Med Terms: Charting Terms and Emergency Codes Flashcards
Abdomen
- Protuberant, distended (large and extends outward)
-Hard, rigid, distended, tympanic, taut (hard board like)
-Relaxed, flaccid (soft, flabby)
-Distended, edematous (swollen, rounded)
-Tympanic, flatulent (filled with gas)
-Pendulous (hangs down)
Amounts
-Profuse, copious (large amounts of drainage)
-Moderate (medium amount of drainage)
-Scant (small amount of drainage)
Back
-Kyphosis (hunchback)
-Lumbar region (small of back)
-Lordosis (swayback)
Bleeding
-Epistaxis (nose bleed)
-Hematuria (blood in urine)
-Hemoptysis (spitting up blood)
-Guaiac positive (positive blood in stool)
Breath
-Halitosis (unpleasant)
-Fetid (foul)
-Fruity, sweet (with sweet fruit-like odor)
-Odor of ammonia (urinous odor)
Breathing
-Respiration (breathing)
-Dyspnea (difficult breathing)
-Apnea (short periods when breathing has ceased)
-Orthopnea (inability to breathe while lying down)
-Tachypnea (rapid breathing)
-Cheyne-Stokes respirations (increasing dyspnea with periods of apnea)
Consciousness
-A&Ox3 (alert, fully conscious, oriented to date, time, place)
-Semi-conscious (only partly conscious)
-Stuporous (unconscious, but can be aroused)
-Comatose (unconscious, cannot be aroused)
Cough
-Continuous, persistent, productive, nonproductive, dry, hacking (type of cough)
-Spasmodic (occurring in spasms)
-Hemoptysis (coughing up or expectoration of blood)
-Stridulous (dead tissue)
Decay
-Tissue necrosis, necrotic (dead tissue)
Defecation
-Diarrhea (frequent liquid defecation)
-Clay or dark brown, black, yellow (color of stool)
-Liquid, soft or hard formed, watery, semi-formed, constipated, undigested food, mucoid (constituents of stool)
Drainage
-Purulent (containing pus)
-Sanguineous ( bloody)
-Serous (of lymphatic fluid)
-Mucopurulent (contains mucus and pus)
-Tenacious (tough, sticky)
-Serosanguineous (bloody, lymphatic (lymphatic))
Edema: swelling in extremities, after depressing for 5 seconds
1+ edema (indented 2mm)
2+ edema (indented 4mm)
3+ edema (indented 6mm)
4+ edema (indented 8mm)
Emesis
-Induced (produced by conscious effort of patient)
-Projectile (ejected a few feet distance)
-Hematemesis (if blood is noticeable)
Eyes
-visual acuity (sharpness of vision)
-Jaundiced (yellow in color)
-edematous (puffy, swollen)
-ptosis of lids (drooping eyelids)
-Photophobia (unusually sensitive to light)
-Diplopia (double vision)
-Strabismus (cross eye, squinting)
-Exophthalmos (abnormal protrusion of eyeball)
-Conjunctivitis (inflammation of conjunctive)
-Mydriasis, pupil dilated (dilation of the pupil)
-Myosis, pupil constricted, pin point (contraction of the pupil)
-Myopia (near-sightedness)
-Hyperopia (far-sightedness)
Faintness
-Syncope/syncopal episode (fainting)
Fever
-Afebrile (without fever)
-Pyrexia (temperature above normal)
-Hyperpyrexia (temperature greatly above normal)
Head
-Frontal region (forehead)
-Temporal region (region over temple)
-Occipital region (back of head)
-Basilar region (base of skull)
-Macrocephaly, hydrocephalus (having a large head)
-Microcephalus (having a small head)
-Parietal (top of head)
Hives
-Urticaria (hives)
-Pruritus (itching)
Joints
-Flexion (bending)
-Extension (to straighten)
-Rotation (revolve around)
-Abduction (move away from median line)
-Adduction (move toward median line)
Lips
-Cyanotic (blue in color)
Medicine (administration)
-Orally (by mouth)
-Rectally (by rectum)
-Inhalation (breathing in)
-Topically (rubbing into skin)
-Subcutaneous (under the skin)
-Intradermal (within the skin)
-Intramuscular (within the muscle)
-Intraspinal, intrathecal (within the spinal canal)
