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Scribe > Initial Exam > Flashcards

Initial Exam Flashcards

1
Q

Abrasion

A

Scrape of the skin due to something abrasive

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2
Q

Acute

A

New, usually of rapid onset and of concern, opposite of chronic

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3
Q

Anterior

A

Located towards the front of the body

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4
Q

Benign

A

Normal, of no danger to health

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5
Q

Bradycardia

A

Slow heart-rate (HR less than 60BPM)

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6
Q

Cardiomegaly

A

Enlarged heart

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7
Q

Cholecystitis

A

Inflammation of the gallbladder

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8
Q

Coronary Artery

A

The artery that supplied heart tissue with blood

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9
Q

Diaphoresis

A

Sweating

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10
Q

Dyspnea

A

Problems with breathing

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11
Q

Dysuria

A

Painful urination

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12
Q

Ecchymosis

A

A bruise

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13
Q

Edema

A

Swelling

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14
Q

Emesis

A

Vomiting

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15
Q

Epistaxis

A

Nose bleed

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16
Q

Erythema

A

Redness/red

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17
Q

Grossly

A

Obviously

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18
Q

Hematemesis

A

Verge amount of blood in the vomit

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19
Q

Hematuria

A

Very large amount of blood in the urine

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20
Q

Hemoptysis

A

Coughing up large amounts of blood

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21
Q

Hepatomegaly

A

Enlarged liver

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22
Q

Infarct

A

Area of dead tissue after a lack of blood supply

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23
Q

Ischemia

A

Lack of blood supply

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24
Q

Laceration

A

Splitting of skin due to trauma

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25
Q

Melena

A

Black tarry stool

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26
Q

Myocardial Infarction (MI)

A

Death of cardiac muscle due to ischemia

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27
Q

Myalgia

A

Muscular pain

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28
Q

Oriented X3

A

Oriented to person, place and time

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29
Q

Pallor

A

Pale skin

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30
Q

Pulmonary embolism (PE)

A

Blocking of a pulmonary artery due to a blood clot

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31
Q

Purulent

A

Pus-like

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32
Q

Rales

A

Crackles; wet crackling noise in the lungs

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33
Q

Rhinorrhea

A

Clear nasal discharge, “runny nose”

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34
Q

Ronchi

A

Rattling noise of mucous in the lungs

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35
Q

Sepsis

A

Dangerous infection of the blood

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36
Q

STEMI

A

ST elevation MI, real-time ongoing death of heart tissue due to ischemia

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37
Q

Syncope

A

“Passing out”, loss of consciousness or fainting

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38
Q

Tachycardia

A

Fast heart rate (HR greater than 100 BPM)

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39
Q

Tachypnea

A

Increased breathing rate

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40
Q

Transient Ischemic Attack (TIA)

A

Minor stroke, where neurological function is regained quickly with time

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41
Q

Vertigo

A

Conditions of dizziness, “room spinning”

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42
Q

Wheezing

A

High pitched sound heard in the lungs of asthmatics or lung disease

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43
Q

Ā

A

Before

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44
Q

AAA

A

abdominal aortic aneurysm

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45
Q

Abx

A

Antibiotics

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46
Q

AMA

A

Against Medical Advice

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47
Q

AMS

A

Altered Mental Status

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48
Q

ASA

A

Acetylsalicylic acid (aspirin)

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49
Q

BID

A

Twice daily

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50
Q

Bilat LE

A

Bilateral lower extremities

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51
Q

BM

A

Bowel movement

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52
Q

BP

A

Blood pressure

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53
Q

c(bar)

A

With

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54
Q

CA

A

Cancer, carcinoma

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55
Q

CABG

A

Coronary Artery Bypass Graft

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56
Q

CAD

A

Coronary Artery disease

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57
Q

CT or CAT

A

Computerized assisted tomography

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58
Q

CHF

A

Congestive heart failure

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59
Q

COPD

A

Chronic obstructive pulmonary disease

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60
Q

CP

A

Chest pain

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61
Q

CPR

A

Cardiopulmonary resuscitation

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62
Q

C-section

A

Caesarian section

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63
Q

CSF

A

Cerebrospinal fluid

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64
Q

CVA

A

Cerebrovascular accident or costovertebral angle

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65
Q

CXR

A

Chest x-ray

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66
Q

C/o

A

Complains of

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67
Q

C-spine

A

Cervical spine

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68
Q

DKA

A

Diabetic ketoacidosis

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69
Q

DM

A

Diabetes Mellitus

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70
Q

DNR

A

Do not resuscitate

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71
Q

DOE

A

Dyspnea of Exertion

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72
Q

DVT

A

Deep vein thrombosis

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73
Q

Dx

A

Diagnosis

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74
Q

Dz

A

Disease

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75
Q

EKG/ECG

A

Electrocardiogram

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76
Q

EtOH

A

Alcohol

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77
Q

FHx

A

Family history

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78
Q

Fx

A

Fracture

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79
Q

GI

A

Gastrointestinal

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80
Q

G/P/Ab

A

Gravida/Para/abortion

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81
Q

GSW

A

Gun Shot Wound

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82
Q

GU

A

Genitourinary

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83
Q

HA

A

Headache

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84
Q

HEENT

A

Head, eyes, ears, nose, throat

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85
Q

HPI

A

History of present illness

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86
Q

HTN

A

Hypertension

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87
Q

Hx

A

History

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88
Q

H&H

A

Hemoglobin and hematocrit

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89
Q

H&P

A

History of present illness and physical exam

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90
Q

I&D

A

Incision and drainage

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91
Q

IDDM

A

Insulin dependent Diabetes mellitus

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92
Q

IUP

A

Intrauterine pregnancy

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93
Q

IVDA

A

IV drug abuse

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94
Q

JVD

A

Jugular vein distension

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95
Q

LLE

A

Left lower extremity

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96
Q

LLQ

A

Left lower quadrant

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97
Q

LNMP

A

Last normal menstrual period

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98
Q

LOC

A

Loss of consciousness

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99
Q

LP

A

Lumbar puncture

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100
Q

LUE

A

Left upper extremity

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101
Q

LUQ

A

Left upper quadrant

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102
Q

MCA

A

Motorcycle accident

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103
Q

MI

A

Myocardial infarction

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104
Q

MVA/MVC

A

Motor vehicle accident/collision

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105
Q

N/A

A

Not applicable

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106
Q

NAD

A

No acute distress, No acute disease

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107
Q

NIDDM

A

Non-insulin diabetes mellitus

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108
Q

NKDA

A

No known drug allergies

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109
Q

Nml or nl

A

Normal

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110
Q

NSAID

A

Non steroid Anti-inflammatory drug

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111
Q

NSR

A

Normal sinus rhythm

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112
Q

NTG

A

Nitroglycerin

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113
Q

N/V/D

A

Nausea/vomiting/diarrhea

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114
Q

O2 sat

A

Oxygen saturation (Sa02)

