Scribeology Study Guide

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

Conjunctival injection

Redness of the conjunctiva

Diplopia

Double vision

Nystagmus

Involuntary rapid movements of the eyes

Cerumen

Ear wax

Dentalgia

Dental pain

Dentition

Condition of the teeth (e.g.

Dysphagia

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 the jaw

Accessory muscle use

Visible usage of muscles not normally used to breathe

Bradypnea

Unusually slow breathing

Cyanosis

Skin turns purple or dark blue due to hypoxia

Dyspnea

Shortness of breath

Expiration

Breathing out

Hemoptysis

Coughing up blood

Inspiration

Breathing in

Intubated

Introduction of a tube into a hollow organ such as the trachea

Orthopnea

Difficulty breathing when lying down

Rales

Abnormal sound heard in the lungs

Respiratory distress

Difficulty breathing

Retraction

Visible pulling inward of the muscles between the ribs when inhaling

Rhonchi

Low-pitched rattling or snoring sounds from partial airway obstruction

Speech dyspnea

Shortness of breath while speaking

Stridor

Sound caused by airway obstruction

Tachypnea

Unusually fast breathing

Wheeze

Whistling sound caused by narrowed airways

Aneurysm

Widening of a blood vessel resulting in a blood sac

Angina

Severe constricting chest pain due to reduced blood flow to heart tissue

Arrhythmia

Abnormal irregular heartbeat

Bradycardia

Unusually slow heart rate

Bruit

Murmur heard during auscultation indicating narrowing of a vessel

Capillary refill

Return of color after pressing down on the skin

Costochondritis

Inflammation of the costal cartilage

Embolism

Obstruction of blood vessels by a clot or foreign substance

Hemorrhage

Loss of blood internally or externally

Hypertension

Elevated blood pressure

Hypotension

Low blood pressure

Infarct

Death of tissue caused by loss of blood supply

Ischemia

Localized area of blood restriction

Murmur

Extra heart sounds

Palpitations

Awareness of one's own heartbeat

Pitting edema

Fluid buildup that leaves an indentation when pressed

Stenosis

Narrowing of an opening

Tachycardia

Unusually fast heart rate

Emesis

Vomit

Hematemesis

Vomiting blood

Hematochezia

Blood in the stool

Hemorrhoid

Swollen and inflamed veins of the rectum or anus

Melena

Black tarry stool

Hepatosplenomegaly

Enlargement of the liver and spleen

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

Loss of bladder control

Inguinal

Groin region

Priapism

Persistent painful erection

Torsion

Twisting of an organ around its axis

Nephrolithiasis

Kidney stones

Arthralgia

Joint pain

Crepitus

Crackling or grating sound in the joints

Edema

Accumulation of fluid causing swelling

Myalgia

Muscle pain

Sacroiliac joint

Joint where the spine meets the pelvis

Spasm

Sudden involuntary muscle contraction

Supple

Flexible neck with normal range of motion

Avulsion

Forcible tearing away of a body part or structure

Contusion

Injury causing broken blood vessels beneath the skin

Ecchymosis

Flat bruise

Erythema

Redness of the skin

Fluctuance

Compressible area indicating pus or fluid

Induration

Localized hardening of soft tissue

Laceration

Cut in the skin

Macular

Flat rash

Maculopapular rash

Flat red rash with small raised 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

Containing or discharging pus

Sanguineous

Drainage containing blood

Alert and oriented

Mental status oriented to person

Ambulatory

Able to walk

Concussion

Brain injury from a bump

Dysphasia

Difficulty speaking or understanding speech due to brain injury or illness

Gait

Manner of walking