All Charting Terms - Front and Back Flashcards
Learn/Review Common Charting Terms (Front and Back Sides)
abdomen large and extends outward
protuberant, distended
hard, board like abdomen
hard, rigid, distended, tympanic, taut
soft, flabby abdomen
relaxed, flaccid
swollen, rounded abdomen
distended, edematous
abdomen filled with gas
tympanic, flatulent
abdomen hangs down
pendulous
large amounts of drainage
profuse, copious
medium amount of drainage
moderate
small amount of drainage
scant
loss of appetite
anorexia
Hunchback
kyphosis
small of back
lumbar region
swayback
lordosis
nose bleed
epistaxis
blood in urine
hematuria
spitting up of blood
hemoptysis
positive blood in stool
Guaiac positive
unpleasant breath
halitosis
foul breath
fetid
breath with sweet fruit-like odor
fruity, sweet
breath with urinous odor
odor of ammonia
breathing
respiration
difficult breathing
dyspnea
short periods when breathing has ceased
apnea
inability to breathe while lying down
orthopnea
rapid breathing
hyperpnea
increasing dyspnea with period of apnea
Cheyne-Stokes respirations
Awake and responsive
alert, fully conscious
only partly conscious
semi-conscious
unconscious, but can be aroused
stuporous
unconscious, cannot be aroused
comatose
ways to describe a cough
continuous, persistent, productive, nonproductive, dry, hacking
cough occurring in spasms
spasmodic
coughing up or expectoration of blood
hemoptysis
dead tissue
tissue necrosis, necrotic
frequent liquid defecation
diarrhea
Ways to describe color of stool
clay or dark brown, black, mustard, yellow, green, tarry, streaked with blood
ways to describe constituents of stool
liquid, soft or hard formed, watery, semi-formed, constipated, undigested foods, mucoid
drainage containing pus
purulent
bloody drainage
sanguineous
drainage of lymphatic fluid
serous
drainage contains mucus and pus
mucopurulent
tough, sticky drainage
tenacious
bloody, lymphatic (serous) drainage
serosanguinous
Swelling in extremities, after depressing for 5 seconds: indented 2 mm
1+ edema
Swelling in extremities, after depressing for 5 seconds: indented 4 mm
2+ edema
Swelling in extremities, after depressing for 5 seconds: indented 6 mm
3+ edema
Swelling in extremities, after depressing for 5 seconds: indented 8 mm
4+ edema
vomit produced by conscious effort of patient
induced emesis
vomit ejected a few feet distance
projectile emesis
vomit with noticeable blood
hematemesis
sharpness of vision
visual acuity
eyes yellow in color
jaundiced
eyes puffy, swollen
edematous
drooping eyelids
ptosis of lids
eyes unusually sensitive to light
photophobia
double vision
diplopia
cross eye, squinting
strabismus
abnormal protrusion of eyeball
exophthalmos
inflammation of conjunctiva
conjunctivitis
dilation of the pupil
mydriasis, pupil dilated
contraction of the pupil
myosis, pupil constricted, pin point
near-sightedness
myopia
far-sightedness
hyperopia
fainting
syncope
without fever
afebrile
temperature above normal
pyrexia
temperature greatly above normal
hyperpyrexia
forehead
frontal region
region of head over temple
temporal region
back of head
occipital region
base of skull
basilar region
having a large head
macrocephaly, hydrocephalus
having a small head
microcephalus
top of head
parietal (right or left)
hives
urticaria
itching
pruritus
bending joints
flexion
to straighten joints
extension
revolve around
rotation
move away from median line
abduction
move toward median line
adduction
lips blue in color
cyanotic
medicine administration by mouth
orally
medicine administration by rectum
rectally
medicine administration breathing in
inhalation
medicine administration rubbing into skin
topically
medicine administration under the skin
subcutaneous
medicine administration within the skin
intradermal
medicine administration within the muscle
intramuscular
medicine administration within the spinal canal
intraspinal, intrathecal
medicine administration within the vein
intravenous
medicine administration pouring into body cavity
instillation
menstruation if present when admitted
menses present
painful menstruation
dysmenorrhea
total absence of menstruation
amenorrhea
profuse or prolonged flow of menstruation
menorrhagia
cessation of menstruation
menopause
very unpleasant odor
offensive, foul
paralysis of the muscles of the face
facial
paralysis of the legs
paraplegia
paralysis of one side of the body
hemiplegia
paralysis of a single limb
monoplegia
paralysis of all 4 extremities and usually the trunk
quadriplegia
large amount of profuse perspiration
diaphoresis, diaphoretic
flat on back, arms straight at sides