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115
Q

OD

A

Overdose

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116
Q

P(bar)

A

Post, after

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117
Q

PCP

A

Primary care physician

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118
Q

PE

A

Pulmonary embolism

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119
Q

PERRL

A

Pupils are equal, round and reactive to light

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120
Q

PO

A

Per Os (by mouth)

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121
Q

Prn

A

As needed

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122
Q

Pt

A

Patient

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123
Q

PTA

A

Prior to arrival

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124
Q

qd

A

Every day

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125
Q

qh

A

Every hour

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126
Q

qhs

A

At every bedtime

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127
Q

q2h

A

Every 2 hours

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128
Q

QID

A

Four times a day

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129
Q

RLE

A

Right lower extremity

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130
Q

RLQ

A

Right lower quadrant

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131
Q

ROM

A

Range of motion

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132
Q

ROS

A

Review of symptoms

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133
Q

RUE

A

Right upper extremity

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134
Q

ROS

A

Review of symptoms

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135
Q

RUE

A

Right upper extremity

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136
Q

RUQ

A

Right upper quadrant

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137
Q

Rx

A

Prescription

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138
Q

r/o

A

Rule out

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139
Q

s(bar)

A

Without

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140
Q

SOB

A

Shortness of breath

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141
Q

s/p

A

Status post

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142
Q

Sx

A

Symptoms

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143
Q

TIA

A

Transient ischemic attack

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144
Q

TID

A

Three times a day

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145
Q

TM

A

Tympanic membrane

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146
Q

Tx

A

Treatment

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147
Q

UA

A

Urinalysis

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148
Q

URI

A

Upper respiratory infection

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149
Q

US

A

Ultrasound

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150
Q

UTD

A

Up to date

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151
Q

UTI

A

Urinary tract infection

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152
Q

WNL

A

Within normal limits

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153
Q

IV

A

Intravenous

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154
Q

IVP

A

Intravenous push

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155
Q

IVPB

A

Intravenous piggy-back

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156
Q

IM

A

Intramuscular

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157
Q

SQ

A

Subcutaneous

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158
Q

PO

A

Per os

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159
Q

PR

A

Per rectum

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160
Q

SL

A

Sub-lingual

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161
Q

gtt

A

Drops

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162
Q

Drip

A

Intravenous Drip

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163
Q

Neb

A

Inhaled Nebulizer

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164
Q

Patch

A

Transdermal

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165
Q

What order do you write medication orders?

A

Medication name > Dosage or strength > Route

Morphine 2.5mg IVP

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166
Q

Anasarca

A

Total body swelling

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167
Q

Auscultation

A

Listening with the stethoscope

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168
Q

Baseline

A

The normal state of being for each specific patient

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169
Q

Differential diagnosis

A

The disease that a physician is considering as the reason for the patients sx

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170
Q

Fundus

A

The bottom aperture of the internal surface of a hallow organ; often referring to the uterus it eye.

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171
Q

Hypertension

A

Persistently high atrial blood pressure (typically>140/90)

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172
Q

Hypotension

A

Persistently low atrial blood pressure (<100/65)

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173
Q

Os

A

Any body orifice

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174
Q

Palpable

A

Able to he touched or easily perceived

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175
Q

Rupture

A

The breaking-open of a bodily structure

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176
Q

Avulsion

A

A forcible pulling away of a part or structure

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177
Q

Crepitus

A

A crackling or gating sound usually of bones

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178
Q

Effusion

A

Escape of fluid into a cavity

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179
Q

Hemangioma

A

Tumor consisting of blood vessels

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180
Q

Stellate

A

Star-shaped, radiating from the center

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181
Q

Acute in chronic

A

New exacerbation of a chronic condition

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182
Q

Fluctuating

A

Symptoms that are always present but changing in severity, never fully resolving.

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183
Q

Intermittent

A

Symptoms that completely resolve at times but continue to return repeatedly

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184
Q

Paroxysmal

A

Occasional, sporadic, transient

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185
Q

Resolved

A

Gone, no longer existing

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186
Q

Transient

A

Resolving spontaneously after onset

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187
Q

Ambulatory

A

Able to move about, not confined to bed.

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188
Q

Articulation

A

Connection between bones, joints

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189
Q

Caudal

A

Toward the feet

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190
Q

Cephalad

A

Towards the head

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191
Q

Diffuse

A

Spread out over a wide area

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192
Q

Doesiflexion

A

Backward flexion, as in bending backward either a hand or foot is

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193
Q

Everted

A

Turned outward

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194
Q

Extension

A

Straightening out

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195
Q

Flexion

A

Bending or angulation

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196
Q

Frontal/coronal plane

A

Divides the body into anterior and posterior parts

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197
Q

Inverted

A

Turned inward

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198
Q

Lateral

A

Farther from the midline

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199
Q

Levator

A

That which raises

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200
Q

Midline

A

Divides the body into left and right

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201
Q

Palmer or volar

A

Palm side of hand or body

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202
Q

Plantar

A

Palm side of foot

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203
Q

Posterior or dorsal

A

Rear or back

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204
Q

Pronator

A

That which turns palm of hand downward

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205
Q

Prone

A

Body position lying face down with forearms and hands turned palm side down

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206
Q

Radial aspect

A

Pertaining to the radial (lateral) side of the arm

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207
Q

Supinator

A

That which turns palm of hand upward

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208
Q

Supine

A

Body position lying face up

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209
Q

Transverse plane

A

Decided the body into upper and lower portions

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210
Q

Ulnar aspect

A

Pertaining to the ulnar (medial) side of an arm

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211
Q

Afebrile

A

Without fever

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212
Q

Alert

A

Looking around, awake, attentive

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213
Q

Body habitus

A

The state of the patients body, often referring to obesity

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214
Q

Cachectic

A

Extremely skinny, bony, malnourished

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215
Q

Combative

A

Aggressively uncooperative

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216
Q

Constitutional

A

The general appearance and nature of a patient

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217
Q

Dehydrated

A

General appearance of lacking water, dry lips, dry mucosa

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218
Q

Distress

A

A patients inability to tolerate their body-state, due to pain or respiratory failure.

