IM1- MED TERM - CHARTING TERMS Flashcards

1
Q

How would you chart about an abdomen that is
large and extends outwards

A

Protuberant, distended

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2
Q

How would you chart about an abdomen that is
hard and board like

A

Hard, rigid, distended, tympanic, taut

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3
Q

How would you chart about an abdomen that is
soft, flabby

A

relaxed, flaccid

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4
Q

How would you chart about an abdomen that is
filled with gas

A

tympanic, flatulent

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5
Q

How would you chart about an abdomen that
hangs down

A

Pendulous

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6
Q

How would you chart
large amounts of drainage

A

profuse, copious

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7
Q

How would you chart
medium amounts of drainage

A

moderate

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8
Q

How would you chart
small amount of drainage

A

scant

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9
Q

How would you chart
Hunchback

A

Kyphosis

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10
Q

How would you chart about the
small of back

A

lumbar region

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11
Q

How would you chart about
Swayback

A

lordosis

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12
Q

How would you chart
nose bleed

A

epistaxis

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13
Q

How would you chart
blood in urine

A

humaturia

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14
Q

How would you chart
spitting up blood

A

hemoptysis

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15
Q

How would you chart
positive blood in stool

A

guaiac positive

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16
Q

How would you chart
“unpleasant” breath

A

halitosis

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17
Q

How would you chart
“foul” breath

A

fetid

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18
Q

How would you chart
breath with sweet fruit like odor

A

fruity,sweet

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19
Q

How would you chart
urinous odor — in breath

A

odor of ammonia

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20
Q

How would you chart
breathing

A

respiration

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21
Q

How would you chart
difficult breathing

A

dyspnea

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22
Q

How would you chart
short periods when breathing has ceased

A

Apnea

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23
Q

How would you chart
inability to breath while lying down

A

Orthopnea

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24
Q

How would you chart
rapid breathing

A

Hyperpnea

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25
How would you chart increasing dyspnea with periods of apnea
Cheyne-stokes respiration
26
How would you chart consciousness that is: alert, full conscious, oriented to date, time, place
Alert, fully conscious
27
How would you chart consciousness that is: only partly conscious
semi-conscious
28
How would you chart consciousness that is: unconscious, but can be aroused
stuporous
29
How would you chart consciousness that is: unconscious, cannot be aroused
comatose
30
How would you chart type of cough (name the types of coughs)
continuous, persistent, productive, nonproductive, dry, hacking
31
How would you chart a cough: occuring in spasms
spasmodic
32
How would you chart a cough: occurring in spasms
spasmodic
33
How would you chart coughing up or expectoration of blood
Hemoptysis
34
How would you chart dead tissue
tissue, necrosis, nercrotic
35
How would you chart frequent liquid defication
Diarrhea
36
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,
37
How would you chart constituents of stool
1. Liquid 2. soft 3. Hard formed 4. watery, 5. Semi formed 6. constipated 7. Undigested foods 8. Mucoid
38
How would you chart containing pus
Purulent
39
How would you chart bloody drainage
sanguineous
40
How would you chart drainage of lymphatic fluid
serous
41
How would you chart drainage that is tough, sticky
tenacious
42
How would you chart bloody, lymphatic (serous) drainage
serosanguinous
43
How would you chart swelling in extremities, after depressing for 5 seconds & it is indented 2mm
1+ edema
44
How would you chart swelling in extremities, after depressing for 5 seconds & it is indented 4mm
2+ edema
45
How would you chart swelling in extremities, after depressing for 5 seconds & it is indented 6mm
3+ edema
46
How would you chart swelling in extremities, after depressing 5 seconds & it is indented 8mm
4+ edema
47
How would you chart emesis that is produced by conscious effort of patient
Induced
48
How would you chart emesis that is ejected a few feet distance
projectile
49
How would you chart emesis that blood is noticeable
Hematemesis
50
How do you chart Sharpness of vision
visual acuity
51
How do you chart Yellow in color (in the eyes)
Jaundiced
52
How do you chart puffy, swollen eyes
edematous
53
How do you chart drooping eyelids
Ptosis of lids
54
How do you chart Unusually sensitive to light
photophobia
55
How do you chart double vision
Diplopia
56
How do you chart cross eye, squinting
Strabismus
57
How do you chart abnormal protrusion of eyeball
exophthalmos
58
How do you chart inflammation of conjunctiva
conjunctivitis
59
How do you chart dilatation of the pupil
myosis, pupil constricted, pin point
60