supine
on side, knees flexed
lateral
on left side, left arm behind back, left leg slightly flexed, right leg greatly flexed
Sim’s (left or right)
head of bed semi-erect
Semi-Fowler’s 40-45° - modified, knees and legs not flexed
on back, buttocks near edge of table, knees well flexed and separated
lithotomy
resting on knees and chest
knee-chest
on back, pelvis and legs higher than head
Trendelenburg
on abdomen, face turned to one side
prone
prone with hips over break in table and feet below level of head
jackknife
pulse number of beats per minute
rate
describe various pulse rhythms
regular or irregular, coupling, galloping
pulse beasts missed at intervals
intermittent
pulse > 100 beats per minute
rapid, fast, tachycardia
pulse slow in rate, < 50 bpm
slow, bradycardia
pulse only scarcely perceptible
thready, weak
pulseless
imperceptible, absent
pulse absent, not palpable, inaudible with Doppler
pulse strength: 0
pulse diminished but palpable
pulse strength: 1+
expected/normal pulse
pulse strength: 2+
strong/full pulse
pulse strength: 3+
bounding pulse, can’t be obliterated
pulse strength: 4+
skin normal
healthy, normal for race
skin blue in color
cyanotic, mottled
skin very white
extreme pallor, ashen
redness of skin
erythema
skin shines
glossy
raw surface on skin
excoriation
skin yellow in color
jaundiced
skin containing colored areas
pigmented
scraped skin
abraded, denuded
cold and moist skin
clammy
speech not understandable
incoherent
speech meaningless, wondering
rambling
words run together
slurring
difficulty speaking
dysphasia
unable to speak
aphasia
difficulty in swallowing
dysphagia
inability to swallow
aphagia
descriptive terms for the throat
red, swollen, inflamed, ulcerated
descriptive terms for the tongue
pink, moist, dry, cracked, swollen, coated, inflamed, ulcerated
to urinate
voiding, micturate
no control over urination
incontinence
large amount of urine voided
diuresis
total suppression of urine
anuria
frequent voiding at night
nocturia
increased amount voided
polyuria
painful urination
dysuria
pus in urine
pyuria
blood in urine
hematuria
scantiness of urine
oliguria
sugar in urine
glycosuria
overweight
obese
abnormal thinness
emaciated, wasting
very underweight
cachectic
Wound discharging pus
suppurating, purulent
black or gray necrotic tissue in wound
eschar
wound drainage
exudate
protuberant, distended
abdomen large and extends outward
hard, rigid, distended, tympanic, taut
hard, board like abdomen
relaxed, flaccid
soft, flabby abdomen
distended, edematous
swollen, rounded abdomen
tympanic, flatulent
abdomen filled with gas
pendulous
abdomen hangs down
profuse, copious
large amounts of drainage
moderate
medium amount of drainage
scant
small amount of drainage
anorexia
loss of appetite
kyphosis
Hunchback
lumbar region
small of back
lordosis
swayback
epistaxis
nose bleed
hematuria
blood in urine
hemoptysis
spitting up of blood
Guaiac positive
positive blood in stool
halitosis
unpleasant breath
fetid
foul breath
fruity, sweet
breath with sweet fruit-like odor
odor of ammonia
breath with urinous odor
respiration
breathing
dyspnea
difficult breathing
apnea
short periods when breathing has ceased
orthopnea
inability to breathe while lying down
hyperpnea
rapid breathing
Cheyne-Stokes respirations
increasing dyspnea with period of apnea
alert, fully conscious
Awake and responsive
semi-conscious
only partly conscious
stuporous
unconscious, but can be aroused
comatose
unconscious, cannot be aroused
continuous, persistent, productive, nonproductive, dry, hacking
ways to describe a cough
spasmodic
cough occurring in spasms
hemoptysis
coughing up or expectoration of blood
tissue necrosis, necrotic
dead tissue
diarrhea
frequent liquid defecation
clay or dark brown, black, mustard, yellow, green, tarry, streaked with blood
Ways to describe color of stool
liquid, soft or hard formed, watery, semi-formed, constipated, undigested foods, mucoid
ways to describe constituents of stool
purulent
drainage containing pus
sanguineous
bloody drainage
serous
drainage of lymphatic fluid
mucopurulent
drainage contains mucus and pus
tenacious
tough, sticky drainage
serosanguinous
bloody, lymphatic (serous) drainage
1+ edema
Swelling in extremities, after depressing for 5 seconds: indented 2 mm
2+ edema
Swelling in extremities, after depressing for 5 seconds: indented 4 mm
3+ edema
Swelling in extremities, after depressing for 5 seconds: indented 6 mm
4+ edema
Swelling in extremities, after depressing for 5 seconds: indented 8 mm
induced emesis
vomit produced by conscious effort of patient
projectile emesis