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219
Q

Elderly

A

Appearing old

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220
Q

Emaciated

A

Extremely thing and malnourished, wasting

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221
Q

Febrile

A

Elevated body temperature, fever, indicative of infection

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222
Q

Ill appearing

A

Not appearing healthy

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223
Q

Inconsolable

A

When an infant or baby cannot be made to stop crying

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224
Q

Morbidly obese

A

Extremely overweight

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225
Q

Non-toxic

A

Appearing stable and at no risk of deterioration

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226
Q

Somnolent

A

Appearing drowsy

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227
Q

Tearful

A

The state of crying, or being about to cry

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228
Q

Unkempt

A

Poor self-hygiene

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229
Q

Well developed

A

Normal state of mental and body development

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230
Q

Atraumatic, normocephalic

A

ATNC; normal external head inspection

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231
Q

Battles sign

A

Brushing behind the ears, indicative of a basilar skull fracture

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232
Q

Cephalgia

A

Headache

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233
Q

Encephalopathy

A

Disease of the brain

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234
Q

Facial angioedema

A

Swelling of the face often secondary to an allergic reaction

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235
Q

Fontanel

A

The forehead and the anterior top of the skull

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236
Q

Meningitis

A

Infection of the meninges, the membranes that contain the brain and the spinal cord

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237
Q

Occipital/occiput

A

The most posterior part of the skull, the back of the head

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238
Q

Parietal

A

Location across the posterior top of the skull

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239
Q

Raccoon eyes

A

Bruising around the eyes; indicative of basilar skull fracture

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240
Q

Sinusitis

A

Infection of the sinuses, usually causing sinus pressure

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241
Q

Temporal

A

The sides of the head, near the temples

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242
Q

Ansicoria

A

Unequal diameter of pupils

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243
Q

Conjunctiva

A

Thin outer lining if the eye and eyelid

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244
Q

Conjunctival exudate

A

Pus in the eye

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245
Q

Cornea

A

Transparent frontal aspect of the eye, covering both the iris and pupil

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246
Q

Diplopia

A

Diagnosis of double vision

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247
Q

EOMI

A

Extra ocular muscles intact

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248
Q

Fluorescein uptake

A

Demonstrates the presence of a corneal abrasion

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249
Q

Fluorescein

A

Orange/yellow eye drops used to detect corneal lesions, abrasions, or foreign bodies

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250
Q

Funduscopic exam

A

The use of an ophthalmoscope to look through the pupil and examine the interior surface of the posterior eye

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251
Q

Fundus of the eye

A

Interior surface of the eye

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252
Q

Hyphema

A

Blood in the anterior chamber of the eye, seen during the funduscopic exam

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253
Q

Lacrimal

A

Referring to tears

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254
Q

Nystagmus

A

Involuntary “shaking” eye movements, rather than normal continuous smooth motion

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255
Q

Opthalmalgia

A

Pain in the eye

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256
Q

Pale conjunctiva

A

Pale inner lining of the eyelid, most often due to anemia

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257
Q

Papilledema

A

Swelling of the optic disk due to increased intracranial pressure, seen funduscopically

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258
Q

Periorbital ecchymosis

A

Bruising around the eyes, indicative of trauma

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259
Q

Photophobia

A

Light sensitivity

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260
Q

Raccoon eyes

A

Bruising around the eyes, indicative of basilar skull fracture

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261
Q

Sclera

A

Dense, fibrous, opaque outer coat enclosing the eyeball except the part covered by the cornea

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262
Q

Sclera ictus

A

Yellowing of the sclera due to jaundice

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263
Q

Stye/hordeolum

A

Small infected bump of the eyelid, usually in between the eyelash hairs

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264
Q

Subconjunctival hemorrhage

A

Blood in the white part of the eye

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265
Q

Sunken eye

A

Sign of dehydration

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266
Q

Auricle

A

External portion of the ears

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267
Q

Cerumen

A

Earwax

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268
Q

Labyrinthitis

A

Infection of the deep inner ear, known as the labyrinth. Often causes vertigo

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269
Q

Loss of landmarks

A

The TM is opaque, no longer transparent. Indicates ear infection

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270
Q

Otalgia

A

Ear ache

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271
Q

Otitis media

A

Middle ear infection

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272
Q

Tinnitus

A

“Ringing in the ears”, the perception of ringing even without an external stimuli

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273
Q

TM bulging

A

“Outpouching” of the TM, indicative of inflammation

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274
Q

TM dullness

A

Absence of light reflection, indicative of ear infection

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275
Q

TM erythema

A

Redness of the TM, often indicative of infection

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276
Q

TM perforation

A

Rupture if the eardrum

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277
Q

Tympanic Membrane

A

TM, the clear membrane inside the ear; ear drum

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278
Q

Epistaxis

A

Hemorrhage from the nose; nose bleeding.

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279
Q

Naris

A

Nostril (pleural is nares)

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280
Q

Septal hematoma

A

Bruise/swelling of the septum (sign of a nose fracture)

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281
Q

Decreased gag reflex

A

Indicative of decreased LOC or brain stem injury. Concern for airway protection.

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282
Q

Dentition

A

Teeth

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283
Q

Dry mucosa

A

Dry tongue, mouth, and lips, indicating significant dehydration.

