Clinical Flashcards
ABC
Airway, breathing, circulation
AD
Right ear (auris dexter)
AK
Above the knee
Ama
Autonomic nervous system
A&P
Anterior, posterior
Auscultation, percussion
AS
Left ear (auris sinister)
AU
Both ears (aures unitas)
A&W
Alive and well
BK
Below knee
BM
Bowel movement
BP, B/P
Blood pressure
BRAT
Bananas, rice, applesauce, toast diet
C
Celsius
CA
Cancer
CC, cc
Chief complaint
CNS
Central nervous system
C/O
Complains of
CXR
Chest xray
D&C
Dilation and curettage
DNR
Do not resuscitate
Dx
Diagnosis
EMS
Emergency medical service
ENT
Ears, nose, throat
Eq
Equivalent
ER
Emergency room
F
Fahrenheit
FH
Family history
F/u
Follow up
FUO
Fever of underdetermined origin
FYI
For your information
GI
Gastrointestinal
HBP
High blood pressure
HEENT
Head, ear, eye, nose, throat
H&P
History and physical
HR
Heart rate
HRT
Hormone replacement therapy
Hx
History
ICU
Intensive care unit
I&D
Incision and drainage
L&A
Light and accommodation
LBP
Lowe blood pressure
LMP
Last menstrual period
L&W
Living and well
MA
Mental age
N/O
No complaints
OD
Right eye (oculus dexter)
OS
Left eye (oculus sinister)
OU
Each eye (oculus uterque)
PE, ex
Physical examination
PERRLA
Pupils equal/round/reactive to light and accommodation
PH
Past history
PNS
Peripheral nervous system
WNL
Within normal limits
VS
Vital signs
UTI
Urinary tract infection
Tx
Treatment
TPR
Temperature, pulse, respiration
TIA
Transient ischemic attack
Sx
Symptoms
SOB
Shortness of breath
SID
Sudden infant death
SH
Social history
ROS
Review of system
ROM
Range of motion
REM
Rapid eye movement
Px
Prognosis
PT
Physical therapy
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
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
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
Surgical asepsis hand washing
- use sterile scrub brush
- wash hand / forearms
- hold hand higher than elbow
- use sterile towel instead of paper towel
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
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
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
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
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)
Sterilization
-destroy all microorganism by dry heat, steam heat, chemical or gases
Gas heat sterilization
For late equipment, used in hosptials
Dry heat sterilization
For instruments prone to corrosion
Chemical sterilization
For heat-sensitive equipment
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
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
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
Vital signs
Measure vital sign to determine how well patient body is functioning
-include temperature, pulse, respiration and BP
Temperature
-average: 98.6 (F) or 37 (C)
Pyrexia
Medical term for fever
Febrile
Describes a patient with fever
Low body temperature causes
-blood loss, fainting, dehydration, fasting, central nervous system injury
Oral temperature
- under tongue in mouth
- 98.6 (F)
- 36.8 (C)
Rectal
Rectum
- 100 (R) (F)
- 37.8 (R) (C)
Axillary
In armpit area (least accurate)
- 97.6 (A) (F)
- 36.4 (A) (C)
Tympanic
Eardrum (quick and easy)
- adult: pull ear up and back
- child: pull ear down and back
- 100 (T) (F)
- 37.8 (T) (C)
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
Temporal pulse
Over temporal bone on side of face
Carotid pulse
Front of neck, next to trachea
Apical
Lower left corner of heart, require stethoscope, used for infants
Brachial pulse
Within bend of elbow
Radial pulse
On thumb side of inner wrist
Femoral pulse
Groin
Popliteal pulse
Posterior of knee
-used to check for circulation
Dorsalis pedis pulse
Top of foot, medically
-used to check for circulation
Arrhythmia
Irregular heartbeat
Bradycardia
Slow, regular beat: less than 60 bpm
Bruit
Sound made by blockage in carotid artery
Extrasystole
An extra beat, heart contraction, which interrupts normal regular rhythm of heart
Pulse oximetry
- Measure percentage of oxygenated hemoglobin
- 95% or higher is normal
- used to access pulmonary function of patient with pneumonia, bronchitis, emphysema, asthma
Pulse pressure
Difference between systolic and diastolic reading
- give tone of arterial wall
- higher than 50 or lower than 30mm Hg is abnormal
Tachycardia
Rapid, regular beat, greater than 90 bpm
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
Dyspnea
Difficult or painful breathing
Eupnea
Normal breathing
Exhalation
Lung deflate, diaphragm rise to assist lung
Hyperpnea
Rapid, deep breathing
Inspiration
Inhalation, lungs fill, diaphragm move down to allow expansion
Tachypnea
Rapid breathing
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
Systolic
Pressure produced on artery vessel as left ventricle contracts, sends blood into artery.
