Scribe Medical Terminology

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 movement 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

Hemotypanum

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

Respiratory

relating to the lungs and respiratory system

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

Cardiovascular

relating to the heart and circulatory system

Aneurysm

widening of the 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

Gastrointestinal

relating to the digestive system

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

Genitourinary

relating to the urinary and genitalia

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

Musculoskeletal

relating to the bones and muscles

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

Integumentary

relating to the skin

Avulsion

a forcible tearing away of a part of 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

itchyq

Purulent

consisting, containing, or discharging pus