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284
Q

Edentulous

A

Without teeth

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285
Q

Gingiva

A

Gums

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286
Q

Lingual

A

Referring to the tongue

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287
Q

Malocclusion

A

Imperfect closure of opposing teeth, indicative of trauma or jaw fracture

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288
Q

Nasopharynx

A

The far back of the nasal canal, where it joins the back of the throat

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289
Q

Odontalgia

A

Painful swallowing

290
Q

Oropharynx

A

The back of he mouth, where it meets the throat

291
Q

Peritonsilar abscess

A

Collection of pus or fluid around the tonsils

292
Q

Pharyngeal erythema

A

Redness of the pharynx, indicating a throat infection

293
Q

Pharyngitis

A

Throat infection

294
Q

Secretion pooling

A

Poor ability to handle secretions (saliva): drooling at the mouth and gagging

295
Q

Tacky mucosa

A

Sticky tongue, mouth, and lips indicating early dehydration

296
Q

Tonsillar edema

A

Swelling of the tonsils, indicating infection

297
Q

Tonsillar exudate

A

Pus on the tonsils, indicating infection of the tonsils

298
Q

Trismus

A

Inability to fully open mouth due to inflamed jaw muscles

299
Q

Uvula midline

A

Uvula in normal position (not shifted)

300
Q

Brudzinski’s sign

A

Neck pain elicited by flexing neck. Hips and knees flex in response to the neck being flexed. Sign of meningitis.

301
Q

C-spine

A

Cervical spine (C1-C7)

302
Q

Carotid bruit

A

Turbulent blood flow heard with auscultation over the carotid artery (Due to carotid narrowing or plaque)

303
Q

Jugular vein distention

A

JVD, sign of CHF

304
Q

Kernig’s sign

A

Neck pain elicited by flexing the hip. Stiff hamstrings/inability to straighten the leg when hip is flexed, sign of meningitis

305
Q

Lymphadenopathy

A

Enlarged lymph nodes

306
Q

Meningismus

A

Stiff neck/signs of meningitis

307
Q

Paraspinal tenderness

A

Tenderness of the muscles next to he vertebrae

308
Q

Supple

A

Flexible, free moving, not-stiff

309
Q

Thyromegaly

A

Enlarged thyroid

310
Q

Trachea midline

A

No deviation of trachea (deviates to unaffected side in pneumothorax)

311
Q

Vertebral tenderness

A

Bony tenderness directly over the vertebrae

312
Q

Aortic aneurysm

A

Diagnosis in which the arterial wall splits apart

313
Q

Arrhythmia

A

Disturbance of rhythm in the heartbeat

314
Q

Aortic rupture

A

Diagnosis in which arterial wall breaks open as could happen in aortic dissection, ruptured aortic aneurysm trauma

315
Q

Atrial fibrillation

A

Irregular beating of the atria; indicates that the sinus node is not conducting a normal sinus rhythm; “a fib”

316
Q

Atrial flutter

A

Irregular beating of the atria; often describes as “a-flutter with 2 to 1 block or 3 to 1 block”

317
Q

Atrial septal defect

A

ASD, a hole in the atrial septum the allows atrial blood to mix

318
Q

Cardiac ischemia

A

Decreased blood flow through the coronary arteries and to the heart. Usually diagnosed by ST segment depressions on EKG

319
Q

Cardiomyopathy

A

Disease of the heart muscles

320
Q

Extra systoles

A

Extra beats of the heart heard during auscultation

321
Q

Friction rub

A

Described as hearing, scratching sound of the heart. Indicative of pericarditis

322
Q

Gallop

A

Three or four sounds resembling the sounds of a gallop

323
Q

Irregularly irregular

A

Heart rhythm of anyone with a fib

324
Q

Murmurs

A

Abnormal heart sound rated on 1-6 scale

325
Q

Myocardial infarction

A

Death of cardiac muscle due to prolonged ischemia when blood flow through the coronary artery is obstructed

326
Q

Myocarditis

A

Inflammation of the heart muscle

327
Q

NSTEMI

A

Non ST segment elevation MI; a heart attack that is not diagnosed on the EKG, but is diagnosed by elevated troponin levels in blood tests

328
Q

Pericardial tamponade

A

Diagnosis due to fluid in the pericardium that exerts pressure on the heart and hampers its ability to contract normally

329
Q

Pericarditis

A

Inflammation of the pericardium evidenced on physical exam by the presence of a friction run on heart auscultation

330
Q

Pulse exam

A

Carotid, brachial, radial, femoral, popliteal, dorsal pedis (DP) or posterior tibia (PT)

331
Q

STEMI

A

ST elevation myocardial infarction, when the EKG shows “ST segment elevation” it indicated an acute heart attack.

332
Q

Ventricular fibrillation

A

Irregular beating of the ventricles; this a terminal even that requires immediate electrical cardioversion

333
Q

Valvular vegetation

A

An infectious growth on the cardiac valves

334
Q

Ventricular septal defect (A VSD)

A

A hole in the ventricular septum that causes blood to mix between the RV and LV

335
Q

Ventricular wall thrombus

A

A blood clot that attaches to the inside wall of the ventricle; pieces of the thrombus can break off and spread to anywhere in the body leading to infractions.

336
Q

Aneurysm

A

Localized ballooning of a vessel due to a weekend vessel wall

337
Q

Bruit

A

A whooshing sound heard during auscultation indicative of a blockage of aneurysm

338
Q

Dissection

A

Blood flow into the wall layers of an artery causing the arterial walls to split apart

339
Q

Deep vein thrombosis

A

DVT; deep clot in the extremity

340
Q

Embolism

A

Obstruction of blood vessels by a revamping clot of blood or foreign substance

341
Q

Hemangioma

A

Tumor consisting of blood vessels

342
Q

Stenosis

A

Narrowing of a body opening or passage

343
Q

Thrombus

A

Blood clot or blockage

344
Q

Vein

A

Vessel carrying blood towards the heart, soft, compressible

345
Q

Accessory muscle use

A

Struggling for breath using extra muscles in addition to the diaphragm

346
Q

Asthma

A

Construction of the airways due to muscular contraction of the bronchioles

347
Q

Atelectasis

A

Collapse of the alveoli in the lungs due to disease or poor inspiration

348
Q

Bradypnea

A

Decreased respiratory rate

349
Q

Bronchiolitis

A

Inflammation/infection of the bronchioles

350
Q

Bronchitis

A

Infection/inflammation of the bronchi

351
Q

COPD

A

Chronic obstructive pulmonary disease

352
Q

Dullness on percussion

A

Fluid or mass under area being percussed

353
Q

Hemoptysis

A

Coughing up blood

354
Q

Hemothorax

A

Blood in the pleural cavity

355
Q

Hyperventilation

A

Breathing too fast A.K.A. Behavioral breathlessness or psychogenic dyspnea

356
Q

Nasal flaring

A

Enlargement of the nostrils during breathing

357
Q

Prolonged expiration

A

Exploratory phase that is markedly longer than the inspiratory phase. Heard in asthmatics

358
Q

Pulmonary embolus

A

Blockage of the pulmonary artery or one of its branches due to a trans located clot

359
Q

Pleurisy

A

Pain while breathing

360
Q

Pneumothorax

A

Presence of air or gas in the pleural space; collapsed lung

361
Q

Pneumonia

A

Infiltrate (infection) inside lung tissue

362
Q

Retractions

A

Visible sinking of the area between the ribs and in the neck during inhalation (respiratory distress)

363
Q

Splinting

A

Avoiding deep inspirations due to increased pain white breathing

364
Q

Sputum

A

Matter coughed up from the lower airways

365
Q

Stridor

A

Upper respiratory rate, common sign in croup

366
Q

Tachypnea

A

Increased respiratory rate, greater than 20 respiration per minutes.

