cuff 20 mm Hg above point which radial pulse disappears
-control valve: controls release of air from cuff
121
Vision test
May be done as part of routine physical exam
- Snellen chart is used most often
- chart made up of rows of letters
- from top to bottom
- letters in each row decrease in size
- patient stands 20 ft from chart, each eye tested separate, both eyes together
- measurement of 20/30 means smallest line an eye, less visual acuity, see at 20 ft is seen by normal eye at 30 ft
- measurement 20/40-1 means smallest line an eye, with less visual acuity, sees at 20 ft is seen by normal eye at 40 ft minus 1
122
Color blindness test
- reader need to identify various character of set of 24 color test plates from pseudoIsochromatic plate Ishihara color vision test book
- green and red blindness most common type of abnormal color perception
- color blindness occurs more in male than female
123
Auscultation
Listen to body sounds with stethoscope
124
Inspection
Visual exam of patient
125
Manipulation
Body part moved to assess range of motion
126
Palpation
Touch skin surface, using some pressure to feel underlying organs to assess texture, temp, movement and shape
127
Percussion
Listen to body sound by tapping to assess resonance of appropriate organ and body cavities
128
Romberg balance test
Assess muscle abnormalities
| -pt stands with feet together, eyes closed
129
Newborn, infant, toddler exam
-length, weight are taken, plotted on growth chart
-immunization are done according to schedule
-Denver II developmental screening test:
—test screens gross, fine motor skills, personal skill, development
—administered periodically between 1 and 6 years of age
130
Newborns
Assess for apgar score 1 and 5 minutes after birth
- measure 5 signs: appearance (color), pulse, grimace (reflex to stimuli), activity (muscle tone), respiration
- each sign scored with 0, 1, 2 and totaled
- BP: 60-90/30-62
- axillary temp: 98.2 F
- receive 1st hep B immunization
131
Infant/toddler
-infant up to 1 year old
-toddler 1-3 years old
-head circumference measure is made, just above eyebrow/top of ear
—performed until 36 months old
-infant pulse (apical): 100-160 with stethoscope for 1 minute, document with number and AP
132
Supine position
For breast, ab, arm, leg, head, neck, EKG
| -laying on back, arms to side
133
Sitting position
- examine head, chest, heart, back, arm, lungs, knee/ankle reflex
- sitting upright on table, legs over side of table
134
Sim’s position
Fexsigmoidoscopy, anal
| -laying on left side, right knee bent, left leg straight, left arm behind back, right arm in front
135
Dorsal recumbent
- Examine head, neck, chest, heart
| - laying on back, arms to side, knee bent, feet flat on table
136
Protologic position
Examine anus / rectum
| -laying on front side, bent at waist, knee bent
137
Lithotomy position
- examine female genitalia, endometrial biopsy
| - laying on back, feet in stirrup
138
Trendelenburg’s position
- some surgical position, low BP, shock
| - lying on back, head below rest of body
139
Fowler’s position
- examine head, neck, chest: for shortness of breath and low back pain
- sitting up at 90 degree angle with back resting on table
140
Prone
Examine back, feet, musculoskeletal
| -lying on stomach, arms by head
141
Knee-chest position
Examine anal, perianal, proctologic
| -lying with front toward table, knee bent, arms by head
142
Ishihara color number plate
Test for color blindness
143
Nasal speculum
Check for structure of nose in adults
144
Ophthalmoscope
Check health of eye
| -red reflex indicate good health
145
Otoscope
Examine inner structure of ear
146
Pen light
Check pupil response to light, nasal passage, tongue, mouth
147
Percussion hammer
Check reflexes
148
Pin wheel
Check touch sensation
149
Pupil toon meter
Test for glaucoma
150
Snellen chart
Used most often to test vision
151
Sphygmpmampmeter
Check BP
152
Stethoscope
Used for auscultation
153
Tape measure
Compare measurement of limbs, circumference of infant head
154
Thermometer
Check temperature
155
Tongue depressor/laryngeal mirror
Check mouth and throat
156
Tuning fork
Used to assess hearing, size C most common
157
Vaginal speculum
Check structure of vagina
158
Cutting
Scissors, scalpel
159
Grasping/clamping
Hemostat, forceps, clamp, needle holder
160
Probing/dilating
