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)