367
Q

Bowel sounds

A

Intestinal sounds heard from auscultation from over the abdomen; hyperactive, hypoactive, diminished, absent, tympanic

368
Q

Cholecystitis

A

Inflammation of the gallbladder

369
Q

Cholelithiasis

A

Production of gallstones

370
Q

Cirrhosis

A

Scaring of the liver tissue affecting the livers ability to function

371
Q

Crohn’s/colitis

A

Types of chronic inflammatory

372
Q

Diffuse

A

Generalized; not localized to any specific location

373
Q

Distension

A

Enlarged or swollen due to internal pressure

374
Q

Diverticulitis

A

Acute inflammation of the diverticular pouches

375
Q

Diverticulosis

A

Formation of diverticuli; pouches in the colon wall

376
Q

Dunphy’s sign

A

Increased pain with coughing

377
Q

Dyspepsia

A

Indigestion

378
Q

Dysphagia

A

Difficulty swallowing

379
Q

Epigastric

A

Upper central region of the abdomen

380
Q

Gastroenteritis

A

General term for inflammation of the GI tract

381
Q

Guarding

A

Tensing of abdominal wall muscles as to guard the internal organs indicative of true abdominal disease

382
Q

Hematemisis

A

Vomiting of blood

383
Q

Hematochezia

A

Bright red blood in the stool

384
Q

Hepatitis

A

Inflammation of the liver

385
Q

Hepatomegaly

A

Enlarged liver

386
Q

Hernia

A

Contend of body cavity bulge out of the area where they are normally contained

387
Q

Ileus

A

Lack of muscular contraction in the intestine leading to disruption of bowel passage air/fluid levels in abdominal x-ray

388
Q

Inguinal

A

Pertaining to the groin region

389
Q

Intussusception

A

One portion of the intestines slides into the next, much like the pieces of a telescope

390
Q

Mass

A

Any abdominal enlargement

391
Q

McBurney’s point

A

RLQ point (1/3 of the way from ASIS to the umbilicus) tenderness indicative of appendicitis

392
Q

Melena

A

Black tarry stool indicative of a GI bleed

393
Q

Murphy’s sign

A

Pain with palpating of the RUQ during inspiration, indicative of cholecystitis

394
Q

Obturator sign

A

RLQ on internal rotation of right thigh indicative of appendicitis

395
Q

Organomegaly

A

Enlarged organ

396
Q

Pancreatitis

A

Inflammation of the pancreas

397
Q

PUD

A

Peptic Ulcer disease; ulcers developing in the stomach causing pain and emesis

398
Q

Peritoneal signs

A

Rebound tenderness, guarding, or rigidity indicative of acute abdominal inflammation

399
Q

Peritonitis

A

Inflammation of the peritoneal (abdominal cavity)

400
Q

Psoas sign

A

RLQ pain with extension of right thigh indicative of appendicitis

401
Q

Prominent aortic pulsation

A

A larger than expected pulsating mass while palpating midline over the abdomen; indicates an aortic aneurysm

402
Q

Pulsatile mass

A

Strong pulse of midline abdomen, possible aortic aneurysm

403
Q

Rebound

A

Pain when releasing hand from abdominal palpation

404
Q

Rigidity

A

Stiffness of the muscles of the abdomen

405
Q

Rovsing’s sign

A

Pain in the RLQ with palpitation of the LLQ indicative of appendicitis

406
Q

Small bowel obstruction

A

SBO; acute blockage of the small intestine

407
Q

Scaphoid

A

Concave, sunken

408
Q

Splenomegaly

A

Enlarged spleen

409
Q

Suprapubic

A

Lower central region on the abdomen

410
Q

Tympany

A

A bell-like noise when tapping the abdomen

411
Q

Abortions

A

Number of terminated pregnancies, spontaneous or induced

412
Q

Adnexa

A

Appendages; in gynecology the ovaries and the Fallopian tubes

413
Q

Adnexal tenderness

A

Tenderness of the ovaries during the pelvic exam, indicative of an ovarian cyst or torsion

414
Q

Blood in the meatus

A

Blood at the urethral opening of a male; sign of trauma or hematuria

415
Q

Cervical os

A

The opening of the cervix; always will be closed unless passing tissue from the cervix

