Term
|
Definition
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Term
|
Definition
| Movement away from the midline |
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Term
|
Definition
| Movement toward the midline |
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Term
|
Definition
| Enlargement of lymph nodes |
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Term
|
Definition
|
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Term
|
Definition
| Altered level of consciousness |
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Term
|
Definition
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|
Term
|
Definition
|
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Term
|
Definition
|
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Term
|
Definition
|
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Term
|
Definition
| A forcible tearing away of a part or structure |
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Term
|
Definition
| Abnormally slow heart beat |
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Term
|
Definition
| Abnormally slow breathing |
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Term
|
Definition
| Sign of meningitis (Neck) |
|
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Term
|
Definition
| A murmur or sound heard in auscultation indicating narrowing of a vessel |
|
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Term
|
Definition
|
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Term
|
Definition
| Noise from carotid artery narrowing heard with stethoscope (Cardio) |
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Term
|
Definition
|
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Term
|
Definition
| Swelling and softening of the nailbed indicating chronic lung problem |
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Term
|
Definition
| White part of eye and inside lining of eyelids (Eyes) |
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|
Term
| Costovetebral angle tenderness (CVA tenderness) |
|
Definition
| Tenderness posteriorly at the lower rib |
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Term
|
Definition
| A crackling or grating sound, usually of bones |
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Term
|
Definition
| Blue skin due to lack of oxygen |
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Term
|
Definition
| Bluish skin color due to lack of oxygenation |
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Term
|
Definition
| The condition of the teeth |
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Term
|
Definition
|
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Term
|
Definition
| Excessive or profuse sweating or perspiration |
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Term
|
Definition
| Upward flexion of the foot |
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Term
|
Definition
| Sign of solid fluid or mass under area being “tapped” |
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Term
|
Definition
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Term
|
Definition
| extraocular movements intact |
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Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Abnormal heart or lung sound |
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|
Term
|
Definition
|
|
Term
|
Definition
| Extra heart sound heard common in CHF |
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Term
|
Definition
| Involuntary tightening of stomach muscles when pushed on – patient cannot control |
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Term
|
Definition
| Tumor consisting of blood vessels |
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Term
|
Definition
| Swelling of blood which occurs in an organ or tissue |
|
|
Term
|
Definition
| No blood detected by chemical test, usually referring to stool or urine |
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|
Term
|
Definition
| Weakness on one half of body |
|
|
Term
|
Definition
| Paralysis on one half of body |
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|
Term
|
Definition
|
|
Term
|
Definition
| Enlargement of the liver and spleen |
|
|
Term
|
Definition
| Persistently low arterial blood pressure |
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|
Term
|
Definition
| Hardened tissue, often from infection |
