Medical Assistan Clinicals
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84 terms
Terms | Definitions |
|---|---|
 scope of practice | Medical assistant should only perform the range of activities that trained |
| CC | Chief complaint/ reason why patient came to see physician |
| HPI | History of present illness/explanation of chief of complaint the onset illness, systoms, and what has been done to treat them |
| PFSH | PAst, Family and social History/ past medical history surgeries, major illness. Family History. Socoal History, martial status, drink, smoke and lifestyle |
| ROS | Review of Systems/conjunction with physical examination helps elicit diagnosis of patient condition |
| Vital Signs | Body Temperature,Respiration,Heart Function |
| Vital signs | Temperature,Pulse, respiration,Blood Pressure |
| Rectal tempature | 98.6F to 100.6F Normal |
| Oral Tempature | 97.6F to 99.6F Normal |
| Axillary Tempature(Under Arm) | 96.6F to 98.6F Normal |
| Tympanic Membrane Temperature | 98.6F |
| Febrile | presence of fever |
| Afebrile | absence of fever |
| Intermittent | fluntuating fever that returns to or below baseline then rise again |
| Remittent | fluntuating fever that remains elevated it does not return to baseline |
| Continuous | A fever that remains constant above the baseline it does not fluctuate |
| How long to wait if patient has been drinking, smoking or eating | 30 minutes |
| how long to leave thermometer in the mouth | 3-5 minutes |
| correct way to take rectal temperature | patient on side-lying position and thermometer and patients hips is held throughout procedure so it wont be lost or broken |
| Axillary Temperature | is accurate and is only taken when no other can be used. area should be dry and clean and be held under arm for 5-10 minutes |
| Tympanic Temperature | is best for children and confused patients. its inserted in the ear and it takes only 1-3 seconds. cant be used if patient has ear disorder or ear drainage |
| Pulse | Normal adult pulse ranges between 60 to 100. Most common i s around wrist for 30 seconds and times by 2 |
| Respiration | Normal range for Adults 12 to 20 per minute counted 30 seconds and times by 2 |
| Apena | temporary complete absence of breathing reduction in the stimuli to the respiratory centers of the brain |
| Tachypnea | respiration rate for more than 40 mins. Most in newborns |
| Bradypnea | Decrease in numbers of respirations, this occurs during sleep |
| Cheyne Stokes | regular pattern of irregular breathing rate |
| Orthopena | difficulty or inability to breath unless in an upright position |
| Hypoventilation | state when reduced amount of air enters the lungs resulting in decreased oxygen level and increased carbon dioxide level in blood |
| Hyperpnea | abnormal increase in the depth and rate of breathing |
| Hyperventilation | state which there is increased amount of air entering the lungs |
| hypo= | slow |
| hyper | fast |
| sphymomanometer | what they wrap around your arm when taking blood pressure |
| 2.5cm | were blood pressure cuff should be placed |
| improper cuff size, arm not at heart level, cuffs not deflated before use, not correct size | can give falsely high readings |
| Anthropometric Measurements | length, height, weight, head circumference used on toddlers and infants |
| height,weight,BMI,waist to hip,body fat | measurements used on adults then compared weight status and risk for various diseases |
| Four principals of physical examination | 1. Inspection 2. Palpation 3. Percussion 4. Ausculation |
| Medical Assistant role in physical examination | Room preparation, Patient preparation,Assisting the Physician |
| To make diagnosis | 1. patient's health history 2. physical examination 3. Laboratory test |
| OSHA | Occupational safety and Health Administration/responsible for identification of various hazards present in the workplace, rules and regulations |
| External Hemorrage | controlling bleeding is most effectively accomplished by elevating the affecte dpart above the heart level and applying direct pressure to the wound. Dont elevate lemb it could cause damage |
| Shock | occurs when there is insufficient return of blood flow to the heart resulting in inadequate supply of oxygen to all organs and tissues of the body . people that in trauma may be in shock |
| Symptoms os shock: | Pale, cold, clammy skin, rapid, weak pulse,increased or shallow breathing, expressionless face/staring eyes |
| Cardiopulmonary Resuscitation | Most healthcare require professionals to be certified in CPR its a must to remain certified |
| Infection Control/Chain of Infection | consits of links, each of which is necessary for infection disease to spread. Infection control is based on the fact that tranmission of infection disease will be prevented or stopped when any level in the chain broken or interrupted |
| Agents | infectious microorganisms that can be classified into group namely: virus, bacteria, fungi, and parasites. may be prevented with use of anti-infection control practices |
| Portal of exit | method which infectectious agent leaves its reservoir |
| Mode of transmission | ways microorganisms travel from the host 1. contact 2. droplet 3. airborne 4. common vehicle 5. Vectorborne |
| Portal of entry | Allow infection agent access to the susceptible host Common entry sites:broken skin,mucous membrane,body systems exposed to the external environment |
| Susceptible | Infectious agent enters a person whos not resistant or immune |
| Medical Asepsis | the distruction of pathogenic microorganisms after they leave the body |
| Disfection | 1:10 solution of household bleach boiling water 212F |
| Gas sterilization | often used for wheelchairs and hospitals beds. useful in hospitals but costly in the office |
| Dry heat sterilization | require higher temperature that steam sterilization but longer exposure times used for instruments that easily corrodes |
| Chemical sterilization | used for chemical disinfection but exposure time is longer |
| Steam sterlization(autoclave) | use steam under pressure to obtain high temperature of 250-254F with exposure times 20-40 mins depends on item |
| Handwashing | most important means of preventing the spread of infection |
| Barrier protection | protective clothing:Masks,goggles,face shields,respirator |
| Isolation precautrions | assumed that all human blood and body fluids were potentially infectious. its two tiers Standard and Transmission based precautions |
| Standard Precautions | infection control method designed to prevent direct with blood and other body fluids and tissues by using barrier protection and work control practices |
| Transmission based precautions | second tier of precautions and are to be used when the patient is known or suspected of being infected with contagious disease |
| Contact precautions | designed to reduce the risk of transmission of microogranisma by direct or indirect contact |
| Airborne precautions | reduce airborne transmission of infections in air and may be inhaled or odject in the same room. Special ventilation required to prevent transmission |
| Droplet precautions | designed to reduce risk of droplets transmission of infectious agents it includes conjuncitvae or mucous membrane of the nose or mouth during coughing, snezzing or talking. droplets only travel 3 feet or less |
| OSHA | Universal Precautions Standards |
| mg | milligrams |
| mcg | micrograms |
| g | grams |
| sig | signetur |
| 1,2,3,4, times | i,ii,iii,iiii |
| po | by mouth |
| pr | by way of the rectum |
| sl | sublingual (under the tounge) |
| IV | interavenous |
| IM | intramuscular (in the muscle) |
| SQ | short of subcutaneous(under the skin) |
| qd | every day |
| bid | twice a day |
| tid | three times a day |
| qid | four times a day |
| Disp | dispense |
| DEA | Drug Enforcement Agency certain controlled substances ,narcotics |
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