416
Q

Cervical motion tenderness

A

CMT; elicited by moving the cervix often indicative of PID

417
Q

CVA Tenderness

A

Costo-vertebral Angle tenderness; tenderness over the kidneys

418
Q

Dysmenorrhea

A

Painful mensturation

419
Q

Dyspareunia

A

Painful intercourse

420
Q

Ectopic pregnancy

A

Egg developing outside the uterus extremely dangerous due to risk of rupture

421
Q

Endometriosis

A

Presence of functioning endometrial tissues outside of the uterus

422
Q

Epididymitis

A

Inflammation of the epididymis

423
Q

Foley catheter

A

A tube inserted through the urethra to drain urine, often left in place

424
Q

Frequency

A

Urinating often

425
Q

GPA

A

Gravida, para, abortus

426
Q

GTPAL

A

Gravida, Term, preterm, abortions, living

427
Q

Gravid

A

The state of being pregnant

428
Q

Gravida

A

Number of total pregnancies

429
Q

Hematuria

A

Blood in the urine

430
Q

Hydronephrosis

A

Swelling of the kidney due to acute blockage of the ureter

431
Q

Inguinal

A

Pertaining to the groin area

432
Q

Nephrolithiasis

A

Kidney stones; synonymous with dean calculi

433
Q

Ovarian torsion

A

Twisting of the ovarian Artery and vein

434
Q

Para

A

Number of viable live offspring born by a woman

435
Q

Pelvic inflammatory disease

A

PID; inflammation of a woman’s reproductive organs

436
Q

Products of conception

A

POC; tissue of an aborted fetus

437
Q

Polyuria

A

Urinating large amounts

438
Q

Pylenonephritis

A

Infection of the kidneys

439
Q

Retention

A

Inability to urinate

440
Q

Spotting

A

Passing very small amounts of blood from the vagina

441
Q

Straight catheter

A

A straight tube inserted to drain urine then immediately removed

442
Q

Testicular torsion

A

Twisting of the spermatic cord

443
Q

Urgency

A

Abrupt onset of urge to urinate

444
Q

Vaginal vault

A

The interior of the vagina

445
Q

Arthralgia

A

Pain in a joint

446
Q

Arthritis

A

Inflammation of the joints

447
Q

Atrophic

A

Showing signs of tissue degradation

448
Q

Avulsion fracture

A

Fragment of bone chipped away from the main bone

449
Q

Bony tenderness

A

Tenderness of the bone indicative of a fracture

450
Q

Boxer’s fracture

A

5th metacarpal fracture

451
Q

Comminuted fracture

A

Splintered and crushed bone broken into multiple fragments

452
Q

Compartment syndrome

A

Compression of the nerves and blood vessels

453
Q

Compound fracture

A

Open fracture; a fracture that penetrates the skin

454
Q

Costochondritis

A

Inflammation of the rib cartilage

455
Q

Deformity

A

Visual abnormality of a bone or anatomical structure

456
Q

Dislocation

A

Disconnected joint; complete misalignment of the joint

457
Q

Fascia

A

Fibrous membrane of connective tissue supporting and separating muscles and body organs

458
Q

Fracture

A

Broken bone

459
Q

Gout

A

Type of arthritis, diagnosed by ordering a Utica acid level

460
Q

Green stick fracture

A

Bone partially breaks and bends

461
Q

Impacted fracture

A

Broken bone smashed into another bone

462
Q

Intertrochanteric fracture

A

Fracture at the proximal end of the femur

463
Q

Malleolus

A

Bony prominence in each side of the ankle

464
Q

Multiple sclerosis

A

Autoimmune disease affecting the brain and spinal cord

465
Q

Myalgia

A

Muscular pain

466
Q

Olecranon

A

Large bony projection of the ulna forming the point of the elbow

467
Q

Osteomyelitis

A

Bone infection

468
Q

Paraspinal tenderness

A

Tenderness of the muscles beside the spine, not indicative of a fracture

469
Q

Radiculopathy

A

Compressed nerve in the spine

470
Q

Sciatica

A

Compression of the sciatic nerve causing back pain with radiation of posterior leg

471
Q

Straight leg raises

A

SLR; maneuver testing for sciatica

472
Q

Snuff box

A

Triangular indentation of the radial dorsal aspect of the hand

473
Q

Spiral fracture

A

Bone is broken in a twisting manner

474
Q

Step-offs

A

Misalignment of the spine indicative of a spinal fracture

475
Q

Subluxation

A

Partial dislocation

476
Q

Tenosynovitis

A

Inflammation of the tendon sheath

477
Q

Transverse fracture

A

Perpendicular break across the bone

478
Q

Vertebral point tenderness

A

Tenderness directly over the spine (vertebrae), increased likelihood of fracture

479
Q

Abrasion

A

Scrape of the skin due to something abrasive

480
Q

Abscess

A

A collection of pus beneath the skin

481
Q

Acne

A

Pimples

482
Q

Acne Vulgaris

A

Severe acne

483
Q

Adenopathy

A

Swelling of lymph-node, usually indicative of an infection distally

484
Q

Anascara

A

Total body swelling

485
Q

Avulsion

A

A forcible pulling away of a part or structure

486
Q

Cyanosis

A

Blue color of skin due to lack of oxygen

487
Q

Debridement

A

Removal of a foreign matter or dead tissue from a wound

488
Q

Dehiscence

A

Splitting apart or separation of skin often used to describe a surgical wound that has re-opened

489
Q

Dermis

A

Layer beneath the epidermis

490
Q

Dermatitis

A

Inflammation of the skin

491
Q

Dusky

A

Somewhat dark in color often indicative of poor circulation

492
Q

Eczema

A

Inflammation condition of the skin characterizes by scaly and I tachypnea rash. May include tiny vesicles with oozing and crusting

493
Q

Eczematous rash

A

Dry, scaly skin consistent with eczema

494
Q

Fluctuance

A

Palpable fluid beneath the skin indicative of infection/pus

495
Q

Folliculitis

A

Inflammation of the hair follicle

496
Q

Fungal rash

A

Commonly used to describe a type of rash caused by fungus like tinea

497
Q

Gangrene

A

Necrotic skin

498
Q

Hematoma

A

Raised area with underlying blood which occurs in tissues resulting from ruptured blood vessels

499
Q

Herpes simplex

A

Viral skin disease, often affecting the mouth or genital region

500
Q

Heroes zoster

A

Shingles, sinful red blisters

501
Q

Hirsute

A

Hairy

502
Q

Hyperpigmented

A

Darker than the surrounding skin

503
Q

Hypopigmented

A

Lighter than the surrounding skin

504
Q

Induration

A

Hardened area of tissue

505
Q

Keloid

A

Hypertrophic scar; raised scar

506
Q

Laceration

A

Cut in the skin due to trauma

507
Q

Lichenified

A

Thick skin with very deep lines

508
Q

Lymphadenopathy

A

Enlargement of a lymph node

509
Q

Lymphangitis

A

Inflammation of a lymphatic vessel; appears as red streaking

510
Q

Macerated

A

Skin softening breakdown often from being wet for a prolonged period of time

511
Q

Macular

A

Flat, red spots on the skin

512
Q

Maculopapular rash

A

Rash with a flat red area that also has raised bumps

513
Q

Mottled

A

Skin that is very poorly perfumes due to poor blood circulation

514
Q

Necrotizing fasciitis

A

Rapidly spreading inflammatory infection located in the deep fascia (presence of gas on X-ray)