Normal is less than 120 mm Hg
Diastolic
Relaxation phase of heart left ventricle refills with blood
Normal is less than 80 mm Hg
Korotkoff’s sound
Sounds between 1st and last sound
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
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
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
Auscultation
Listen to body sounds with stethoscope
Inspection
Visual exam of patient
Manipulation
Body part moved to assess range of motion
Palpation
Touch skin surface, using some pressure to feel underlying organs to assess texture, temp, movement and shape
Percussion
Listen to body sound by tapping to assess resonance of appropriate organ and body cavities
Romberg balance test
Assess muscle abnormalities
-pt stands with feet together, eyes closed
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
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
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
Supine position
For breast, ab, arm, leg, head, neck, EKG
-laying on back, arms to side
Sitting position
- examine head, chest, heart, back, arm, lungs, knee/ankle reflex
- sitting upright on table, legs over side of table
Sim’s position
Fexsigmoidoscopy, anal
-laying on left side, right knee bent, left leg straight, left arm behind back, right arm in front
Dorsal recumbent
- Examine head, neck, chest, heart
- laying on back, arms to side, knee bent, feet flat on table
Protologic position
Examine anus / rectum
-laying on front side, bent at waist, knee bent
Lithotomy position
- examine female genitalia, endometrial biopsy
- laying on back, feet in stirrup
Trendelenburg’s position
- some surgical position, low BP, shock
- lying on back, head below rest of body
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
Prone
Examine back, feet, musculoskeletal
-lying on stomach, arms by head
Knee-chest position
Examine anal, perianal, proctologic
-lying with front toward table, knee bent, arms by head
Ishihara color number plate
Test for color blindness
Nasal speculum
Check for structure of nose in adults
Ophthalmoscope
Check health of eye
-red reflex indicate good health
Otoscope
Examine inner structure of ear
Pen light
Check pupil response to light, nasal passage, tongue, mouth
Percussion hammer
Check reflexes
Pin wheel
Check touch sensation
Pupil toon meter
Test for glaucoma
Snellen chart
Used most often to test vision
Sphygmpmampmeter
Check BP
Stethoscope
Used for auscultation
Tape measure
Compare measurement of limbs, circumference of infant head
Thermometer
Check temperature
Tongue depressor/laryngeal mirror
Check mouth and throat
Tuning fork
Used to assess hearing, size C most common
Vaginal speculum
Check structure of vagina
Cutting
Scissors, scalpel
Grasping/clamping
Hemostat, forceps, clamp, needle holder
Probing/dilating
Speculum, scope, probe, retractor, dilator
Vaporizing tissue
Laser
Sewing tissue
Suture
Basal metabolic rate
Represent energy used while fasting or resting to maintain vital functions
Metabolism
All chemical reaction occur within cells of living organism to allow for growth, reproduction, energy production, waste excretion-anabolism
Catabolism
Anabolism
Use energy to construct components of cells
-proteins and nuclei acids
Catabolism
Break down organic matter and receive energy by cellular respiration
Calorie
Unit of heat energy
-amount of oxygen used
Nutrients
Consist of carbohydrate, protein, fats
-essential to supply energy from chemical in food that body cannot synthesize
Carbohydrate
For energy, classified by complexity
- simple sugar: white bread, rice, potatoes, pasta
- complex plant food: most vegetables and fruit produce
Protein
- build and repair body tissue
- composed of amino acids
Fats
- for energy and heat
- saturated: animal fat
- unsaturated: liquid at room temp
- monounsaturated: olives, avocados
- polyunsaturated: nuts, seeds
Grain
Highest daily amount
-at least 3 oz of whole grain
Vegetable
Variety: more dark green and orange
Fruits
Variety: fresh, frozen, canned, dried, less juice
Dairy
Low fat or no fat
Meat and beans
Low-fat, lean meat, poultry, fish, nuts, beans
Oils
Lowest daily amount
- fish, nuts, vegetables
- less solid fat (butter, shortening)