Speculum, scope, probe, retractor, dilator
161
Vaporizing tissue
Laser
162
Sewing tissue
Suture
163
Basal metabolic rate
Represent energy used while fasting or resting to maintain vital functions
164
Metabolism
All chemical reaction occur within cells of living organism to allow for growth, reproduction, energy production, waste excretion-anabolism
Catabolism
165
Anabolism
Use energy to construct components of cells
| -proteins and nuclei acids
166
Catabolism
Break down organic matter and receive energy by cellular respiration
167
Calorie
Unit of heat energy
| -amount of oxygen used
168
Nutrients
Consist of carbohydrate, protein, fats
| -essential to supply energy from chemical in food that body cannot synthesize
169
Carbohydrate
For energy, classified by complexity
- simple sugar: white bread, rice, potatoes, pasta
- complex plant food: most vegetables and fruit produce
170
Protein
- build and repair body tissue
| - composed of amino acids
171
Fats
- for energy and heat
- saturated: animal fat
- unsaturated: liquid at room temp
- monounsaturated: olives, avocados
- polyunsaturated: nuts, seeds
172
Grain
Highest daily amount
| -at least 3 oz of whole grain
173
Vegetable
Variety: more dark green and orange
174
Fruits
Variety: fresh, frozen, canned, dried, less juice
175
Dairy
Low fat or no fat
176
Meat and beans
Low-fat, lean meat, poultry, fish, nuts, beans
177
Oils
Lowest daily amount
- fish, nuts, vegetables
- less solid fat (butter, shortening)
- no trans fats
178
Vitamin A
Fat soluble, beta carotene
| Prevent night blindness
179
Vitamin E
Fat soluble
| Anticoagulant
180
Vitamin D
Fat soluble, for calcium absorption
| Lower risk of rickets and osteomalacia
181
Vitamin K
Fat soluble, for blood clot, lower risk of hemorrhage
182
Vitamin C
Water soluble, lower risk of scurvy, heal wounds, protect against infection
183
Vitamin B
Water soluble, support metabolism, promote hemoglobin formation
184
Calcium
Bone building, cardiac function, muscle contraction, blood coagulation
185
Chloride
Body pH and fluid balance
186
Phosphorus
Metabolism of protein, calcium, glucose
187
Sodium
Body pH balance, muscle contraction control, level regulated by kidney
188
Potassium
Protein synthesis, pH balance, heartbeat regulation
189
Magnesium
Bone building, metabolism, enzyme activity
190
Zinc
Growth, healing, sense of taste glucose tolerance
191
Iron
Hemoglobin component needed for oxygen transport through body
192
Thermotherapy
Application of dry, moist heat for pain relief, lower occurrence of muscle spasm, localized swelling, encourage tissue repair, encourage infected area drainage
193
Diathermy
Type of termotherapy
- produce heat in body tissue by high-frequency current
- use for arthritis, tendonitis
194
Ultraviolet
Type of thermotherapy
| -controlled lamp exposure therapy
195
Ultrasound
Type of thermotherapy
- use water-soluble gel and high frequency sound waves
- most common use of diathermy
196
Cryotherapy
- application of dry or moist cold
- use for: vasoconstriction, involuntary muscle contraction, decrease blood supply to area, numbing effect on nerve ending, controlling bleed or swelling, pain
197
Massage
Used to lower pain and muscle tension
198
Electric muscle stimulation
- transcutaneous electric nerve stimulation (TENS) unit use for orthopedics:
- arthritis, back injury, sports injury
- not for patient with cardiac disease or pacemakers due to electrical stimulation
199
Traction
- part of body pulled or stretch
| - to align bone or relieve vertebral bone compression, reduce/relieve spasm/shortenings
200
Walker
Mobility device
| -top of walker should be just below waist, same height as top of hip bone, elbow bent 30 degrees while using
201
Crutches
Should reach 1-1.5 inch below armpit
- handgrips at top of hip line
- patient stands on good leg, moves crutches ahead of good foot
202
Medical emergencies
- check scene for safety
- check for life threatening condition: no sign of life, unconscious, convulsions, respiratory distress, severe bleeding, deep wound, chest or other severe pain
- call 911
- check second time: mental orientation, vital sign, skin color/moister, abnormal skin color, palpitate for pain, bone fracture, bleeding
-care for injured or ill person, if alone take action:
—call 911 first-if unconscious or sudden collapse of infant or child.