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|
Term
|
Definition
|
|
Term
| Irregularly irregular rhythm |
|
Definition
| No consistent pattern to the heart rhythm, usually implying atrial |
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|
Term
|
Definition
| Yellow discoloration of the skin |
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|
Term
|
Definition
| Articulation or junction between two or more bones or cartilage |
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Term
|
Definition
|
|
Term
|
Definition
| Scar formation consisting of dense tissue |
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|
Term
|
Definition
|
|
Term
|
Definition
| Enlargement of lymph nodes |
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|
Term
|
Definition
| Infection traveling up lymphatic system |
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|
Term
|
Definition
| Small colored spot on the skin |
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|
Term
|
Definition
| Any firm abnormality seen or palpated on physical exam |
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|
Term
|
Definition
| Abnormal heart sound rated on 1 to 6 scales, 6 being the loudest |
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|
Term
|
Definition
| Involuntary rapid eye movements |
|
|
Term
|
Definition
| Enlargement of the abdominal organs, usually spleen, liver or kidneys |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Able to be touched or easily perceived |
|
|
Term
|
Definition
| Water retention in the foot/ankle area |
|
|
Term
|
Definition
| Tiny red spot occurring on the skin caused by a small amount of subcutaneous bleeding |
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|
Term
|
Definition
| Downward flexion of the foot |
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|
Term
|
Definition
|
|
Term
|
Definition
| Indicates airway narrowing on expiration, common in asthma |
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|
Term
| Prominent abdominal aortic pulsation |
|
Definition
| Possible abdominal aortic aneurysm |
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|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Clicking, rattling, or crackling noises heard in the lungs on inhalation, indicating fluid in |
|
|
Term
|
Definition
| Pain when releasing hand from abdominal palpation or from other movement |
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|
Term
|
Definition
| Sucking in between ribs or sternum, during inspiration – usually children |
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|
Term
|
Definition
| A coarse sound in the lungs that indicates the presence of thick fluid |
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|
Term
|
Definition
| Falling to one sign standing with eyes closed |
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|
Term
|
Definition
|
|
Term
|
Definition
| Not moving because of pain |
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|
Term
|
Definition
|
|
Term
|
Definition
| Harsh or high-pitched respiratory sound, caused by obstruction of upper airway passages |
|
|
Term
|
Definition
| High pitched sound heard on inspiration that is indicative of airway obstruction |
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|
Term
|
Definition
| Abnormal rapid heart beat |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Extremely rapid respiration |
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|
Term
|
Definition
|
|
Term
|
Definition
| Condition of being distended or swollen |
|
|
Term
|
Definition
| Round, localized area of edema on the skin attended by severe itching |
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|
Term
| Vertebral point tenderness |
|
Definition
| Tenderness over bumps on spine on back |
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|
Term
| Erythema (Multiple Systems) |
|
Definition
|
|
Term
| Contusion (Multiple Systems) |
|
Definition
|
|
Term
|
Definition
| Where pain is felt on the release of applied pressure upon the abdomen |
|
|
Term
|
Definition
| Tensing of the abdominal wall muscles to guard inflamed organs, can be voluntary or involuntary |
|
|
Term
| Organomegaly (Abdomen/GI) |
|
Definition
|
|
Term
| Stool Guaiac (Abdomen/GI) |
|
Definition
|
|
Term
| Murphy's Sign (Abdomen/GI) |
|
Definition
| Right upper quadrant (RUQ) tenderness |
|
|
Term
| McBurney's Sign (Abdomen/GI) |