- no trans fats
Vitamin A
Fat soluble, beta carotene
Prevent night blindness
Vitamin E
Fat soluble
Anticoagulant
Vitamin D
Fat soluble, for calcium absorption
Lower risk of rickets and osteomalacia
Vitamin K
Fat soluble, for blood clot, lower risk of hemorrhage
Vitamin C
Water soluble, lower risk of scurvy, heal wounds, protect against infection
Vitamin B
Water soluble, support metabolism, promote hemoglobin formation
Calcium
Bone building, cardiac function, muscle contraction, blood coagulation
Chloride
Body pH and fluid balance
Phosphorus
Metabolism of protein, calcium, glucose
Sodium
Body pH balance, muscle contraction control, level regulated by kidney
Potassium
Protein synthesis, pH balance, heartbeat regulation
Magnesium
Bone building, metabolism, enzyme activity
Zinc
Growth, healing, sense of taste glucose tolerance
Iron
Hemoglobin component needed for oxygen transport through body
Thermotherapy
Application of dry, moist heat for pain relief, lower occurrence of muscle spasm, localized swelling, encourage tissue repair, encourage infected area drainage
Diathermy
Type of termotherapy
- produce heat in body tissue by high-frequency current
- use for arthritis, tendonitis
Ultraviolet
Type of thermotherapy
-controlled lamp exposure therapy
Ultrasound
Type of thermotherapy
- use water-soluble gel and high frequency sound waves
- most common use of diathermy
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
Massage
Used to lower pain and muscle tension
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
Traction
- part of body pulled or stretch
- to align bone or relieve vertebral bone compression, reduce/relieve spasm/shortenings
Walker
Mobility device
-top of walker should be just below waist, same height as top of hip bone, elbow bent 30 degrees while using
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
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
ABC of cardiopulmonary resuscitation
CPR
- A: check airways
- B: look, listen, feel for breathing
- C: check carotid artery for circulation (pulse)
Medical office emergency equipment
- cardiac code cart
- oxygen with mask delivery
- cold packs
- wound care kit
- personal protective equipment
- childbirth or delivery kit
First degree burns
Red, no blister
Tx: immerse in cool water, apply sterile, cool, wet compress
Second degree burn
Red, blistering
-tx: immerse in cool water 1-2 hours, cover with dry sterile dressing
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
Chemical burn
- if powered agent: try to brush off
- if not, rinse copiously, cover with sterile dressing
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
Convulsion
- S/s: jerking, spasmodic body movement, loss of consciousness
- care: activate EMS, protect head, maintain airway
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
Bleeding from limb, head or neck
Elevate injured part above heart if possible
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
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
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
Anaphylactic
Severe allergic reaction
-low blood pressure, edema, tachycardia, dyspnea
Cardio genie
Impaired cardiac function
Hypovolemic
Hemorrhagic, low blood volume
Insulin
Severe hypoglycemia
Neurogenic
Trauma to nervous system
-fainting (blood vessel dilate, loss of tone, low BP, heart rate)
Septic
Infection spread by blood to all body systems
Traumatic
Loss of interstitial fluid
-large burn areas
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
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
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
Fractures
Care: immobilize with splint, elevate (if possible), apply ice packs, use sling for fractured clavicle or arms
Inhaled, ingested, injected poisoning: chemical or natural
Activate EMS Call poison control for instructions Use personal protective equipment Check ABC Check vitals
Insulin shock
Moist, pale, rapid heart rate, confusion
-care: give food containing sugar will rapidly absorbed (orange juice/glucose gel)
Diabetic coma
- s/s: dry, flushed skin, fruity breath, extreme thirst, confusion, rapid respiration
- care: activate EMS, provider must administer insulin