vomit ejected a few feet distance
hematemesis
vomit with noticeable blood
visual acuity
sharpness of vision
jaundiced
eyes yellow in color
edematous
eyes puffy, swollen
ptosis of lids
drooping eyelids
photophobia
eyes unusually sensitive to light double vision
diplopia
double vision
strabismus
cross eye, squinting
exophthalmos
abnormal protrusion of eyeball
conjunctivitis
inflammation of conjunctiva
mydriasis, pupil dilated
dilation of the pupil
myosis, pupil constricted, pin point
contraction of the pupil
myopia
near-sightedness
hyperopia
far-sightedness
syncope
fainting
afebrile
without fever
pyrexia
temperature above normal
hyperpyrexia
temperature greatly above normal
frontal region
forehead
temporal region
region of head over temple
occipital region
back of head
basilar region
base of skull
macrocephaly, hydrocephalus
having a large head
microcephalus
having a small head
parietal (right or left)
top of head
urticaria
hives
pruritus
itching
flexion
bending joints
extension
to straighten joints
rotation
revolve around
abduction
move away from median line
adduction
move toward median line
cyanotic
lips blue in color
orally
medicine administration by mouth
rectally
medicine administration by rectum
inhalation
medicine administration breathing in
topically
medicine administration rubbing into skin
subcutaneous
medicine administration under the skin
intradermal
medicine administration within the skin
intramuscular
medicine administration within the muscle
intraspinal, intrathecal
medicine administration within the spinal canal
intravenous
medicine administration within the vein
instillation
medicine administration pouring into body cavity
menses present
menstruation if present when admitted
dysmenorrhea
painful menstruation
amenorrhea
total absence of menstruation
menorrhagia
profuse or prolonged flow of menstruation
menopause
cessation of menstruation
offensive, foul
very unpleasant odor
facial
paralysis of the muscles of the face
paraplegia
paralysis of the legs
hemiplegia
paralysis of one side of the body
monoplegia
paralysis of a single limb
quadriplegia
paralysis of all 4 extremities and usually the trunk
diaphoresis, diaphoretic
large amount of profuse perspiration
supine
flat on back, arms straight at sides
lateral
on side, knees flexed
Sim’s (left or right)
on left side, left arm behind back, left leg slightly flexed, right leg greatly flexed
Semi-Fowler’s 40-45° - modified, knees and legs not flexed
head of bed semi-erect
lithotomy
on back, buttocks near edge of table, knees well flexed and separated
knee-chest
resting on knees and chest
Trendelenburg
on back, pelvis and legs higher than head
prone
on abdomen, face turned to one side
jackknife
prone with hips over break in table and feet below level of head
rate
pulse number of beats per minute
regular or irregular, coupling, galloping
describe various pulse rhythms
intermittent
pulse beasts missed at intervals
rapid, fast, tachycardia
pulse > 100 beats per minute
slow, bradycardia
pulse slow in rate, < 50 bpm
thready, weak
pulse only scarcely perceptible
imperceptible, absent
pulseless
pulse strength: 0
pulse absent, not palpable, inaudible with Doppler
pulse strength: 1+
pulse diminished but palpable
pulse strength: 2+
expected/normal pulse
pulse strength: 3+
strong/full pulse
pulse strength: 4+
bounding pulse, can’t be obliterated
healthy, normal for race
skin normal
cyanotic, mottled
skin blue in color
extreme pallor, ashen
skin very white
erythema
redness of skin
glossy
skin shines
excoriation
raw surface on skin
jaundiced
skin yellow in color
pigmented
skin containing colored areas
abraded, denuded
scraped skin
clammy
cold and moist skin
incoherent
speech not understandable
rambling
speech meaningless, wondering
slurring
words run together
dysphasia
difficulty speaking
aphasia
unable to speak
dysphagia
difficulty in swallowing
aphagia
inability to swallow
red, swollen, inflamed, ulcerated
descriptive terms for the throat
pink, moist, dry, cracked, swollen, coated, inflamed, ulcerated
descriptive terms for the tongue
voiding, micturate
to urinate
incontinence
no control over urination
diuresis
large amount of urine voided
anuria
total suppression of urine
nocturia
frequent voiding at night
polyuria
increased amount voided
dysuria
painful urination
pyuria
pus in urine
hematuria
blood in urine
oliguria
scantiness of urine
glycosuria
sugar in urine
obese
overweight
emaciated, wasting
abnormal thinness
cachectic
very underweight
suppurating, purulent
Wound discharging pus
eschar
black or gray necrotic tissue in wound
exudate
wound drainage
