test Flashcards
1
Q
anatomical position
A
standing erect with arms at sides and palms of hands turned forward
2
Q
anterior
A
situated towards front
3
Q
C-spine
A
cervical spine (C1-C7)
4
Q
Diffuse
A
generalized, not localized to any specific location
5
Q
distal
A
farther from the trunk of body
6
Q
epigastric
A
upper central region of the abdomen
7
Q
fontanel
A
anatomical feature of an infant’s skull, the “soft-spot”
8
Q
Inferior
A
lower on the body farther from the head
9
Q
L-spine
A
lumbar spine (L1-L5)
10
Q
lateral
A
farther from the midline
11
Q
LLE
A
Left Lower Extremity, or Left leg
12
Q
LLQ
A
Left Lower Quadrant, Left Lower Quadrant of the abdoment
13
Q
LUE
A
Left Upper Extremity, Left arm
14
Q
LUQ
A
Left Upper Quadrant of hte abdomen
15
Q
medial
A
nearer to the midline
16
Q
palmar, or volar
A
palm side of hand or body
17
Q
Plantar
A
sole of foot
18
Q
posterior, or dorsal
A
rear or back
19
Q
prone
A
body position lying face down with forearms and hands turned palm side
20
Q
proximal
A
nearer to the trunk of the body
21
Q
RLE
A
Right Lower Extremity, or right leg
22
Q
RLQ
A
Right Lower Quadrant of the abdomen
23
Q
RUE
A
Right Upper Extremity, or right arm
24
Q
RUQ
A
Right Upper Quadrant of the abdomen
25
Superficial
nearer to the surface
26
superior
higher on the body, nearer to the head
27
supine
body position lying face up
28
suprapubic
lower central region on the abdomen
29
T-spine
Thoracic spine (T1-T12)
30
Acute
(Timing) new onset, likely concerning
31
acute on chronic
(Timing) new exacerbation of a chronic condition
32
chronic
(Timing) long standing, constant.
33
Fluctuating
(Timing) Symptoms that are always present but changing in severity, never fully resolving
34
Intermittent
(Timing) Symptoms that completely resolve at times, but continue to return repeatedly
35
Paroxysmal
(Timing) occasional, sporadic, transient
36
Resolved
(Timing) Gone, no longer existing
37
Transient
(Timing) Resolving spontaneously after onset
38
waxing and waning
(Timing) symptoms going in and out
39
FHx
Family history, a part of the medical chart that lists diseases and health conditions in the family that may put the patient at increased risk
40
HIPAA
Health Insurance Portability and Accountability Act. Federal law that protects sensitive patient information
41
pt
patient
42
r/o
rule out
43
ROS
review of system. A part of the medical chart that is a checklist of the symptoms the patient has, grouped by body system
44
s/p
status post (after). (e.g., headache s/p fall, headache after fall)
45
SHx
social history, a part of the chart that addresses lifestyle contributing factors to illness
46
Sx
symptoms
47
Tx
treatment
48
UTD
up to date
49
WNL
within normal limits (normal, not of concern)
50
dx
diagnosis
51
abscess
collection of pus beneath the skin
52
appendicitis
dangerous infection of the appendix
53
arthritis
inflammation of the joints
54
A fib
atrial fibrillation, irregular and very rapid heart rhythm. arrythmia
55
Bell's Palsy
localized facial nerve dysfunction that causes facial droop and numbness
56
bronchitis
inflammation or infection of the bronchi, or upper airway
57
CA
cancer, carcinoma
58
cellulitis
infection of skin cells
59
CVA
cerebrovascular accident, or stroke. hemorrhagic or ischemic in nature
60
Cholecystitis
inflammation of the gallbladder
61
Cholelithiasis
production of gallstones
62
COPD
chronic obstructive pulmonary disease, causes obstructed airflow to the lungs
63
CRF, CKD
chronic renal failure, chornic kidney disease Decreased ability for kidneys to filter waste and fluid from the blood.