|
Definition
| Right lower quadrant (RLQ) tenderness |
|
|
Term
| Rovsing's Sign (Abdomen/GI) |
|
Definition
| Palpation of the LLQ results in more pain to the RLQ, indicator of appendicitis |
|
|
Term
| Obturator Sign (Abdomen/GI) |
|
Definition
| Abdominal pain with flexion and internal rotation of the hip |
|
|
Term
|
Definition
| Abdominal pain elicited when the patient is lying on their side and the thigh is hyperextended |
|
|
Term
|
Definition
| Inward curvature of a portion of the spine, swayback |
|
|
Term
| Straight Leg Raise (Back) |
|
Definition
| A test performed to determine back pain. The patient raises each leg individually until pain is elicited. Test is measured in terms of degrees (pain at 15, 30, 45, 60, 75, or 90 degrees) |
|
|
Term
|
Definition
| Curving of the spine which causes bowing of the back, hunchback |
|
|
Term
| CVA Tenderness (Back & GU) |
|
Definition
| Costovertebral Angle Tenderness |
|
|
Term
| Bradycardia (Cardiovascular) |
|
Definition
| Slow heart rate, heart rate under 60 |
|
|
Term
| Tachycardia (Cardiovascular) |
|
Definition
| fast heart rate, heart rate over 100 |
|
|
Term
|
Definition
| Measered 1+, 2+, 3+, and 4+. 2+ is considered normal |
|
|
Term
|
Definition
| Extra or unusual sound heard during a heartbeat. Can be Systolic, Diastolic, Crescendo, Decrescendo or Crescendo-Decrescendo and are graded from 1-6 |
|
|
Term
| S1 and S2 (Cardiovascular) |
|
Definition
| The first and teh second heart sounds (the lub and dub) caused by the closing of the AV valves and semilunar valves |
|
|
Term
| Edema (Cardiovascular, MSE, & Skin) |
|
Definition
| Swelling. Graded 1+, 2+, 3+, and 4+ pitting edema |
|
|
Term
| Pedal Edmea (Cardiovascular) |
|
Definition
| Pitting edema of the feet |
|
|
Term
|
Definition
|
|
Term
| Dialysis Shunt (Cardiovascular) |
|
Definition
| MEDHOST will ask 1) Location, 2) Palpable pulse, 3) Ascultated thrill, 4) Erythema, 5) Edema, and 6) Bleeding. Where is it? Can the MD feel a pules? Can the MD hear a thrill? Is there any redness, swelling, or bleeding? |
|
|
Term
|
Definition
|
|
Term
| Emaciated (Constitutional) |
|
Definition
|
|
Term
|
Definition
| With fever (opposite is "afebrile", without fever) |
|
|
Term
| Lethargic (Constitutional) |
|
Definition
| Minimally responsive (Note: this word is not often used as most Physician's equate lethargic to meaning near death. A better choice might be "somnolent" which means appearing tired or sleepy) |
|
|
Term
| Odor - ETOH (Constitutional) |
|
Definition
|
|
Term
| Odor - ketotic (Constitutional) |
|
Definition
|
|
Term
|
Definition
| Swelling of the thyroid gland |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Bloody discharge (from the ears) |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| TM's are not visible due to...(various reasons) |
|
|
Term
|
Definition
| Cerebral Spinal Fluid nasal discharge |
|
|
Term
|
Definition
| Missing teeth, partially or completely |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Yellowing of the whites of the eyes |
|
|
Term
|
Definition
| Pupils Equal, Round, and Reactive to Light and Accomodation |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Redness of the conjunctiva, bloodshot eyes, "pink eye" |
|
|
Term
|
Definition
| A strip of dye used to stain the eye and examine for abrasions or foreign bodies |
|
|
Term
|
Definition
| Drooping of the upper eyelid |
|
|
Term
|
Definition
| Optic disc swelling secondary to elevated intracranial pressure |
|
|
Term
| Nystagmus (Verticle/Rotary) (Eyes) |
|
Definition
| Involuntary movement of the eye, in a vertical or circular pattern |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Vaginal injury (the area between the anus and the vulva) |
|
|
Term
|
Definition
|
|
Term
| Hemotympanum (Head/face & ENT) |
|
Definition
| Blood in the tympanic cavity of the middle ear |
|
|
Term
| Decreased ROM (MS/extremity) |
|
Definition
| Decreased Range of Motion |
|
|
Term
|
Definition
| Color of the skin (pink, warm, and brisk capillary refill are normal. Cold, dusky, mottled, pale, sluggish capillary refill are abnormal) |
|
|
Term
| Subungual Hematoma (MS/extremity: Nails) |
|
Definition
|
|
Term
| Homan's Sign (MS/extremity: DVT Exam) |
|
Definition
| Pain in the calf of popliteal region with abrupt dorsiflexion |
|
|
Term
|
Definition
Used to determine risk of spinal cord injury (*important to document if a patient presents with or is given a c-collar) |
