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ROS terms (scribe job) > Terms seen in the PE > Flashcards

Terms seen in the PE Flashcards

1
Q

Abrasion

A

scrape of scratch (Skin)

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2
Q

Abscess

A

collection of puss under the skin (Skin)

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3
Q

accessory muscle use

A

the use of muscles not normally used for breathing (indicates respiratory distress) (respiratory/chest)

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4
Q

adnexa

A

structures connected to the uterus (GU)

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5
Q

afebrile

A

without evidence of fever (constitutional)

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6
Q

affect

A

describes how the patient appears with respect to interacting with others. Usually describes as “flat”, “depressed”, or “normal’ (constitutional)

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7
Q

AKA

A

Above the knee amputation (musculoskeletal)

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8
Q

Alert

A

responsive (constitutional)

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9
Q

alert and oriented x3

A

oriented to person, place, and time (constitutional)

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10
Q

Anisocoria

A

unequal pupils (Eyes)

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11
Q

Anus

A

the external opening of the rectum (abdomen/GI)

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12
Q

Ascites

A

accumulation of fluid in the abdomen causing swelling (abdomen/GI)

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13
Q

Ataxia

A

loss of full control of bodily movements

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14
Q

atraumatic

A

without evidence of injury (Head)

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15
Q

auricle

A

external ear (ENT)

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16
Q

auscultation

A

the act of listening to lung sounds (respiratory/chest)

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17
Q

awake

A

conscious

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18
Q

bibasilar

A

at the bases of both lungs (respiratory/chest)

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19
Q

bimunual

A

pelvic exam using digits (fingers) (GU)

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20
Q

Bipolar

A

Specific psychiatric diagnosis characterized by swellings of mood, usually depression or mania like behavior

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21
Q

BKA

A

below the knee amputation

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22
Q

Blanching

A

Descriptive term relating to a certain type of rash (skin)

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23
Q

Bowel sounds

A

sounds made by the movement of the intestines during digestion (abdomen/GI)

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24
Q

Brachial pulse

A

pulse found on the upper arm (CVS)

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25
Q

Bradycardia

A

slow heart beat (CVS)

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26
Q

Brudzinski Sign

A

One of the clinical signs of meningitis (Neck)

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27
Q

Bulging

A

Descriptive word that can be associated with tympanic membrane (ENT)

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28
Q

Cachectic

A

wasting away (constitutional)

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29
Q

calcaneus

A

heel of the foot (musculoskeletal)

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30
Q

Capillary refill

A

rate at which blood refills in the capillaries (CVS)

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31
Q

Carotid bruit

A

Abnormal sound heart when auscultating the carotid artery (neck)

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32
Q

Carpals/metacarpals

A

bones of the hands (musculoskeletal)

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33
Q

Cerumen

A

Ear wax (ENT

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34
Q

Cerebellum

A

back part of the brain; function is to coordinate and regulate muscular activity (neurologic)

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35
Q

Cervical Motion Tenderness (CMT)

A

tenderness when moving the cervix (during bimanual exam) (GU)

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36
Q

Cervix

A

part of the uterus (GU)

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37
Q

Chest wall

A

bony muscular structures that form the outer framework of the chest (resp/chest)

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38
Q

Circumcised

A

removal of the foreskin of the penis (GU)

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39
Q

Clubbing

A

broadening of the extremities and abnormal curving of the nail beds

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40
Q

comfortable

A

not in distress (const)

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41
Q

Conjunctiva

A

Inside the eyelid covering part of the sclera (Eyes)

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42
Q

Cornea

A

transparent part of the eye that covers the iris and pupil (Eyes)

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43
Q

Crackles (coarse or fine)

A

abnormal breath sound (clicking sounds) (resp/chest)

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44
Q

Cranial nerves

A

12 pairs of nerves that can be seen on the ventral (bottom) surface of the brain (Neuro)

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45
Q

Crepitus

A

describe the grating, crackling or popping sounds and sensations experienced under the skin and joints (Musculoskeletal)

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46
Q

CVA (Costovertebral angle)

A

Area of the back over the kidney (Back)

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47
Q

Cyanosis

A

bluish discoloration of the skin (resp/chest)

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48
Q

Dentition

A

pertaining to the quality of teeth (ENT)

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49
Q

Deviated

A

descriptive word relating to the septum (ENT)

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50
Q

Distention

A

bloating of the abdomen (abdomen/GI)

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51
Q

Dorsalis pedis

A

pulse found on top of the food (CVS)

