Tags & Description
somnolent
drowsy or sleepy disposition
cachectic/emaciated
physically wasting (extremely thin)
morbidly obese
large body mass index (BMI)
nontoxic appearing
well-appearing patient in minimal distress (often used to describe well-appearing pediatric patients)
normocephalic
normal appearance and size of the head
atraumatic
no signs of trauma present
cyanosis
bluish discoloration of the skin due to a lack of oxygen
pallor
an unhealthy paleness of the skin
erythema
superficial reddening of the skin
jaundice
yellowing of skin due to abnormal bilirubin build-up
abrasion
superficial wound to the top most layer of the skin
contusion
a region of skin in which blood capillaries are ruptured; aka bruise
ecchymosis
an area of ruptured blood vessels similar to a contusion; aka bruise
laceration
a cut in the skin
puncture
a small hole in the skin
wheal
round, localized area of edema on the skin
wheal-and-flare
(a reaction) rash or hives (irregular, blanch raised areas with redness)
urticaria
hives or wheals which are either redder or paler than the surrounding area and are often accompanied by itching
maculopapular
rash or hives (flat red area covered with small confluent bumps)
pustules
small collection of pus under the skin
bullae
fluid-filled blisters
petechiae
a small round flat dark-red spot caused by bleeding into the skin or beneath the mucus membrane
purpura
purple spots or blotches (don’t turn white when pressed)
induration
a hardened area of normally soft tissue
fluctuance
movable and compressible
hemangloma
a benign tumor consisting of blood vessels
cornea
the transparent coat of the eyeball that covers the iris and pupil; lets light into the eye
sclera
the dense fibrous opaque outer coat enclosing the eyeball - except the part covered by the cornea
conjunctiva
white area of the eyes
icterus
yellowing of sclera due to bilirubin build-up (often seen with jaundice)
subconjunctival hemorrhage
bright red patches in conjunctiva of eyes due to ruptured blood vessels
extraocular movements intact (eomi)
appropriate function of the extraocular muscles, tested with “follow my finger”
pupils equal, round and reactive to light (perrl)
normal evaluation of the size, shape of the pupils and their reaction to light
papilledema
swelling of the optic disk due to an increase in intracranial pressure
fundi sharp
non-swollen optic nerve on exam of fundus (back of eye) with ophthalamoscope
visual acuity
acuteness/sharpness of vision as measured by the eye chart
eyelid eversion
flipping the eyelid for exam underneath the eyelid
normal palpebral conjunctiva
eyelid membrane is clear
exophthalmos
bulging of eyes out of socket
nystagmus
involuntary rapid eye movements - often reported as horizontal, vertical, or rotary
erythema of the external canal
redness of outer ear canal
cerumen impaction
excessive earwax
tympanic membrane (tm)
eardrum
erythematous tm
red color of the tm
bulging tm
protruding/outward curvature of the tm
retracted tm
inward curve of the tm
poor light reflect
cone of light does not reflect on tm
unable to visualize landmarks
provider cannot see landmarks behind tm
hemotympanum
blood on the tm
mastoid tenderness
tenderness over mastoid bone (located posterior to ear)
clear rhinorrhea
clear nasal drainage
septal deviation
displacement of nasal septum
septal hematoma
bruising or bleeding in the nasal septum
dry mucous membranes
dry mouth
tongue laceration
cut on the tongue
no signs of oral trauma
no cuts/chipped teeth/etc.
dental caries
cavity
poor dentition
bad teeth
pericoronitis
infection of the gums
parotid mass
enlargement of the parotid gland
trismus
inability to open mouth normally due to spasm of the jaw muscles
normal jaw approximation
normal jaw alignment
malocclusion
misalignment of the teeth when mouth closed
uvula midline
no deviation of the uvula to one side or another
pharyngeal erythema
redness of the throat
pharyngeal exudate
pus seen on the posterior throat
peritonsilar abscess
deep abscess adjacent to infected tonsils (collection of pus/swelling which is usually only visible if drained)
carotid bruit
abnormal flow of blood through the carotid artery
jugular vein distension (jvd)
swelling of the jugular vein (usually seen in heart failure patients)
cervical vertebral tenderness
pain along cervical spine
no step-offs or crepitus
no misalignment of the vertebral bodies (spinous processes) as the spine is palpated
anterior cervical lymphadenopathy
swollen lymph nodes under jaw and along anterior neck area
trachea midline
no deviation of trachea from its usual location
meningismus
patient has neck stiffness, photophobia, and headache which may suggest meningitis
nuchal rigidity
neck stiffness with neck movement
bradycardia
slow heart rate; less than 60 beats per minute
tachycardia
fast heart rate; greater than 100 beats per minute
murmur
an abnormal sound heard when listening to the heart
systolic murmur
heart murmur heard during systole (active pumping)
diastolic murmur
heart murmur heard during diastole (rest/active filling)
distant heart sounds
faint-sounding heart beats
rubs
coarse sounds produced when the heart “rubs” on inflamed pericardium (heart tissue) during contractions
gallops
extra/abnormal heart sounds (should only hear 2 distinct sounds, but you hear 3 or 4 sounds)
bradypnea
abnormally slow breathing