Scribe Study Set

Atraumatic

No evidence of trauma to the body

diaphoresis

excessive sweating

febrile

fever

Mailase

generalized discomfort or weakness.

Normocephalic

Normal head.

polydipsia

excessive thirst

polyuria

excessive urination

conjuctiva

Thin outer lining of the eye and eyelid. "white part"

conjuctival injection

Redness of the conjuctiva

diplopia

double vision

nystagmus

Involuntary rapid eye movements

cerumen

ear wax

dentalgia

tooth pain

Dentition

teeth

dysphagia

difficulty swallowing

epistaxis

nosebleed

Hemotympanum

blood in the middle ear

rhinorrhea

runny nose

septal deviation

displacement of nasal septum

tinnitus

ringing in the ears

Trismus

Inability to open the jaw due to pain

Accessory muscle use

Visible usage of muscles not normally used to breathe

bradypnea

abnormally slow breathing

cyanosis

bluish discoloration of the skin

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 lying down

rale

Abnormal sound heard in lungs

respritory distress

trouble breathing

retraction

visible pulling inward of the muscles between the ribs when inhaling

Rhonci

Rattling noise of mucous in the lungs

Speech dyspnea

Shortness of breath when speaking

stridor

Sound heard when there is an obstruction of the airways

Tachypnea

rapid breathing

wheeze

Difficult breathing with a whistling sound resulting from narrowing of the lumen of the respiratory passageways

anuerysm

widening of an artery

Angina

chest pain

Arrythmia

Abnormal heart rhythm

Bradycardia

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

costochodritis

inflammation of the costal cartilage

embolism

Obstruction of a blood vessel by a clot of blood or foreign substance

Hemmorrhage

excessive bleeding

Hypertension

high blood pressure

hypotension

low blood pressure

Infarct

death of tissue caused by loss of blood supply

ischemia

Temporary, localized area of blood restriction

murmur

abnormal heart sound

palpations

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

fast heart rate

-emesis

to vomit

hematemesis

vomiting blood

hematochezia

blood in stool

hemorrhoids

swollen and inflamed veins on rectum or anus

melena

Black tarry stool

hepatosplenomegaly

enlargement of the liver and spleen

Urolithasis

Kidney stone/bladder stone

cervical

neck region

dysmenorrhea

painful menstruation

dysuria

painful urination

hematuria

blood in the urine

incontinence

inability to control urination

Inguinal

groin area

priapism

persistent and painful erection

Torsion

twisting of an organ around its own axis

mephrolithiasis

kidney stones

arthralgia

joint pain

Crepitus

a crackling or grating sound usually of bones

edema

Abnormal accumulation of fluid in interstitial spaces of tissues.

myalgia

muscle pain

sacroiliac joint

where the spine meets the pelvis

-spasm

involuntary contraction

supple

flexible neck that can easily move during the exam

Avulsion

A forcible pulling away of a part or structure

contusion

bruise

Ecchynosis

bruise thats not elevated

erythema

redness of the skin

Fluctuance

capable of being moved or compressed, indicated presence of pus

induration

local hard area on the skin

laceration

to cut

macular

flat rash

Maculopapular rash

rash characterized by flat red rashes that are covered in small bumps

Melanoma

The most serious form of skin cancer

nuchal rigidity

neck stiffness

pallor

paleness

Papular

Solid, raised lesion with distinct borders

Pruritic

itchy

purulent

containing pus

sanguineous

bloody drainage

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

a bruise like injury of the brain

dysphasia

Inability to understand verbal commands as a result of brain injury/illness

gait

manner of walking