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52
Q

Dry

A

referring to the moisture of the skin (Skin)

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53
Q

DTRs

A

Deep tendon reflexes (measured as 1+, 2+, etc) (Musculoskeletal)

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54
Q

Dull

A

descriptive word that can be associated with tympanic membrane (ENT)

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55
Q

Ecchymosis

A

bruising (skin)

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56
Q

Ectopy

A

Extra heart beat outside of the normal rhythm

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57
Q

Edema

A

fluid collection causing swelling

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58
Q

EOMI

A

Extraocular movements intact

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59
Q

Epitaxis

A

bloody nose

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60
Q

Erythema/Erythematous

A

redness

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61
Q

Exophthalmos

A

Eye protruding from the head

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62
Q

Expressive aphasia

A

severe impairment of speech

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63
Q

Exudate

A

pustules (ENT)

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64
Q

Fever

A

has fever (const)

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65
Q

Femoral pulse

A

pulse found in the inguinal area of the body (CVS)

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66
Q

Flexion

A

bending forward (back)

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67
Q

Fontanelle

A

the soft spot on the top of an infants head (head)

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68
Q

Fundus

A

Interior surface of the eye (eyes)

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69
Q

Gallop

A

abnormal heart sound (CVS)

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70
Q

Gravid

A

notably pregnant

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71
Q

Gravid abdomen

A

notably pregnant abdomen

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72
Q

Guaiac test

A

test performed to check for hidden blood in stool

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73
Q

Guarding

A

voluntary or involuntary tensing of muscles in the abdomen

74
Q

Hematoma

A

collection of blood under the skin

75
Q

Hemiparesis

A

weakness on one side of the body

76
Q

Hemiplegia

A

inability to move one half of the body

77
Q

Hemorrhoids

A

a painful, swollen vein or group of veins near the anus (abdomen/GI)

78
Q

Hemotympanum

A

blood behind the ear drum (Abdomen/GI)

79
Q

Hepatomegaly

A

enlargement of the liver (abdomen/GI)

80
Q

Homicidal ideation

A

patient verbalizing thoughts of harming others (Psych)

81
Q

Hyperactive bowel sounds

A

increased bowel sounds (abd/GI)

82
Q

hypoactive bowel sounds

A

decreased bowel sounds (abd/GI)

83
Q

Hypomania

A

A form of bipolar illness with marked psychomotor agitation, grandiosity, hallucinations, sleeplessness, paranoia at times (Psych)

84
Q

Hypoxic

A

oxygen deficiency (related to the pulse oximetry vital sign) (resp/chest)

85
Q

Icterus

A

yellowing of the eye (eye)

86
Q

inguinal hernia

A

hernia near the groin area (GU)

87
Q

intercostal

A

between ribs

88
Q

intoxicated

A

appears altered and under the influence of substance (const)

89
Q

Iris

A

the color part of your eye (eye)

90
Q

Jaundice

A

yellowing of the skin (skin)

91
Q

JVD

A

Bulging of blood veins on the sides of the neck (neck)

92
Q

Kernigs

A

clinical signs of meningitis (neck)

93
Q

L-Spine

A

lumbar spine (back)

94
Q

Labia Majora/minora

A

skin surrounding the opening of the vagina (GU)

95
Q

Lesion

A

sore on the skin (skin)

96
Q

LLE

A

left lower extremity

97
Q

LUE

A

left upper extremity

98
Q

lumbar

99
Q

Lymphadenopathy

A

enlargement of the lymph nodes

100
Q

malleolus

101
Q

malocclusion

A

misalignment of this jaw

102
Q

McBurney’s Point

A

name given to the point on the body over the right side of the abdomen between the belly button and hip (sign of acute appendicitis)

103
Q

meningismus

A

clinical signs of meningitis

104
Q

mood

A

describes how the patient appears to be acting

105
Q

Mucosa

A

membranes in the mouth (ENT)

106
Q

Murmur

A

abnormal hears sound, measured as “x/6” systolic or diastolic

107
Q

Murphy’s Sign

A

physical exam finding that indicates a potential abnormality of the gallbladder often associated with acute cholecystitis (abdomen/GI)

108
Q

Nares

109
Q

NEXUS criteria

A

criteria used to clinically rule our a c-spine fracture

110
Q

No acute distress (NAD)

A

not in pain or discomfort (const)

111
Q

No step offs

A

vertebrae are in alignment on back of neck (neck)

112
Q

Non-toxic

A

not ill appearing (conts)

