Common Clinical Medical Terminology

ProScribe

Arrhythmia

An alteration in the rhythm of the heart beat

Bradycardia

objectively categorized slow heart rate, typically below 60 beats per minute (bpm)

Edema

an abnormal infiltration and excess accumulation of serous fluid in connective tissue or a serous cavity, typically seen as swelling in the legs

Friction rub

a sound heard on auscultation caused by the rubbing

together of two serous surfaces; commonly called simply a “rub”

Gallop

an abnormal third or fourth heart sound beyond the typical “lub dub” pattern

Murmur

an abnormal “whooshing” sound heard on auscultation of the heart indicating a structural or functional abnormality

Tachycardia

objectively categorized rapid heart rate, typically above 100 bpm

Palpitation

a sensation in which a person perceives an irregular, forceful, or rapid heartbeat

Ischemia

a decrease in the blood supply to a bodily organ, tissue, or body part caused by constriction or obstruction of the blood vessels

Angina

chest pain caused by insufficient blood supply to the heart

Cardiomegaly

abnormal enlargement of the heart, most commonly seen on chest x-ray as a sign of congestive heart failure

Ectopy

a temporary abnormal heartbeat (not a sustained abnormal rhythm) that can be read on an EKG or perceived by the patient as a palpitation

Bruit

an abnormal sound heard on auscultation that indicates the narrowing of an artery, most commonly the carotid artery

Infarct

an area of tissue death caused by an obstruction in oxygen supply, typically by a clot in the heart or brain

Abrasion

the rubbing or scraping of the surface layer from an area of the skin

Abscess

an enclosed collection of pus somewhere in the body, most often involving the skin

Gauge

a diameter of a needle (larger gauge = smaller needle)

Purulence

pus, or the condition of containing or discharging pus

Contusion

injury to tissue with or without skin discoloration, without skin breakage from blunt trauma; commonly known as a bruise

Ecchymosis

similar to a contusion, but specifically an area of bluish discoloration >1 cm in diameter; different in that it may not necessarily result from trauma; also commonly known as “bruising”

Erythema

abnormal redness, typically of the skin or mucous membranes, in the presence of inflammation, injury, or infection

Jaundice

an abnormal yellowing, typically of the skin and from abnormally high levels of bilirubin in the blood

Laceration

a cut of the skin typically caused by accidental contact with a sharp object or edge; contrast with incision (intentional) and abrasion (superficial scrape only)

Pallor

deficiency of color especially of the face and/or skin; noun form of the adjective pal

Fluctuance

capable of being moved or compressed, typically as it relates to the presence/absence of pus in a possible abscess

Cyanosis

bluish discoloration of a tissue resulting from oxygen deprivation

Diaphoresis

excessive sweating as a medical symptom

Scleral icterus

yellowing of the “white part of the eye” in patients with liver disease due to elevated bilirubin levels

Dehiscence

a separation of layers, especially the parting of the sutured edges of a surgical wound

Crepitus

a grating, crackling, or popping sound or sensations under the skin and in joints; also sometime the presence of air trapped in subcutaneous tissue that can feel like “Rice Krispies” on the skin

Debridement

medical removal of nonviable skin tissue, typically after an injury

Decubitus ulcer

an ulceration of tissue deprived of adequate blood supply by prolonged pressure; known commonly as a “bed sore”

Induration

area of localized hardening of body tissues, especially as it relates to the skin

Macule

a small area of discoloration of the skin that is not raised; contrast with papules

Papule

a small rounded growth on the skin that is raised, typically the medical term for a pimple or similar lesion

Petechiae

pinpoint areas of hemorrhage in the subcutaneous tissue that typically appear purple or red

Pruritus

medical term for itching

Skin turgor

a comment on the elasticity of the skin

Tenting

skin that does not “snap back” towards the body immediately when pulled/pinched; indicative of dehydration and decreased skin turgor

Tinea

medical term for a fungal skin infection; most commonly ringworm

Urticaria

raised, itchy areas of the skin typically seen with an allergic reaction; commonly “hives”

Hemorrhage

a copious discharge of blood. It can be internal or external

Hematoma

a mass of usually clotted blood that forms in a tissue, organ, or body space as a result of a broken blood vessel

Affect (noun)

a psychological term for the observable expression of emotion; common abnormal affects may be “flat” or “blunted”

Mood

a sustained and pervasive state of emotion

Syncope

loss of consciousness resulting from insufficient blood flow to the brain; commonly “passing out”

Aphasia

the symptomatic inability to express oneself through communication such as speaking

Glasgow Coma Scale (GCS)

a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns following head trauma

Hemiparesis

muscular weakness or partial paralysis of the entire left or right side of the body (a neurologic finding/symptom)

Hemiplegia

total paralysis of the entire left or right side of the body.