515
Q

Papular

A

Raised bumps

516
Q

Petechial rash

A

Red or purple discolorations on the skin that do not blanch (lighten) with applied pressure (a sign of meningitis)

517
Q

Pitting edema

A

Edema that retains an imprint when touched

518
Q

Pruritic

A

Itchy

519
Q

Psoriasis

A

Autoimmune disease of the skin. Dry, scaly, red, itchy patches of skin

520
Q

Scarlantiniform rash

A

Coarse, sandpaper texture rash (streptococcus infection)

521
Q

Serosanguinous

A

Consisting of serum and blood

522
Q

Subungual

A

Beneath the nail

523
Q

Tenting

A

Slow return of the skin to its normal position after being pinched; a sign of dehydration or aging or both

524
Q

Turgor

A

Skin elasticity

525
Q

Urticarial rash

A

Hives; a red raised, and often itchy rash consistent with allergic reactions

526
Q

Vesicular rash

A

Vesicles; fluid filled blisters

527
Q

Vitiligo

A

Depigmentation of patches of skin

528
Q

Wheals

A

Urticarial; red, raised rash, consistent with allergic reactions

529
Q

Afferent pupillary defect

A

APD; an abnormal finding of dilation of the pupil instead of constriction in response to a shining light

530
Q

Aniscora

A

Unequal diameter of pupils

531
Q

Antalgic gait

A

Limping

532
Q

Aphasic

A

Inability to generate and understand language due to a damage to the brain. Either inability to create words (expressive aphasia) or understand words (receptive aphasia)

533
Q

Ataxia

A

Loss of coordination

534
Q

Babinski sign

A

The toes flex upward when sole of foot is stimulated, indicating motor nerve damage

535
Q

Bell’s Palsy

A

A localized facial nerve dysfunction that causes facial dropping and numbness

536
Q

Clonus

A

Involuntary muscle contractions and relaxations

537
Q

CN 1

A

Olfactory. Smell

538
Q

CN 2

A

Optic. Vision

539
Q

CN 3

A

Oculomotor. EOM

540
Q

CN 4

A

Trochlear hearing

541
Q

CN 5

A

Trigeminal. Sensation in face

542
Q

CN 6

A

Abducens

543
Q

CN 7

A

Accessory

544
Q

CN 8

A

Vestibulocochlear hearing.

545
Q

CN9

A

Glossopharyngeal. Gag reflex.

546
Q

CN 10

A

Vagus

547
Q

CN 11

A

Hypoglossal

548
Q

Decrease rectal tone

A

Diminished anal sphincter muscle contraction, indicative of neurological damage.

549
Q

Dysarthria

A

Poor mechanical articulation of speech due to abnormal lips, tongue and check motor function

550
Q

Dysphasia

A

Difficulty in neurologically generating or understanding language

551
Q

EOMI

A

Extraocular movements intact

552
Q

EOM palsy

A

Paralysis of the face

553
Q

Facial asymmetry

A

Dropping of one side of the face indication neurological damage

554
Q

Facial palsy

A

Paralysis of the face

555
Q

Finger-nose-finger

A

A test to evaluate cerebellar function

556
Q

Funduscopic exam

A

Inside of the as seen with ophthalmoscope looking for increased cranial pressure

557
Q

Grand mal seizure

A

Epileptic attack characterized by convulsions, stupor and temporary LOC

558
Q

Hemiparesis

A

Weakness of one half of the body

559
Q

Hemiplegia

A

Paralysis of one half of the body

560
Q

Moves all extremities

A

(MAEx4) the pt moves their arms and legs normally, indicating nml motor Function

561
Q

Neuralgia

A

Sharp pain along the course of a nerve or several nerves

562
Q

Normal DTRs

A

Normal deep tendon reflexes, rated 2/4

563
Q

Papilledema

A

Swelling of the optic nerve sheath, as noted with funduscopic examination

564
Q

Paresthesia

A

Abnormal tactile sensation often described as tingling, numbness, or pinpricking

565
Q

Post-ictal

A

The state of somnolence and decreased responsiveness after a seizure

566
Q

Pronator drift

A

Involuntary turning or lowering of forearm when outstretched

567
Q

Romberg’s sign

A

Falling to one side when standing with feet together and eyes closed, indicating abnormal cerebellar function or inner ear dysfunction

568
Q

Saturday Night Palsy

A

A permanent localized numbers or weakness to a specific nerve’s distal innervation

569
Q

Status epilepticus

A

Repetitive seizures without regaining consciousness between them

570
Q

Strength 5/5

A

Normal strength of the extremities

571
Q

Tongue deviation

A

Tongue pointing to one side

572
Q

Tonic clonic

A

Description of a Grand-mal or generalized seizure with stupor and transient LOC

573
Q

Abnormal judgment

A

Lack of normal decision making

574
Q

Affect

A

The expressed or observed emotional and social responses

575
Q

Anxiety reaction

A

Commonly known as an “anxiety attack”

576
Q

Auditory hallucinations

A

Hearing voices, noises, music, or sounds that are not actually real

577
Q

Depressed

A

Appearing sad, unhappy

578
Q

Flat affect

A

Lack of normal interaction, monotone, unemotional

579
Q

Homicidal ideation

A

Thoughts of killing another person

580
Q

Non-communicative

A

Lacking the desire or ability to communicate

581
Q

Odd affect

A

Strange interactions, unusual expressions, “weird”