—care for up to 2 minutes: any drowning person, unwitnessed adolescent, child or infant collapse and unconscious
203
ABC of cardiopulmonary resuscitation
CPR
- A: check airways
- B: look, listen, feel for breathing
- C: check carotid artery for circulation (pulse)
204
Medical office emergency equipment
- cardiac code cart
- oxygen with mask delivery
- cold packs
- wound care kit
- personal protective equipment
- childbirth or delivery kit
205
First degree burns
Red, no blister
| Tx: immerse in cool water, apply sterile, cool, wet compress
206
Second degree burn
Red, blistering
| -tx: immerse in cool water 1-2 hours, cover with dry sterile dressing
207
Third degree burn
- full skin thickness, may involve muscle
- tx: cover with thick, dry sterile dressing/dressing soaked in sterile saline solution if available
- do not pull off adhere clothing because of infection and dehydration
208
Chemical burn
- if powered agent: try to brush off
| - if not, rinse copiously, cover with sterile dressing
209
Myocardial infarction
S/s: chest pain, left arm pain, jaw pain, sweating, indigestion, rapid respiration, nausea, vomiting
-care: active EMS, get code cart/oxygen, check ABC if needed, check vital sign, keep patient calm
210
Convulsion
- S/s: jerking, spasmodic body movement, loss of consciousness
- care: activate EMS, protect head, maintain airway
211
Stroke
Cerebrovascular accident
- S/S: slurred speech, confusion, paralysis to 1 side of body, unequal pupils
- care: activate EMS, maintain airway, check vital sign, keep patient calm
212
Bleeding from limb, head or neck
Elevate injured part above heart if possible
213
Severe bleeding
- apply direct pressure with sterile compress
- add more compress as needed, do not replace used compress, it disturb clotting process
- life or death situation: last resort is tourniquet application, not time of application
214
Syncope
- s/s: unconsciousness result from drop in BP or low level of oxygen
- care: place in supine position with head lower than heart
- maintain open airway
- apply cool compress to forehead
- loosen tight clothing
215
Shock
- s/s: cool, pale, moist skin, low BP, weak / rapid pulse, agitation, restlessness, dyspnea, weakness
- care: active EMS, maintain airway, place in Trendelenburg’s position (if no head injury), check vitals, keep patient warm
216
Anaphylactic
Severe allergic reaction
| -low blood pressure, edema, tachycardia, dyspnea
217
Cardio genie
Impaired cardiac function
218
Hypovolemic
Hemorrhagic, low blood volume
219
Insulin
Severe hypoglycemia
220
Neurogenic
Trauma to nervous system
| -fainting (blood vessel dilate, loss of tone, low BP, heart rate)
221
Septic
Infection spread by blood to all body systems
222
Traumatic
Loss of interstitial fluid
| -large burn areas
223
Ashtma
Narrowing airway causing breathing difficulty or wheezing sound
-care: check ABC, patient upright, if possible, assist with inhaler, monitor oxygen with pulse oximeter, keep patient calm
224
Hyperventilation
Leading to lower carbon dioxide level results in dizziness or unconsciousness
-care: place paper bag over patient nose and mouth, have patient breath slow and calm
225
Choking
Coughing audibly
-encourage patient to continue coughing
clutching throat, unable to produce sound
-perform himlich’s maneuver: bear hug from behind, 1 hand cover balled fist below ribs/above navel, pull in upward thrusts to dislodge foreign object
226
Fractures
Care: immobilize with splint, elevate (if possible), apply ice packs, use sling for fractured clavicle or arms
227
Inhaled, ingested, injected poisoning: chemical or natural
```
Activate EMS
Call poison control for instructions
Use personal protective equipment
Check ABC
Check vitals
```
228
Insulin shock
Moist, pale, rapid heart rate, confusion
| -care: give food containing sugar will rapidly absorbed (orange juice/glucose gel)
229
Diabetic coma
- s/s: dry, flushed skin, fruity breath, extreme thirst, confusion, rapid respiration
- care: activate EMS, provider must administer insulin