64
cirrhosis
inflammation of an organ by degenerative changes, especially the liver
65
CHF
congestive heart failure, serious condition which the heart does not pump blood as efficiently
66
conjuctivitis
infection of the outer layer of the eye
67
CABG
coronary artery bypass graft, invasive procedure used to treat coronary artery disease
68
CAD
coronary artery disease, buildup of plaque in the arteries
69
Costochondritis
inflammation of rib cartilage
70
croup
viral infection of the upper airway with barking cough, stridor
71
DVT
deep vein thrombosis, blood clot forming deep in body, usually in leg
72
dermatitis
inflammation of the skin
73
diverticulitis
acute inflammation of the diverticula pouches
74
ectopic pregnancy
egg developing outside of the uterus extremely dangerous due to rupture
75
endometriosis
presence of functioning endometrial tissue outside of the uterus
76
gastroenteritis
inflammation of the GI tract
77
GERD
gastrointestinal reflux disease, when stomach acids go from stomach into esophagus
78
gout
type of arthritis, diagnosed by ordering a uric acid level
79
hepatitis
inflammation of the liver
80
hyperglycemia
high blood sugar due to diabetes
81
HLD
hyperlipidemia, high cholesterol
82
HTN
hypertension, high blood pressure (>140/90)
83
hypoglycemia
low blood sugar
84
hypotension
low blood sugar (<100/65)
85
IDDM
insulin-dependent diabetes mellitus. Diabetes requiring the use of insulin injections
86
Lymphangitis
Inflammation of a lymphatic vessel, appears as red streaking
87
MS
multiple sclerosis, autoimmune disease affective brain and spinal cord
88
MI
myocardial infarction, heart attack
89
nephrolithiasis / renal calculi
kidney stone
90
NIDDM
non-insulin dependent diabetes mellitus, diabetes not requiring the use of insulin injections
91
OM
otitis media, inner ear infection
92
pancreatitis
inflammation of the pancreas
93
PID
pelvic inflammatory disease
94
PUD
peptic ulcer disease
95
pericarditis
inflammation of the pericardium
96
PVD
peripheral vascular disease. blood circulation disorder that causes the blood vessels to narrow, block, or spasm
97
pharyngitis
throat infection
98
PNU
pneumonia, infection inside lung tissue
99
pneumothorax
presence of air or gas in the pleural space
100
psoriasis
autoimmune skin disease, dry, scaly, red patches of skin
101
PE
pulmonary embolism. blockage of pulmonary artery due to clot
102
pneumothorax
presence of air or gas in the pleural space, collapsed lung
103
pyelonephritis
infection on the kidneys
104
sciatica
compression of the sciatic nerve causing back pain with radiation to posterior leg
105
sepsis
dangerous infection of the blood
106
sinusitis
infection/inflammation of the sinuses
107
tinea
fungal rash
108
TIA
transient ischemic attack. mini stroke, neurological function restored over time
109
URI
upper respiratory infection
110
UTI
urinary tract infection, kidneys, ureters, bladder, urethra
111
BMP
basic metabolic panel. blood test that measures lots of things
112
CXR
chest x-ray
113
CBC
complete blood count, blood test used to evaluate overall health, wide range of disorders
114
CMP
complete metabolic panel, blood test that measures 14 different substances
115
CT/CAT
computerized assisted tomography. XR procedure that does cross section scans of the body
116
EKG/ECG
electrocardiogram
117
H&H
hemoglobin and hematocrit, rd blood cell measurements to evaluate anemia
118
UA
urinalysis, urine test to detect a wide range of disorders
119
abx
antibiotics
120
ASA
acetylsalicylic acid (aspirin)
121
aspirin
acetylsalicylic acid
122
B.I.D
(bis in die) twice daily
123
IM
intramuscular
124
NKDA
no known drug allergies
125
NSAID
non-steroidal anti-inflammatory drug (ibuprofen, motrin)
126
PO
per os (by mouth)
127
p.r.n
(pro re nata) as needed
128
q.h.s
(quaque hora somni) at every bedtime
129
q.i.d
