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Clinical 2 final

final review for clinical 2

EMR electronic medical records
EHR electronic health records
SOMR source oriented medical record
POMR problem oriented medical record
SOAP subjective; objective;assessment;plan
usual distance for a social encounter 4-12 feet
personal, social, and family history are included in a comprehensive medical history
chief complaint is what type of information subjective
VS, pain, color of skin are examples of what type of information objective
doctors physical findings are what part of the soap note assesment
most common complaint during menopause hot flashes
cervix is enlarged and some of the uterine lining is scraped away D&C
doctor feels for the ovaries during which portion of the pelvic exam bimanual
average menstrual cycle is how many days 28
average age for menopause to occur 52
most common long term health issue occurring post menopausal osteoporosis
term pregnancy is how many weeks 37-42
used to estimate the due date nageles rule
lying flat on the back supine
lying flat on the stomach prone
position used for pelvic exams lithotomy
position used for colonoscopies and enema administration sims
specializes in treating eye disorders ophthalmologist
most common distance visual acuity test snellen chart
checks for color blindness ishihara
lazy eye amblyopia
crossed eyes strabismus
abnormal curvature of the cornea astigmatism
abdominal pain described as gnawing, burning and cramping visceral
pain that gets worse with movement parietal
pain that is felt in another area referred
most accurate core temperature rectal and temporal
rectal temp 99.6
oral temp 98.6
axillary temp 97.6
normal respiratory rate for the average adult 12-16/min
normal pulse rate for the average adult 60-100
normal blood pressure 100-120/60-80
controlled hypertension 130/90
difficulty breathing dyspnea
if the radial pulse is irregular it should be followed with a apical pulse
pulse found in the groin femoral
pulse used when performing a blood pressure brachial
pulse checked when performing CPR carotid
blood pressure that drops upon standing orthostatic hypotension
heart contracts distending the walls of an artery creating a pulse
blood pressure result is always written as a fraction
measurement of the greatest amount of force applied to the arterial walls systole
measurement recorded during the relaxation phase of contraction diastole
the difference between the systolic and diastolic pressure pulse pressure
rapid respiration with normal or shallow breaths tachypnea
rapid deep respiration hyperventilation
applying passive movement to a joint manipulation
measurements of different areas of the body, including vital signs mensuration
evaluation done through touching palpation
evaluation done through listening with a stethoscope auscultation
tympanic membrane eardrum
instrument used to evaluate general hearing tuning fork
specialized instrument themeasures hearing acuity at differet frequencies audiometer
procedure used to determine whether or not the middle ear is transmitting sound waves tympanometry
entire colon examined with a flexible lighted videoscope colonoscopy
refers to the first 28 days of life newborn
first year of life infant
children 1-3 years toddler
infant height, weight and head circumference are plotted on a growth chart
first vaccination is given at birth in the hospital
preferred site for IM injections on infants vastus lateralus
Muscle used for IM injections on older children deltoid
removal of the foreskin of the penis circumcision
eye disorders that commonly occur with increased age cataracts and glaucoma
considered to be the fifth vital sign pain scale
most effective type of questioning when interviewing a patient open ended
includes patients previous health concerns, current health concerns, current medication personal medical history
alcohol use, smoking, caffeine intake, drug use, are examples of social history
pulse found on top of foot dorsalis pedis
pulse found behind the ankle posterior tibial
absence of menstrual flow amenorrhea
painful menstruation dysmenorrhea
scanty urination oliguria
polyuria excessive amounts of urine
need to urinate during normal hours of sleep nocturia
immediate need to urinate urgency
inability to retain urine incontinence
difficult or painful urination dysuria
insertion of a thin scope with a light into the urethra through to the bladder cystoscopy
shock waves to break down kidney stones lithotripsy
abnormally large head macrocephaly
abnormally small head microcephaly
provider inserts a gloved finger into the rectum to check for prostrate enlargement DRE (digital rectal exam)