Malaise

an indefinite feeling of weakness or lack of health often indicative of or accompanying the onset of an illness; feeling generally weak or “wiped out”

Neuralgia

pain along the distribution of a nerve(s), typically perceived as burning or stabbing in nature

Paresthesia

an abnormal sensation of the skin associated with nerve dysfunction; commonly “pins and needles”

Phonophobia

abnormal sensitivity to noise commonly associated with migraines

Photophobia

abnormal sensitivity to light commonly associated with migraines

Tinnitus

medical term for ringing in the ears

Deep Tendon Reflexes (DTRs)

involuntary muscle contraction elicited by percussion of a muscle tendon (the test with the hammer we have all seen before); rated on a number scale with 2+ being normal

Paraspinal

the area on either side of the spine (directly over the spine would be “midline”); typically used when describing tenderness or muscle spasm

Anisocoria

unequal pupil size that may indicate serious neurologic dysfunction. It can also be baseline or normal for many patients

Ataxia

medical term for incoordination due to dysfunction of the central nervous system

Babinski Reflex

a neurologic test on physical exam that involves stimulation to the sole of the foot to elicit certain responses

Brudzinski’s Sign

a test performed on physical exam that involves flexing the neck and/or lower extremities to monitor involuntary movements; performed when there is concern for meningitis

Facial droop

unilateral sagging of the face due to paralysis of the muscles on one side, typically a neurologic physical exam finding with stroke and Bell’s palsy

Flat affect

a severe reduction in emotional expressiveness, typically noted as a psychological physical exam finding in patients with depression and/or schizophrenia

Lethargic

decreased level of consciousness; typically noted as a general physical exam finding

Nystagmus

rapid, involuntary movement of the eyes, typically noted as a neurologic physical exam finding

Postictal state

a state of decreased/altered level of consciousness following an epileptic seizure

Pronator drift

a neurologic test on physical exam that involves holding both arms straight out at shoulder height with palms facing upward; if one side of the body is weaker than the other, as in a stroke, one arm will drop and turn inward

Somnolent

medical term for drowsy or less alert than baseline, typically as it relates to a general physical exam finding

Straight Leg Raise (SLR) Test

a physical exam test that involves lifting the fully extended legs of a supine patient one at a time; this is typically performed in patients with back pain

Auscultation

the act of listening to sounds arising from within organs (as in the lungs or heart) as an aid to diagnosis and treatment

Dyspnea

difficult or labored breathing; shortness of breath

Rales

a type of abnormal respiratory or breath sound heard on auscultation, typically from fluid buildup in congestive heart failure; also known as “crackles”

Rhinorrhea

excessive mucus secretion from the nose, a runny nose

Rhonchi

low-pitched, snore-like sounds heard on auscultation of the chest when air channels are partially obstructed, typically by mucus; worrisome for pneumonia

Sputum

mucus/pus expectorated from the lungs, typically in a diseased state

Hemoptysis

the coughing up of blood or bloody sputum (a respiratory finding/symptom)

Homan’s Sign

pain in the calf of the leg upon dorsiflexion (backward bending) of the foot on physical exam, typically concerning for blood clot in the leg (DVT)

Effusion

the escape of a fluid from the blood vessels or lymphatics into the tissues or a body cavity; most commonly in the context of pleural effusion seen on chest x-ray

Basilar

relating to or situated at the base, typically referring to the skull or the lungs

Hypoxia

decreased oxygen supply in the body or an area of the body

Orthopnea

difficulty breathing that occurs when lying flat due to fluid in the lungs (typically indicative of congestive heart failure)

Stridor

an abnormal, high-pitched breathing sound during inspiration (inhaling) caused by a blockage in the throat or voice box (larynx)

Tachypnea

abnormally fast respiratory rate, typically greater than 20 BPM

Splinting

a respiratory physical exam finding where a patient refrains from taking full deep breaths due to pain on inspiration; also refers to the act of placing a form of immobilization on an injured extremity

Retractions

visible sinking of the skin between/around the bones of the chest typically viewed as a sign of respiratory distress

Accessory muscle use

atypical muscles, such as those of the shoulder girdle, are used to help with breathing effort in patients in respiratory distress (physical exam finding)

Non Rebreather Mask (NRB)

a device used to deliver high concentrations of oxygen to patients in acute respiratory distress

Dyspepsia

medical term for the symptoms of indigestion

Dysphagia

difficulty swallowing related to muscular or nervous problems (not mechanical choking on an object such as food)

Emesis

a medical term for vomiting

Epigastric

referring to the area of the abdomen lying upon/over the stomach; the region at the top middle if a “hashtag” were drawn on the abdominal wall

Guarding

tensing of the muscles of the abdominal wall to protect sensitive inflammation of underlying organs upon direct pressure/palpation

Hepatomegaly

abnormal enlargement of the liver, typically a sign of liver disease discovered on palpation of the abdomen

Rebound

a sensation of pain felt when pressure is quickly removed (instead of applied) from the abdomen

Suprapubic

referring to the area of the abdomen lying upon/over the urinary bladder; the region at the bottom-middle if a “hashtag” were drawn on the abdominal wall

Hematemesis

the vomiting of blood from an upper gastrointestinal bleed which may appear frankly red or dark like coffee grounds. This can be found in patients with ulcers, liver failure, and patients on blood thinners

Hematochezia

the passage of fresh, red blood per anus; indicative of a lower gastrointestinal bleed

Anasarca

marked total body swelling due to fluid buildup, typically caused by failure of the liver, kidneys, or heart

Ascites

abnormal swelling in the abdominal region due to fluid buildup, typically due to severe liver failure