(quater in die) four times a day
130
rx
prescription (as in 'recipe')
131
t.i.d
(ter in die), three times a day
132
afebrile
(constitutional) without fever
133
ambulatory
(constitutional) able to move about, not confined to a bed
134
cachetic
(constitutional) extremely bony, malnourished
135
constitutional
the general appearance of the patient
136
distress
(constitutional) inability to tolerate their body state due to pain, or respiratory failure
137
NAD
(constitutional) no acute distress, patient is comfortable
138
febrile
(constitutional) feverish
139
lethargic
(constitutional) septic, very sick, about to die
140
malaise
(constitutional) generalized discomfort or weakness
141
non-toxic
(constitutional) appearing stable, no risk of deterioration
142
somnolent
(constitutional) appearing drowsy
143
unkempt
(constitutional) poor self hygiene
144
well developed
(constitutional) normal state of mental and body development
145
conjunctiva
(eye) thin outer lining of the eye and eyelid
146
cornea
(eye) transparent frontal aspect of the eye, covering both the iris and pupil
147
EOMI
(eye) extraocular muscles intact, testing that examines the function of the eye muscle
148
fundoscopic exam
use of ophthalmoscope to look through pupil and examine interior surface of posterior eye
149
nystagmus
(eye) involuntary shaking eye movements
150
ophthalmalgia
(eye) pain in eye
151
pale conjunctiva
(eye) pale inner aspect of the eyelid most often due to anemia
152
periorbital ecchymosis
(eye) bruising around the eyes, indicative of trauma
153
photophobia
(eye) light sensitivity
154
PERRL
(eye) pupils equal, round reactive to light. common normal exam finding
155
scleral icterus
(eye) yellowing of the sclera (whites of the eye) due to jaundice
156
sclerae anicteric
(eyes) sclera is white and normal
157
subconjunctival hemorrhage
(eye) blood in white part of the eye
158
cerumen
(ENT) earwax
159
dentition
(ENT) teeth
160
dry mucosa
(ENT) dry tongue, mouth, and lips indicating dehydration
161
edentulous
(ENT) without teeth
162
epistaxis
(ENT) nosebleed
163
gingiva
(ENT) gums
164
nare
(ENT) nostril
165
oropharynx
(ENT) back of mouth where it meets the throat
166
otalgia
(ENT) earache
167
pharyngeal erythema
(ENT) redness of the pharynx, indicating throat infection
168
rhinorrhea
(ENT) clear nasal discharge, runny nose
169
tinnitus
(ENT) ringing in ears
170
TM erythema
(ENT) redness of the TM, infection sign
171
tonsillar exudate
(ENT) pus on tonsils, indicating infection of tonsils
172
T&A
(ENT) tonsillectomy and adenoidectomy, tonsils and adenoids removed in surgery
173
TM
(ENT) tympanic membrane
174
carotid bruit
(neck) whooshing blood flow heard with auscultation. often because of plaque narrowing
175
lymphadenopathy
(neck) enlarged lymph nodes
176
meningismus
(neck) stiff neck as sign of meningitis
177
supple
(neck) flexible, not stiff
178
thyromegaly
(neck) enlarged thyroid
179
JVD
(neck) jugular vein distention, enlarged bulging jugular vein, sign of heart distention due to blood volume increase
180
CV
cardiovascular
181
aneurysm
(CV) localized ballooning of a vessel due to a weakened vessel wall
182
artery
(CV) blood vessel carrying blood away from the heat
183
bradycardia
(CV) slow heart rate HR<60
184
cardiomegaly
(CV) enlarged heart
185
coronary artery
(CV) artery that supplies heart with blood
186
dorsalis pedis pulse
(CV) pulse found on dorsum (top) of foot
187
murmur
(CV) abnormal heart sound, rated on 1-6 scale
188
NSR
(CV) normal sinus rhythm, rhythm of a healthy heart
189
palpitation
(CV) to beat rapidly, irregularly, forcefully on heart
190
pulse exam
(CV) on carotid, brachial, radial, femoral, etc. arteries
191
RRR
(CV) regular rate and rhythm, normal heart sounds at a regular rate (60-100 bpm)
192
stenosis
(CV) narrowing of a body opening or passage
193
tachycardia
