Scribe terms

Atraumatic (Constitutional)

No evidence of trauma to the body

Diaphoresis (Constitutional)

Excessive sweating

Febrile (Constitutional)

Having a fever

Malaise (Constitutional)

Generalized discomfort or weakness

Normocephalic (Constitutional)

Normal shaped head

Polydipsia (Constitutional)

Excessive thirst

Polyuria (Constitutional)

Excessive urination

Conjunctiva (Eyes)

Membrane lining of the eyelids and covering of the eyeball; “white part”

Conjunctival injection (Eyes)

Redness of the conjunctiva

Diplopia (Eyes)

Double vision

Nystagmus (Eyes)

Involuntary rapid movements of the eyes

Cerumen (ENT)

Ear wax

Dentalgia (ENT)

Dental pain

Dentition (ENT)

Indicating the condition of teeth (i.e. intact)

Dysphagia (ENT)

Painful/difficulty swallowing

Epistaxis (ENT)

Bleeding of the nose

Hemotympanum (ENT)

Blood in the middle ear

Rhinorrhea (ENT)

Runny nose

Septal deviation (ENT)

Displacement of the nasal septum

Tinnitus (ENT)

Ringing of the ears

Trismus (ENT)

Inability to open jaw

Accessory muscle use (Respiratory)

Visible usage of muscles not normally used to breathe

Bradypnea (Respiratory)

Unusually slow breathing

Cyanosis (Respiratory)

When the skin turns purple or dark blue (typically due to hypoxia)

Dyspnea (Respiratory)

Shortness of breath

Expiration (Respiratory)

Breathing out

Hemoptysis (Respiratory)

Coughing up blood

Inspiration (Respiratory)

Breathing in

Intubated (Respiratory)

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

Orthopnea (Respiratory)

Difficulty breathing when laying down

Rale (Respiratory)

Abnormal sound heard in lungs

Respiratory distress (Respiratory)

Difficulty breathing

Retraction (Respiratory)

Visible pulling inward of the muscles between the ribs when inhaling

Rhonchi (Respiratory)

Whistling sound heard when there is a partial obstruction of the lungs

Speech dyspnea (Respiratory)

Shortness of breath when speaking

Stridor (Respiratory)

Sound heard when there is an obstruction of the airways

Tachypnea (Respiratory)

Unusually fast breathing

Wheeze (Respiratory)

Whistling sound due to narrowing of the lumen in respiratory passages

Aneurysm (Cardiovascular)

Widening of a blood vessel that results in a blood sac

Angina (Cardiovascular)

Severe, constricting chest pain due to heart tissues not receiving enough blood

Arrhythmia (Cardiovascular)

Abnormal, irregular heartbeat

Bradycardia (Cardiovascular)

Usually slow heart rate

Bruit (Cardiovascular)

A murmur or sound heard in auscultation indicating narrowing of a vessel

Capillary refill (Cardiovascular)

The return of color after pressing down on the skin

Costochondritis (Cardiovascular)

Inflammation of the costal cartilage

Embolism (Cardiovascular)

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

Hemorrhage (Cardiovascular)

Loss of blood from the body, internally or externally

Hypertension (Cardiovascular)

Elevated blood pressure

Hypotension (Cardiovascular)

Low blood pressure

Infarct (Cardiovascular)

Death of a tissue caused by loss of blood supply

Ischemia (Cardiovascular)

Temporary, localized area of blood restriction

Murmur (Cardiovascular)

Extra heart sounds

Palpitations (Cardiovascular)

Awareness of one’s own heartbeat

Pitting edema (Cardiovascular)

Fluid buildup (typically legs) that leaves a “pit”/indentation when pressed

Stenosis (Cardiovascular)

Narrowing of an opening

Tachycardia (Cardiovascular)

Unusually fast heart rate

Emesis (Gastrointestinal)

Vomit

Hematemesis (Gastrointestinal)

Vomit with blood in it

Hematochezia (Gastrointestinal)

Blood in stool

Hemorrhoid (Gastrointestinal)

Swollen and inflamed veins on the rectum or anus

Melena (Gastrointestinal)

Black, tarry stool

Hepatosplenomegaly (Gastrointestinal)

Enlargement of the spleen and liver

Urolithiasis (Gastrointestinal)

Kidney stone

Cervical (Genitourinary)

Pertaining to the neck or cervix of the uterus

Dysmenorrhea (Genitourinary)

Painful menstruation

Dysuria (Genitourinary)

Painful urination

Hematuria (Genitourinary)

Blood in the urine

Incontinence (Genitourinary)

Sudden, involuntary urge to pass urine

Inguinal (Genitourinary)

Groin region

Priapism (Genitourinary)

Persistent and painful erection, often due to trauma

Torsion (Genitourinary)

Twisting of an organ around its own axis

Nephrolithiasis (Genitourinary)

Kidney stones

Arthralgia (Musculoskeletal)

Joint pain

Crepitus (Musculoskeletal)

Crackling or grating sound usually heard in the bones

Edema (Musculoskeletal)

Accumulation of fluid in the interstitial spaces; swelling

Myalgia (Musculoskeletal)

Muscle pain; body aches

Sacroiliac joint (SI joint) (Musculoskeletal)

Where the spine meets the pelvis

Spasm (Musculoskeletal)

Sudden, involuntary muscle contraction

Supple (Musculoskeletal)

Flexible neck that can easily move during the exam

Avulsion (Integumentary)

A forcible tearing away of a part or structure

Contusion (Integumentary)

Trauma that results in broken blood vessels beneath the skin

Ecchymosis (Integumentary)

Bruise that is not elevated

Erythema (Integumentary)

Redness of the skin

Fluctuance (Integumentary)

Capable of being moved/compressed; indicates presence of pus

Induration (Integumentary)

Localized hardening of soft tissue

Laceration (Integumentary)

Cut in the skin

Macular (Integumentary)

Flat rash

Maculopapular rash (Integumentary)

Flat red rash covered in small bumps

Melanoma (Integumentary)

Most deadly type of skin cancer

Nuchal rigidity (Integumentary)

Neck stiffness

Pallor (Integumentary)

Paleness of the skin

Papular (Integumentary)

Solid, raised lesion with distinct borders

Pruritic (Integumentary)

Itchy

Purulent (Integumentary)

Consisting of/containing/discharging pus

Sanguineous (Integumentary)

Drainage that is a mixture of pus and blood

Alert and oriented (A&Ox4) (Neurological)

Mental function: oriented to person, place, time, situation (A&Ox4 if all 4)

Ambulatory (Neurological)

Able to walk

Concussion (Neurological)

Loss of consciousness due to severe head injury

Dysphasia (Neurological)

Inability to understand verbal commands due to brain injury/illness

Gait (Neurological)

A manner of walking