IM1- MED TERM - CHARTING TERMS Flashcards
How would you chart about an abdomen that is
large and extends outwards
Protuberant, distended
How would you chart about an abdomen that is
hard and board like
Hard, rigid, distended, tympanic, taut
How would you chart about an abdomen that is
soft, flabby
relaxed, flaccid
How would you chart about an abdomen that is
filled with gas
tympanic, flatulent
How would you chart about an abdomen that
hangs down
Pendulous
How would you chart
large amounts of drainage
profuse, copious
How would you chart
medium amounts of drainage
moderate
How would you chart
small amount of drainage
scant
How would you chart
Hunchback
Kyphosis
How would you chart about the
small of back
lumbar region
How would you chart about
Swayback
lordosis
How would you chart
nose bleed
epistaxis
How would you chart
blood in urine
humaturia
How would you chart
spitting up blood
hemoptysis
How would you chart
positive blood in stool
guaiac positive
How would you chart
“unpleasant” breath
halitosis
How would you chart
“foul” breath
fetid
How would you chart
breath with sweet fruit like odor
fruity,sweet
How would you chart
urinous odor — in breath
odor of ammonia
How would you chart
breathing
respiration
How would you chart
difficult breathing
dyspnea
How would you chart
short periods when breathing has ceased
Apnea
How would you chart
inability to breath while lying down
Orthopnea
How would you chart
rapid breathing
Hyperpnea
How would you chart
increasing dyspnea with periods of apnea
Cheyne-stokes respiration
How would you chart consciousness that is:
alert, full conscious, oriented to date, time, place
Alert, fully conscious
How would you chart consciousness that is:
only partly conscious
semi-conscious
How would you chart consciousness that is:
unconscious, but can be aroused
stuporous
How would you chart consciousness that is:
unconscious, cannot be aroused
comatose
How would you chart
type of cough (name the types of coughs)
continuous, persistent, productive, nonproductive, dry, hacking
How would you chart a cough:
occuring in spasms
spasmodic
How would you chart a cough:
occurring in spasms
spasmodic
How would you chart
coughing up or expectoration of blood
Hemoptysis
How would you chart
dead tissue
tissue, necrosis, nercrotic
How would you chart
frequent liquid defication
Diarrhea
How would you chart
Color of stool
1.Clay
2. dark brown
3. black
4.mustard
5. yellow
6. green
7.tarry
8. streaked with blood,
How would you chart
constituents of stool
- Liquid
- soft
- Hard formed
- watery,
- Semi formed
- constipated
- Undigested foods
- Mucoid
How would you chart
containing pus
Purulent
How would you chart
bloody drainage
sanguineous
How would you chart
drainage of lymphatic fluid
serous
How would you chart
drainage that is tough, sticky
tenacious
How would you chart
bloody, lymphatic (serous) drainage
serosanguinous
How would you chart swelling in extremities, after depressing for 5 seconds
& it is indented 2mm
1+ edema
How would you chart swelling in extremities, after depressing for 5 seconds
& it is indented 4mm
2+ edema
How would you chart swelling in extremities, after depressing for 5 seconds
& it is indented 6mm
3+ edema
How would you chart swelling in extremities, after depressing 5 seconds
& it is indented 8mm
4+ edema
How would you chart emesis
that is produced by conscious effort of patient
Induced
How would you chart emesis
that is ejected a few feet distance
projectile
How would you chart emesis that
blood is noticeable
Hematemesis
How do you chart
Sharpness of vision
visual acuity
How do you chart
Yellow in color (in the eyes)
Jaundiced
How do you chart
puffy, swollen eyes
edematous
How do you chart
drooping eyelids
Ptosis of lids
How do you chart
Unusually sensitive to light
photophobia
How do you chart
double vision
Diplopia
How do you chart
cross eye, squinting
Strabismus
How do you chart
abnormal protrusion of eyeball
exophthalmos
How do you chart
inflammation of conjunctiva
conjunctivitis
How do you chart
dilatation of the pupil
myosis, pupil constricted, pin point
How do you chart
near-sightedness
myopia
How do you chart
far-sighteness
hyperopia
How do you chart
fainting
syncope
How do you chart
without fever
Afebrile
How do you chart
temperature above normal
pyrexia
How do you chart
temperature greatly above normal
hyperpyrexia
How do you chart
forehead
frontal region
How do you chart
region over temple
temporal region
How do you chart
back of head
occipital region
How do you chart
base of skull
basilar region
How do you chart
having a large head
macrocephaly, hydrocephaly
How do you chart
having a small head
microcephalus
How do you chart
top of head
Parietal (right or left)