How do you chart near-sightedness
myopia
61
How do you chart far-sighteness
hyperopia
62
How do you chart fainting
syncope
63
How do you chart without fever
Afebrile
64
How do you chart temperature above normal
pyrexia
65
How do you chart temperature greatly above normal
hyperpyrexia
66
How do you chart forehead
frontal region
67
How do you chart region over temple
temporal region
68
How do you chart back of head
occipital region
69
How do you chart base of skull
basilar region
70
How do you chart having a large head
macrocephaly, hydrocephaly
71
How do you chart having a small head
microcephalus
72
How do you chart top of head
Parietal (right or left)
73
How do you chart hives
Urticaria
74
How do you chart itching
pruritus
75
How do you chart bending (of joints)
flexion
76
How do you chart straighten (of joints)
extension
77
How do you chart revolve around (joints)
rotation
78
How do you chart move away from median line
abduction
79
How do you chart move toward median line
adduction
80
How do you chart blue in color
cyanotic
81
How do you chart my mouth (meds)
orally
82
How do you chart by rectum (meds)
rectally
83
How do you chart breathing in (meds)
inhalation
84
How do you chart rubbing into skin (meds)
topically
85
How do you chart under the skin
subcutaneous
86
How do you chart within the skin
intradermal
87
How do you chart within the muscle
intramuscular
88
how do you chart within the spinal canal
intraspinal, intrathecal
89
How do you chart within the vein
intravenous
90
How do you chart pouring into body cavity
instillation
91
How do you chart a menstrual period that is present when admitted
menses present
92
How do you chart painful (menstruation)
dysmenorrhea
93
How do you chart total absence of menstruation
amenorrhea
94
How do you chart profuse or prolonged flow
menorrhagia
95
How do you chart cessation of (menstruation)
menopause
96
How do you chart very unpleasant odor
offensive, foul
97
How do you chart paralysis of the muscle of the face
Facial paralysis
98
How do you chart paralysis of the legs
paraplegia
99
how do you chart paralysis of one side of the body
hemiplegia
100
How do you chart paralysis of a single limb
monoplegia
101
How do you chart paralysis of all four extremities & usually the trunk
quadraplegia
102
How do you chart large amount of profuse (perspiration)
diaphoresis, diaphoretic
103
How do you chart flat on back, arms straight at sides (position)
supine
104
How do you chart on side, knees flexed
lateral
105
How do you chart on left side, left arm behind back, left leg slightly flexed, right leg greatly flexed
Sims (left or right)
106
How do you chart head of bed semi- erect
semi-fowlers 40-45-- modified knees & legs not flexed
107
How do you chart On back, buttocks near edge of table, knees well flexed and separated
lithotomy
108
How do you chart resting on knees and chest
knee-chest
109
How do you chart prone with hips over break in table and feet below level of head?
jackknife
110
How do you chart On back, pelvis and legs higher than head
Trendelenburg
111
How do you chart number of beats per min
rate
112
How do you chart on abdomen, face turned to one side
prone
113
How do you chart rhythm
regular or irregular, coupling, galloping
114
How do you chart beats missed at intervals
intermittent
115
How do you chart >100 beats per minute (bpm)
rapid, fast, tachycardia
116
How do you chart slow in rate <50 bpm
slow, bradycardia
117
How do you chart only scarcely perceptible
thready, weak
118
How do you chart pulseless
imperceptible, absent
119
How do you chart pulse strength
1. 0 = absent, not palpable, inaudible with doppler 2. 1+ = diminished/palpable 3. 2+ = expected/normal 4. 3+ = strong/full pulse 5. 4+ = bounding, can't be obliterated
120
How do you chart normal skin
healthy, normal for race
121
How do you chart blue in color (skin)
cyanotic, mottled
122
How do you chart very white
extreme pallor, ashen
123
How do you chart redness
erythema
124
How do you chart shines
glossy
125
How do you chart raw surface
excoriation
126
How do you chart yellow in color
Jaundiced
127
How do you chart containing colored area
pigmented
128
How do you chart scraped
abraded, denuded
129
How do you chart cold and moist
clammy
130
How do you chart not understandable
incoherent
131
How do you chart meaningless, wondering
rambling
132
How do you chart words run together
slurring
133
How do you chart difficultly speaking
dysphasia
134
How do you chart unable to speak
aphasia
135
How do you chart difficulty in swallowing
dysphagia
136
How do you chart inability to swallow
aphagia
137
How do you chart other descriptive terms related to throat
red, swollen, inflamed, ulcerated
138
How do you chart descriptive terms related to tongue
pink, moist, dry, cracked, swollen, coated, inflamed, ulcerated
139
How do you chart to urinate
voiding, micturate
140
How do you chart no control over urination
incontinence
141
How do you chart large amount of urine voided
diuresis
142
How do you chart total suppression of urine
anuria
143
How do you chart frequent voiding of urine at night
nocturia
144
How do you chart increased amount voided
polyuria
145
How do you chart painful urine
dysuria
146
How do you chart pus in urine
pyuria
147
How do you chart blood in urine
hematuria
148
How do you chart scantiness of urine
oliguria
149
How do you chart sugar in urine
glycosuria
150
How do you chart overweight
obese
151
How do you chart abnormal thinness
emaciated, wasting
152
How do you chart very underweight
cachectic
153
How do you chart discharging pus
suppurating, purulent
154
How do you chart black or gray necrotic tissue
eschar
155
How do you chart wound drainage
exudate