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Atraumatic
No evidence of trauma to the body
Diaphoresis
excessive sweating
Febrile
having a fever
Malaise
Generalized discomfort or weakness
Normocephalic
Normal shaped head
Polydipsia
excessive thirst
Polyuria
excessive urination
Conjunctiva
Membrane lining of the eyelids and covering of the eyeball; "white part"
Conjunctival injection
Redness of the conjunctiva
Diplopia
double vision
Nystagmus
Involuntary rapid movements of the eyes
Cerumen
Ear Wax
Dentalgia
Dental Pain
Dentition
indicating the condition of teeth (i.e. intact)
Dysphagia
Painful/difficulty swallowing
Epistaxis
bleeding of the nose
Hemotympanum
blood in the middle ear
Rhinorrhea
Runny nose
Septal Deviation
displacement of the nasal septum
Tinnitus
ringing of the ears
Trismus
Inability to open jaw
Accessory muscle use
Visible usage of muscles not normally used to breathe
Bradypnea
unusually slow breathing
Cyanosis
When the skin turns purple or dark blue (typically due to hypoxia)
Dyspnea
shortness of breath
Expiration
Breathing out
Hemoptysis
coughing up blood
Inspiration
Breathing in
Intubated
introduction of a tube into a hallow organ, such as the trachea
Orthopnea
difficulty breathing when laying down
Rale
Abnormal sound heard in lungs
Respiratory Distress
Difficulty breathing
Retraction
visible pulling inward of the muscles between the ribs when inhaling
Rhonchi
Whistling sound heard when there is a partial obstruction of the lungs
Speech dyspnea
Shortness of breath when speaking
Stridor
Sound heard when there is an obstruction of the airways
Tachypnea
unusually fast breathing
Wheeze
Difficulty breathing makes a whistling sound that is a result from the narrowing of the lumen in respiratory passages
Aneurysm
Widening of a blood vessel that results in a blood sac
Angina
Severe, constricting chest pain due to heart tissues not receiving enough blood
Arrhythmia
Abnormal, irregular heartbeat
Bradycardia
usually slow heart rate
Bruit
A murmur or sound heard in auscultation indicating narrowing of a vessel
Capillary Refill
the return of color after pressing down on the skin
Costochondritis
Inflammation of the costal cartilage
Embolism
Obstruction of blood vessels by a clot of blood or foreign substance
Hemorrhage
loss of blood from the body, internally or externally
Hypertension
elevated blood pressure
Hypotension
low blood pressure
Infarct
Death of a tissue caused by loss of blood supply
Ischemia
Temporary, localized area of blood restriction
Murmur
extra heart sounds
Palpitations
awareness of one's own heartbeat
Pitting Edema
Fluid buildup, typically in the legs, that leaves a "pit" or indention when pressed
Stenosis
narrowing of an opening
Tachycardia
unusually fast heart rate
Emesis
vomit
Hematemesis
vomit with blood in it
Hematochezia
Blood in stool
Hemorrhoid
swollen and inflamed veins on the rectum or anus
Melena
Black, tarry stool
Hepatosplenomegaly
Enlargement of the spleen and liver
Urolithiasis
Kidney stone
Cervical
Pertaining to the neck or cervix of the uterus
Dysmenorrhea
Painful menstruation
Dysuria
painful urination
Hematuria
blood in the urine
Incontinence
sudden, involuntary urge to pass urine
Inguinal
Groin Region
Priapism
persistent and painful erection, often due to trauma
Torsion
twisting of an organ around its own axis
Nephrolithiasis
kidney stones
Arthralgia
joint pain
Crepitus
Crackling or grating sound that is usually heard in the bones
Edema
Accumulation of fluid in the interstitial spaces, swelling
Myalgia
muscle pain, body aches
Sacroiliac Joint (SI) Joint
where the spine meets the pelvis
Spasm
sudden, involuntary muscle contraction
Supple
flexible neck that can easily move during the exam
Avulsion
a forcible tearing away of a part or structure
Contusion
Trauma that results in broken blood vessels beneath the skin
Ecchymosis
Bruise that is not elevated
Erythema
redness of the skin
Fluctuance
capable of being moved or compressed, indicated presence of pus
Induration
Localized hardening of soft tissue
Laceration
cut in the skin
Macular
Flat rash
Maculopapular Rash
rash characterized by flat red rashes that are covered in small bumps
Melanoma
most deadly type of skin cancer
Nuchal rigidity
neck stiffness
Pallor
paleness of the skin
Papular
Solid, raised lesion with distinct borders
Pruritic
itchy
Purulent
consisting, containing, or discharging pus
Sanguineous
drainage that is a mixture of pus and blood
Alert and oriented
measuring of mental function, measured in orientation to person, place, time, and situation. If a person is oriented to all 4, it is recorded as A&Ox4
Ambulatory
able to walk
Concussion
loss of consciousness due to severe head injury
Dysphasia
Inability to understand verbal commands as a result of brain injury/illness
Gait
a manner of walking