582
Q

Pressured speech

A

Abnormal rate of speech, speaking quickly and urgently

583
Q

Suicidal ideation

A

Thoughts of killing oneself

584
Q

Tangential thoughts

A

Thought processes that do not follow normal or logical progressions

585
Q

Visual hallucinations

A

Seeing objects, people, or things that do not actually exist

586
Q

Withdrawn

A

Uninterested and non-participatory

587
Q

A&O

A

Alert and oriented

588
Q

ABC

A

Airway, breathing, circulation

589
Q

ABG

A

Arterial blood pressure

590
Q

Abnl

A

Abnormal

591
Q

ACLS

A

Advanced cardiac life support

592
Q

ADH

A

Antidiuretic hormone

593
Q

ADLs

A

Activities of daily living

594
Q

AICD

A

Automated implantable cardiac defibrillator

595
Q

AIDS

A

Acquired immune deficiency syndrome

596
Q

ALS

A

Advanced life support

597
Q

AM

A

Morning

598
Q

Amb

A

Ambulate

599
Q

AMI

A

Acute myocardial infarction

600
Q

Ant

A

Anterior

601
Q

APAP

A

Acetaminophen

602
Q

APGAR

A

Appearance, pulse, grimace, activity, respiration - used to assess newborns

603
Q

APN

A

Advanced practice nurse

604
Q

ARF

A

Acute renal failure

605
Q

ARDS

A

Acute respiratory distress syndrome

606
Q

ASCVD

A

Atherosclerotic cardiovascular disease

607
Q

at/nc

A

Atraumatic normocephalic

608
Q

BAC

A

Blood alcohol level

609
Q

BBB

A

Bundle branch block

610
Q

BC

A

Blood culture

611
Q

BIB

A

Brought in by

612
Q

BiPAP

A

Biphasic positive airway pressure

613
Q

BLE

A

Bilateral lower extremities

614
Q

BLS

A

Basic life support

615
Q

BNP

A

B-type natriuretic peptide

616
Q

BP

A

Blood pressure

617
Q

BPH

A

Benign prostatic hyperplasia

618
Q

BRB

A

Bright red blood

619
Q

BS

A

Blood sugar, bowel sounds, breath sounds

620
Q

BSA

A

Body surface area

621
Q

BTL

A

Bilateral tubal ligation

622
Q

BUN

A

Blood urea nitrogen

623
Q

Bx

A

Biopsy

624
Q

c diff

A

Clostridium difficile

625
Q

Ca++

A

Calcium

626
Q

cap

A

Community acquired pneumonia

627
Q

CAT or CT

A

Computed axial tomography

628
Q

CBD

A

Common bile duct

629
Q

CCE

A

Clubbing, cyanosis, edema

630
Q

CCU

A

Critical care unit

631
Q

cdi

A

Clean, dry, intact

632
Q

CDU

A

Clinical Decisions Unit

633
Q

CHI

A

Closed head injury

634
Q

CK

A

Creatine kinase

635
Q

CKD

A

Chronic kidney disease

636
Q

CKMB

A

Creatine kinase mb isoenzyme

637
Q

CLL

A

Chronic lymphocytic leukemia

638
Q

CMP

A

Complete metabolic panel

639
Q

cm

A

Centimeter

640
Q

CMS

A

Circulation motor sensory

641
Q

CMT

A

Cervical motion tenderness

642
Q

c/o

A

Complains of

643
Q

CO

A

Carbon monoxide

644
Q

CPAP

A

Continuous positive airway pressure

645
Q

CPK

A

Creatine phosphokinase

646
Q

CPOE

A

Computerized physician order entry

647
Q

CPS

A

Child protective services

648
Q

Creat

A

Creatinine

649
Q

CRP

A

C-reactive protein

650
Q

CRF

A

Chronic renal failure

651
Q

CRI

A

Chronic renal insufficiency

652
Q

CTA

A

Clear to auscultation

653
Q

CV

A

Cardiovascular

654
Q

CVD

A

Cardiovascular disease

655
Q

c/w

A

Consistent with

656
Q

CX

A

Culture

657
Q

D5W

A

5% dextrose in water

658
Q

DC

A

Discontinue

659
Q

D/C

A

Discharge

660
Q

D&C

A

Dilation and curettage

661
Q

DDD

A

Degenerative Disc Disease

662
Q

DDx

A

Differential diagnosis

663
Q

Dig

A

Digoxin

664
Q

DIP

A

Distal interphalangeal joint

665
Q

Dispo

A

Disposition

666
Q

DJD

A

Degenerative joint disease

667
Q

DP

A

Dorsal pedis

668
Q

DTR

A

Deep tendon reflex

669
Q

DTs

A

Delirium tremens

670
Q

Dx

A

Diagnosis

671
Q

DZ

A

Disease

672
Q

EAC

A

External auditory canal

673
Q

ECHO

A

Echocardiogram

674
Q

E.coli

A

Escherichia coli

675
Q

EDD

A

Expected delivery date

676
Q

EEG

A

Electroencephalogram

677
Q

EF

A

Ejection fracture

678
Q

EGD

A

Esophagogastroduodenoscopy

679
Q

EJ

A

External jugular

680
Q

EMR

A

Electronic medical record

681
Q

EMTALA

A

Emergency medical treatment and active labor act

682
Q

ERCP

A

Endoscopic retrograde cholangiopancreatography

683
Q

ESR

A

Erythrocyte sedimentation rate

684
Q

ESRD

A

End stage renal disease

685
Q

ETT

A

Endotracheal tube

686
Q

Ext

A

Extremities

687
Q

FAS

A

Fetal alcohol syndrome

688
Q

FAST

A

Focused assessment with sonography for trauma

689
Q

FB

A

Foreign body

690
Q

Fem-pop

A

Femoropopliteal bypass surgery

691
Q

FHT

A

Fetal heart tones

692
Q

FFP

A

Fresh frozen plasma

693
Q

FOS

A

Full of stool

694
Q

FROM

A

Full range of motion

695
Q

FSBG

A

Finger stick blood glucose

696
Q

Fx

A

Fracture

697
Q

GB

A

Gallbladder

698
Q

GC

A

Gonorrhea

699
Q

GCS

A

Glasgow coma scale

700
Q

GERD

A

Gastroesophageal reflux disease

701
Q

GFR

A

Glomerular filtration rate

702
Q

gtts

A

Drops

703
Q

G-tube

A

Gastronomy tube

704
Q

GU

A

Genitourinary

705
Q

GYN

A

Gynecology

706
Q

HBP

A

High blood pressure

707
Q

Hct

A

Hematocrit

708
Q

HI

A

Homicidal ideation

709
Q

HIV

A

Human immunodeficiency virus

710
Q

HOCM

A

Hypertrophic obstructive cardiomyopathy

711
Q

HR

A

Heart rate

712
Q

HSV

A

Herpes simplex virus

713
Q

I&O

A

Intake and output

714
Q

ICD-10

A

International classification of Disease - 10th revision

715
Q

ICH

A

Intracranial hemorrhage

716
Q

ID

A

Infectious disease

717
Q

JVD

A

Jugular vein distention

718
Q

LAD

A

Left anterior descending

719
Q

LBBB

A

Left bundle block branch

720
Q

LBP

A

Lower back pain

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