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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 the eyelids and covering of the eyeball; “white part”
Conjunctival injection
Redness of the conjunctiva
Diplopia
Double vision
Nystagmus
Involuntary rapid eye movements
Cerumen
Ear wax
Dentalgia
Dental pain
Dentition
indicating the Condition of the teeth
Dysphagia
Difficulty or painful swallowing
Epistaxis
Nosebleed
Hemotympanum
Blood in the middle ear
Rhinorrhea
Runny nose
Septal deviation
Displacement of the nasal septum
Tinnitus
Ringing in the ears
Trismus
Inability to open jaw
Accessory muscle use
visible Use of muscles not normally used to breathe
Bradypnea
Slow breathing
Cyanosis
Skin turns purple/blue due to low oxygen (hypoxia)
Dyspnea
Shortness of breath
Expiration
Breathing out
Hemoptysis
Coughing up blood
Inspiration
Breathing in
Intubated
Tube insertion into a hallow organ like the trachea
Orthopnea
Difficulty breathing while lying down
Rale
Abnormal sound heard in the lung
Respiratory distress
Difficulty breathing
Retraction
visible Pulling in of muscles between ribs when inhaling
Rhonchi
Whistling sound due to partial lung obstruction
Speech dyspnea
Shortness of breath while speaking
Stridor
sound heard when there is an obstruction of the airways
Tachypnea
Rapid breathing
Wheeze
Whistling breath sound from narrowed lumen in respiratory passages
Aneurysm
widening of a blood vessel that results in a blood sac
Angina
severe, constriction Chest pain from poor blood flow to heart
Arrhythmia
abnormal, Irregular heartbeat
Bradycardia
Slow heart rate
Bruit
a murmur or sound heard in auscultatioon indicating narrowing of a vessel
Capillary refill
skin returning to normal color after pressing down
Costochondritis
Inflammation of costal rib cartilage
Embolism
obstruction of blood vessels by a clot of blood or foreign substance
Hemorrhage
loss of blood from body, internally or externally (Excessive bleeding)
Hypertension
High blood pressure
Hypotension
Low blood pressure
Infarct
Tissue death due to lack of blood
Ischemia
Temporary blood restriction
Murmur
Extra heart sound
Palpitations
Awareness of heart beating
Pitting edema
fluid buildup that leave a “pit” or indention when pressed
Stenosis
Narrowing of an opening
Tachycardia
Fast heart rate
Emesis
Vomiting
Hematemesis
Vomiting blood
Hematochezia
Blood in stool
Hemorrhoid
Swollen and inflammed rectal/anus veins
Melena
Black, tarry stool
Hepatosplenomegaly
Enlarged liver and spleen
Urolithiasis
Kidney stone
Cervical
Relating to cervix or neck or the uterus
Dysmenorrhea
Painful menstruation
Dysuria
Painful urination
Hematuria
Blood in urine
Incontinence
sudden, Involuntary urination
Inguinal
Groin area
Priapism
Persistent painful erection, due to trauma
Torsion
Twisting of an organ around its own axis
Nephrolithiasis
Kidney stones
Arthralgia
Joint pain
Crepitus
Crackling or grating sound heard in the bones
Edema
Swelling, accumulation of fluid in the interstitial spaces
Myalgia
Muscle pain, body aches
Sacroiliac Joint (SI)
Joint between spine and pelvis
Spasm
Sudden muscle contraction
Supple
flexible, Easily movable neck
Avulsion
Forcible tearing away of a structure
Contusion
trauma that results in broken blood vessels beneath the skin
Ecchymosis
Flat bruise, not elevated
Erythema
Skin redness
Fluctuance
capable of being moved or compressed, indicated presence of pus
Induration
localized Hardening of soft tissue
Laceration
Cut in skin
Macular
Flat rash
Maculopapular Rash
Red rash with small bumps
Melanoma
Deadly skin cancer
Nuchal rigidity
Neck stiffness
Pallor
Paleness of the skin
Papular
Solid raised lesion with distinct boarders
Pruritic
Itchy
Purulent
consisting, containing, or discharging pus
Sanguineous
Drainage of pus and blood
Alert and Oriented
Awareness of person, place, time, and situation- all for is recorded as A&Ox4
Ambulatory
Able to walk
Concussion
Head trauma with unconsciousness
Dysphasia
inability to understand verbal commands as a result of brain injury/illness
Gait
Manner of walking