|
|
Term
|
Definition
|
|
Term
| Crepitus (Neck & Chest/axilla) |
|
Definition
| Grating, crackling, or popping sounds experienced under the skin and in the joints |
|
|
Term
| Lymphadenopathy (Neck & Chest/axilla) |
|
Definition
|
|
Term
|
Definition
|
|
Term
| Orientation x1, x2, x3, or x4 |
|
Definition
| Oriented to person, place, time, and situation(Neuro) |
|
|
Term
|
Definition
| Poor articulation of speech(Neuro) |
|
|
Term
|
Definition
| Expressive: difficulty speaking, cannot get the words out(Neuro) |
|
|
Term
|
Definition
| patients balance is tested while standing with the eyes open and then with the eyes shut. A loss of balabce with the eyes closed is a positive, abnormal test(Neuro) |
|
|
Term
|
Definition
| Abnormal body posture which involves the arms and legs held straight out, toes pointed downward, and the head and neck arching backward. The muscles are tightened and held rigidly. Usually indicative of severe damage to the brain (Neuro) |
|
|
Term
|
Definition
| Abnormal body posture which involves rigidity, flexion of the arms, clenched fists, and extended legs. The arms are bent inward toward the body with the wrists and fingers bent and held on the chest(Neuro) |
|
|
Term
|
Definition
| Unsteady, staggering or irregular gait(Neuro) |
|
|
Term
|
Definition
| Deep Tendon Reflexes, measured from 0-5+ with 2+ being normal(Neuro) |
|
|
Term
|
Definition
| Scale which aims to give a recording of the conscious state of a person, scores are between 3 (deep unconsciousness) and 15 (awake and alert) (Neuro) |
|
|
Term
|
Definition
| Neurological test based upon what the big toe does when the sole of the foot is stimulated. A down going big toe is normal(Neuro) |
|
|
Term
|
Definition
| Thoughts or desires to harm another person(Psych) |
|
|
Term
|
Definition
| The inability to breathe easily unless one is sitting up straight or standing. Will often hear of "3 pillow orthopnea" meaning the patient cannot sleep unless propped up on 3 pillows(Respiratory) |
|
|
Term
|
Definition
| Visible sinking of the chest wall with inspiration(Respiratory) |
|
|
Term
|
Definition
| Reduced inspiratory effort(Respiratory) |
|
|
Term
|
Definition
| Commonly refered to as Crackles, the clicking or rattling noises heard on auscultation of the lungs(Respiratory) |
|
|
Term
|
Definition
| Coarse rattling sound somewhat like snoring, heard on auscultation of the lungs(Respiratory) |
|
|
Term
|
Definition
| High pitched, harsh, vibratory noise caused by parital airway obstruction(Respiratory) |
|
|
Term
|
Definition
| Chest pain with deep breathing(Respiratory) |
|
|
Term
|
Definition
| Profuse perspiration(Skin) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Tearing away (commonly refered to as a skin tear)(Skin) |
|
|
Term
|
Definition
| Almost any abnormality involving any tissue or organ due to disease or any injury. (Skin) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| The process or fact of being eroded away(Skin) |
|
|
Term
|
Definition
| A small red or purple spot on the body caused by a minor hemorrhage (Skin) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Abnormaility in the skin's ability to change shape and return to normal (elasticity)(Skin) |
|
|
Term
|
Definition
| A skin rash in which the lesions are flat and less than 1cm in diameter(Skin: Rash) |
|
|
Term
|
Definition
| Small, solid, rounded bumps rising from the skin that are usually 0.5cm or less in diameter. Papules may open when scratched and become crusty and infected(Skin: Rash) |
|
|
Term
|
Definition
| Hives, itchy wheals(Skin: Rash) |
|
|
Term
|
Definition
| When pinched and lifted the skin remains tented instead of returning to its normal, flat state. This usually indicates dehydration(Skin: Turgor) |
|
|
Term
|
Definition
| Mentally dulled (an acceptable caviat for not obtaining HPI/ROS)(HPI/ROS) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| A lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye(Neuro: Finger to nose test) |
|
|
Term
|
Definition
| Strength is measured from 1-5 over 5, a patient may exhibit 5/5 strength in the left upper extremity but only 4/5 strength in the right. 5/5 in all is normal(Neuro: Motor) |
|
|
Term
|
Definition
| To tear or wear off the skin; abrade; chafe |
|
|
Term
|
Definition
| No Cervical Motion Tenderness(GU: Pelvic Exam) |
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|