-Intravenous (within the vein)
-Intraosseous (withing the bone)
-Instillation (pouring into body cavity)
Menstruation
-Menses present (if present when admitted)
-Dysmenorrhea (painful)
-Amenorrhea (total absence of)
-Menorrhagia (profuse or prolonged flow)
-Menopause (cessation of)
Odor
-Offensive, foul (very unpleasant)
Paralysis
-Facial (of the muscles of the face)
-Paraplegia (of the legs)
-Hemiplegia (of one side of the body)
-Monoplegia (of a single limb)
-Quadriplegia (of all 4 extremities and usually the trunk)
Perspiration
-Diaphoresis, diaphoretic (large amount/profuse)
Positions
-Supine (flat on back, arms straight at sides)
-Lateral (on side, knees flexed)
-Sim’s (on side with one straight leg one bent leg)
-Semi-Fowler’s 40-50 degree (head of bed semi-erect)
-Lithotomy (on back, buttocks near edge of table)
-Knee-chest (resting on knees and chest)
-Trendelenburg (on back, pelvis and legs higher that head)
-Prone (on abdomen, face turned to one side)
-Jackknife (prone with hips over break in table and feed below level of head)
-Orthopneic (Seated, leaning forward, bracing elbows on lap or on table)
Pulse
-Rate (number of beats per minute)
-Regular or irregular, coupling, galloping (rhythm)
-Intermittent (beats missed at intervals)
-Rapid, fast, tachycardia (>100 beats per minute)
- Slow, bradycardia (slow in rate <50 bpm)
-Thready, weak (only scarcely perceptible)
-Imperceptible, absent (pulseless)
-Pulse strength
0=absent, not palpable, inaudible with doppler
1+=diminished/palpable
2+=expected/normal
3+=strong/full pulse
4+=bounding, cant be obliterated
-Normal in rate and rhythm (normal)
Skin
-Healthy, normal for race (normal)
-Cyanotic (blue in color)
-Extreme pallor, ashen (very white)
-Erythema (redness)
-Glossy (shines)
-Excoriation (raw surface)
-Jaundiced (yellow in color)
-Pigmented (containing colored areas)
-Abraded, denuded (scraped)
-Clammy (cold and moist)
-Mottled (splotchy r/t poor circulation)
Speech
-Incoherent (not understandable)
-Rambling (meaningless, wondering)
-Slurring (words run together)
-Dysphasia (difficulty speaking)
-Aphasia (unable to speak)
Throat
-Dysphagia (difficulty in swallowing)
-Aphagia (inability to swallow)
-Red, swollen, inflamed, ulcerated (other descriptive terms)
Tongue
-Pink, moist, dry, cracked, swollen, inflamed, ulcerated (descriptive terms)
Urination
-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)
Weight
-Obese (overweight)
-Emaciated, wasting (abnormal thinness)
-Cachectic (very underweight)
Wounds
-Suppurating, purulent (discharging pus)
-Eschar (black or gray necrotic tissue)
-Exudate (wound drainage)
Code Blue
Cardiac or Respiratory Arrest, urgent medical assistance needed
Security alert
Violent behavior, Hostage situation, Lockdown, Bomb threat, Active shooter
Sever Weather
Stage 1: watch for deteriorating conditions
Stage 2: Warning, close doors and windows
Stage 3: Imminent danger, evacuate to interior of building
Internal Event
Usually indicates utility failures may need to evacuate certain areas
External Event
Usually involving multiple casualties.
Hospital will prepare for influx of multiple patients and mass casualty protocols will be enacted
Fire
location will be announced, as well as an “All Clear” announcement after fire has been put out.
Follow R.A.C.E. and P.A.S.S. methods for safety of pt’s and employees.
Missing Adult/Child/Infant
last seen location, approximate age, and clothing will be announced.
-Remember things like
-Clothing
-Age
-Direction of travel
-What time they left the building
Not allowed to physically keep someone from leaving building, but take note of suspicious individuals.