ultrasound to detect benign prostatic enlargement TRUS ( transrectal ultrasound)
surgical procedure where the vas deferens is cut to prevent sperm from entering the ejaculate vasectomy
male impotence erectile dysfunction (ED)
farsightedness due to aging presbyopia
nearsightedness myopia
farsightedness hyperopia
screening for near visual acuity jaegar chart
to be used in the eye only opthalmic
to be used in the ear only otic
fecal sample test done to check for various types of microorganisms stool culture
age that is suggested to start SBE (self breast exam) 20
children 3-5 years preschool
other areas that are assessed in the pediatric patient to evaluate growth and development sensory, motor and language development
vaccine scheduled is put forth by which organization CDC (centers for disease control)
blood work that monitors kidney function BUN; creatinine; uric acid and protien
surgeon cuts away overgrown tissue of the prostate TURP
catheter that remains in the bladder for a long period of time Foley catherter
medication used to treat pain and discomfort of a UTI pyridium
common antibiotic used to treat urinary infections macrobid; bactrim
medications used to treat ED cialis; viagra
medications used to treat BPH flomax; avodart; proscar
medications used to treat over active bladder detrol; ditrpan; vesicare
medications used to treat enuresis DDAVP; elavil
this blood test may indicate prostate cancer if elevated PSA
normal vital signs for newborns HR 130-160; RR 30-60; BP60-70/30-40
Normal vital signs for 3-10 year olds HR 60-120; RR 18-30; BP 80-120/40-80
sitting on the end of exam table wsitting
lying flat on back supine
`lying flat on the stomach prone
lying flat on back with knees bent feet flat on table dorsal recumbant
lying on side with bottom leg straight and top leg bent sims
sitting up against table at 45 degrees semi fowlers
hips and buttocks at end of table feet in stirrups lithotomy
chest on table knees bent with hips a buttocks raised knee chest
head placed lower than the heart and feet raised above the level of the heart trendelenburg
observing the patient visually inspection
kistening with a stethoscope ascultation
evaluation by touching palpation
evaluation of sound created by tapping fingers on the body percussion
evaluation by measuring mensuration
applying passive movement to a joint while using force manipulation
exam technique for vital signs auscultation;mensuration;palpation
exam technique for abdomen inspection;auscultation;palpation;perecussion
exam technique for thorax and lungs inspection; auscultation;palpation;percussion
exam technique for cardiovascular system inspection; auscultation; palpation
stomach acid backs up into the esophogaus GERD
acute or chronic inflammation of the colon ulcerative colitis
inflammation of any portion of the GI tract but the terminal ilieum is most common Crohns disease
chronic progressive imflammatory disease of the lover cirrhosis
laxative miralax
antacids prilosec
antidiarrheal imodium
antiemetic zofran
medication for IBS lotronex
medication for ulcerative colitis asacol
medications for GI infections Cipro and Flagyl
amniotic fluid is aspirated to test for genetic disorders and lung maturity amniocentesis
this test if done around 24-28 weeks gestation to check for diabetes GTT glucose tolerance test
test is done to detect neural tube defects AFP
increased blood pressure and protienuria during pregnancy pre eclampsia
excessive vomiting and nausea during pregnancy hyperemsis gravidarum
placenta detaches from the uterus placenta abruptio
placenta is low lying and may block the cervix placenta previa
test that checks stool for various types of bacteria stool culture
most common GI disorder in the US causeing intermittent abdominal pain, cramping, bloating, diarrhea and/or constipation IBS
hypertension BP >150/90
medication stimulates ovulation clomid
progesterone based BC Depro provera; mini pill; nexplanon
estrogen based BC Ortho Evra; ortho trycyline; nuva ring
permanent BC that scars the fallopian tubes Essure
abx for chalmydia doxycycline and azithromycin
abx for syphilis PCN G
progesterone based IUD mirena; skylar
copper IUD that causes inflammation preventing implantation paragard
if this level is elevated it indicates lack of estrogen; done to confirm menopause FSH(follicle stimulating hormone)
pregnancy hormone HCG( human chorionic goandotropin
tests for Tay Sachs; Sickle Cell and Thalassemia CVS(chorionic villi sampling)
vaginal culture that is done later in pregnancy to detect life threatening infection group B strep
Created by: clarevoyant1019
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