How do you chart
hives
Urticaria
How do you chart
itching
pruritus
How do you chart
bending (of joints)
flexion
How do you chart
straighten (of joints)
extension
How do you chart
revolve around (joints)
rotation
How do you chart
move away from median line
abduction
How do you chart move toward median line
adduction
How do you chart
blue in color
cyanotic
How do you chart
my mouth (meds)
orally
How do you chart
by rectum (meds)
rectally
How do you chart
breathing in (meds)
inhalation
How do you chart
rubbing into skin (meds)
topically
How do you chart
under the skin
subcutaneous
How do you chart
within the skin
intradermal
How do you chart
within the muscle
intramuscular
how do you chart
within the spinal canal
intraspinal, intrathecal
How do you chart
within the vein
intravenous
How do you chart
pouring into body cavity
instillation
How do you chart
a menstrual period that is present when admitted
menses present
How do you chart
painful (menstruation)
dysmenorrhea
How do you chart
total absence of menstruation
amenorrhea
How do you chart
profuse or prolonged flow
menorrhagia
How do you chart
cessation of (menstruation)
menopause
How do you chart
very unpleasant odor
offensive, foul
How do you chart
paralysis of the muscle of the face
Facial paralysis
How do you chart
paralysis of the legs
paraplegia
how do you chart
paralysis of one side of the body
hemiplegia
How do you chart
paralysis of a single limb
monoplegia
How do you chart
paralysis of all four extremities & usually the trunk
quadraplegia
How do you chart
large amount of profuse (perspiration)
diaphoresis, diaphoretic
How do you chart
flat on back, arms straight at sides (position)
supine
How do you chart
on side, knees flexed
lateral
How do you chart
on left side, left arm behind back, left leg slightly flexed, right leg greatly flexed
Sims (left or right)
How do you chart
head of bed semi- erect
semi-fowlers 40-45– modified knees & legs not flexed
How do you chart
On back, buttocks near edge of table, knees well flexed and separated
lithotomy
How do you chart
resting on knees and chest
knee-chest
How do you chart
prone with hips over break in table and feet below level of head?
jackknife
How do you chart
On back, pelvis and legs higher than head
Trendelenburg
How do you chart
number of beats per min
rate
How do you chart
on abdomen, face turned to one side
prone
How do you chart
rhythm
regular or irregular, coupling, galloping
How do you chart
beats missed at intervals
intermittent
How do you chart
>100 beats per minute (bpm)
rapid, fast, tachycardia
How do you chart
slow in rate <50 bpm
slow, bradycardia
How do you chart
only scarcely perceptible
thready, weak
How do you chart
pulseless
imperceptible, absent
How do you chart
pulse strength
- 0 = absent, not palpable, inaudible with doppler
- 1+ = diminished/palpable
- 2+ = expected/normal
- 3+ = strong/full pulse
- 4+ = bounding, can’t be obliterated
How do you chart
normal skin
healthy, normal for race
How do you chart
blue in color (skin)
cyanotic, mottled
How do you chart
very white
extreme pallor, ashen
How do you chart
redness
erythema
How do you chart
shines
glossy
How do you chart
raw surface
excoriation
How do you chart
yellow in color
Jaundiced
How do you chart
containing colored area
pigmented
How do you chart
scraped
abraded, denuded
How do you chart
cold and moist
clammy
How do you chart
not understandable
incoherent
How do you chart
meaningless, wondering
rambling
How do you chart
words run together
slurring
How do you chart
difficultly speaking
dysphasia
How do you chart
unable to speak
aphasia
How do you chart
difficulty in swallowing
dysphagia
How do you chart
inability to swallow
aphagia
How do you chart
other descriptive terms related to throat
red, swollen, inflamed, ulcerated
How do you chart
descriptive terms related to tongue
pink, moist, dry, cracked, swollen, coated, inflamed, ulcerated
How do you chart
to urinate
voiding, micturate
How do you chart
no control over urination
incontinence
How do you chart
large amount of urine voided
diuresis
How do you chart
total suppression of urine
anuria
How do you chart
frequent voiding of urine at night
nocturia
How do you chart
increased amount voided
polyuria
How do you chart
painful urine
dysuria
How do you chart
pus in urine
pyuria
How do you chart
blood in urine
hematuria
How do you chart
scantiness of urine
oliguria
How do you chart
sugar in urine
glycosuria
How do you chart
overweight
obese
How do you chart
abnormal thinness
emaciated, wasting
How do you chart
very underweight
cachectic
How do you chart
discharging pus
suppurating, purulent
How do you chart
black or gray necrotic tissue
eschar
How do you chart
wound drainage
exudate