113
Q

normal perfusion

A

appropriate blood flow to the extremities

114
Q

Normocephalic

A

normal head

115
Q

Nuchal rigidity

A

Neck stiffness

116
Q

Obese

A

significantly overweight

117
Q

Obtunded

A

Not awake or able to answer questions

118
Q

Occult blood

A

blood in the stool that is no visible to the eye

119
Q

Olecranon

120
Q

organic

A

refers to medical cause of a psychiatric problem

121
Q

Os

A

opening of cervix

122
Q

patella

123
Q

pale/pallor

A

having less pigment; related to skin color

124
Q

Patent airway

A

airway is clear

125
Q

penile

A

pertaining to the penis

126
Q

Percussion

A

tapping on the chest

127
Q

perineum

A

skin between the anus and the reproductive organs

128
Q

Peritoneal signs

A

findings during PE that suggest an abnormality to the lining of the abdomen

129
Q

PERRL

A

pupils equal, round and reactive to light

130
Q

Personality disorder

A

complex psychiatric disorder involving incomplete development of personality and ability to relate to other that manifests with difficulties in interacting with others

131
Q

Peterchiae

A

red spots on skin

132
Q

phalanges

A

fingers and toes

133
Q

pharyngeal erythema

A

redness of the throat

134
Q

pharynx

135
Q

Pronator drift

A

patient asked to hold both arms fully extended at shoulder level in front of him/her with palms upward

136
Q

pulses

A

checking for blood circulation

137
Q

radial pulse

A

pulse found in the wrist

138
Q

rales

A

abnormal breath sound

139
Q

rebound tenderness

A

pain that is felt on the release of pressure applied to the abdomen

140
Q

rectal tone

A

the strength of the muscles controlling the rectum

141
Q

regular rate and rhythm (RRR)

A

appropriate rate and rhythm

142
Q

respiratory distress

A

difficulty breathing

143
Q

retina

A

part of detailed eye exam

144
Q

retractions

A

when the muscles between the ribs pull inward; usually a sign that the person has a breathing problem

145
Q

Rhinorrhea

A

runny nose

146
Q

rhonchi

A

abnormal breath sound (whistling or snoring sound)

147
Q

RLE

A

right lower extremity

148
Q

Romberg’s

A

Neurologic test that is position if the patinets sways or falls while the patient’s eyes are closed and he/she is standing

149
Q

Rovsing’s sign

A

pressure applied to the left lower quadrant of the abdomen increases pain in the right lower quadrant (sign of acute appendicitis)

150
Q

Rub

A

abnormal heart sound

151
Q

RUE

A

right upper extremity

152
Q

Sacrum

153
Q

Schizophrenia

A

psychiatric diagnosis characterized by hallucinations, affect changes, psychomotor changes and loss of normal social skills

154
Q

Sclera

A

the white of the eye

155
Q

Scloliosis

A

abnormal curvature of the spine

156
Q

Septum

A

the internal wall of the nose dividing the nostrils

157
Q

snuff box

A

area at the base of the thumb/distal radius (often palpated to rule out fructure)

158
Q

Speculum

A

tool utilized in female pelvic exam

159
Q

Splenomegaly

A

Abnormal enlargement of the spleen

160
Q

straight leg raise

A

testing for sciatica

161
Q

suicidal ideation

A

verbalizing thoughts of harming oneself

162
Q

Supple

A

Easily manipulated

163
Q

T-spine

A

thoracic spine (mid portion of the back)

164
Q

Tachycardia

A

Fast heart beat

165
Q

Tarsals/metatarsals

A

bones of the feet

166
Q

tersticle

A

male gonad

167
Q

Thrush

A

white coating in the mouth and on the tongue

168
Q

thyromegal

A

enlarged thyroid

169
Q

tonsil

A

tissue in the back of the throat

170
Q

Torsion

A

twisting (testicular or ovarian torsion)

171
Q

tripoding

A

when patients sits/stands leaning forward and supporting the upper body with hands on the knees or on another surface (indicates respiratory distress)

172
Q

tympanic memberane

173
Q

Umbillicus

A

belly button

174
Q

Urethra

A

external opening to the urinary tract

175
Q

Urticaria

A

type of rash

176
Q

uterus

A

female womb

177
Q

Uvula

A

structure that hangs down in the back of the throat

178
Q

Vault

A

inside the vagina

179
Q

vulva

A

female genitalia

180
Q

Wheezing

A

abnormal breath sound (whistling or rattling)

ROS terms (scribe job) (4 decks)

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