(CV) fast heart rate >100 bpm
194
thrombus
(CV) blood clot or blockage
195
vein
(CV) vessel carrying blood towards the heart
196
bradypnea
(respiratory/pulmonary) decreased RR
197
CTA
(respiratory/pulmonary) clear to auscultation
198
dyspnea
(respiratory/pulmonary) difficulty or shortness of breath
199
DOE
(respiratory/pulmonary) dyspnea on exertion, dypsnea during light exercise such as walking
200
hemoptysis
(respiratory/pulmonary) coughing up gross amounts of blood
201
hypoxia
(respiratory/pulmonary) low SaO2 of body, not enough oxygen in the blood
202
pleurisy
(respiratory/pulmonary) pain with breathing
203
rales crackles
(respiratory/pulmonary) wet crackling in lungs
204
rhonchi
(respiratory/pulmonary) mucous rolling around in bronchi
205
SOB
(respiratory/pulmonary) shortness of breath
206
sputum
(respiratory/pulmonary) mixed matter with saliva passed through the mouth
207
stridor
(respiratory/pulmonary) upper airway noise, common sign in croup
208
tachypnea
(respiratory/pulmonary) increased respiratory rate
209
wheezing
(respiratory/pulmonary) high pitched sound heard in the lungs with asthmatics or lung disease
210
dyspepsia
(GI) indigestion
211
dysphagia
(GI) difficulty swallowing
212
emesis
(GI) vomiting
213
hematemesis
(GI) gross amounts of blood in vomit
214
hematochezia
(GI) bright red blood in the stool
215
hepatomegaly
(GI) enlarged liver
216
hernia
(GI) protrusion of part of an internal organ or tissue through weak area of muscle
217
McBurney's point
(GI) RLQ point tenderness, appendicitis
218
melena
(GI) black tarry stool indicative of upper GI bleed
219
Murphy's sign
(GI) RUQ point tenderness, cholecystitis
220
N/V/D
(GI) nausea, vomiting, diarrhea
221
organomegaly
(GI) enlarged organ
222
peritoneal signs
(GI) rebound, guarding, rigidity, signs of peritonitis
223
splenomegaly
(GI) enlarged spleen
224
adnexal tenderness
tenderness of ovaries during pelvic exam, indicative of ovarian cyst
225
cervical os
(GU) opening of cervix
226
CVA tenderness
(GU) costovertebral angle tenderness, tenderness over kidneys
227
dysmenorrhea
(GU) painful menstruation
228
dysuria
(GU) painful urination
229
Foley catheter
(GU) tube inserted through urethra to drain urine, often left in place
230
Foley catheter
(GU) tube inserted through urethra to drain urine, often left in place
231
frequency
(GU) urinating often
232
G/P/Ab
(GU) gravida, para, abortion. #times pregnant, #live children born, #failed pregnancies
233
gravid
(GU) the state of being pregnant
234
hematuria
(GU) blood in urine
235
IUP
(GU) intrauterine pregnancy. normal egg fertilization
236
LNMP
(GU) last normal menstrual period, first day of ones period
237
OB/GYN
obstetrics and gynecology
238
spotting
passing small amounts of blood from the vagina
239
urgency
abrupt urge to urinate
240
arthralgias
(musculoskeletal) joint aches
241
atrophic
(musculoskeletal) showing signs of tissue breakdown
242
bony tenderness
(musculoskeletal) tenderness of bone indicating fracture
243
deformity
(musculoskeletal) visual abnormality of bone or anatomical structure
244
dislocation
(musculoskeletal) disconnected joint
245
Fx
(musculoskeletal) fracture
246
kyphosis
(musculoskeletal) hunchback, rounded thoracic cavity of spine
247
malleolus
(musculoskeletal) bony prominence on each side of the ankle
248
myalgia
(musculoskeletal) muscular pain
249
paraspinal tenderness
(musculoskeletal) tenderness of muscles beside the spine
250
ROM
(musculoskeletal) range of motion of join
251
vertebral point tenderness
(musculoskeletal) tenderness directly over the vertebra
252
abrasion
(skin) scrape
253
avulsion
(skin) forcible pulling away of a part
254
cyanosis
(skin) blue color of skin due to hypoxia
255
diaphoresis
(skin) sweating
256
ecchymosis
(skin) bruising
257
eczematous rash
(skin) dry, scaly skin consistent with eczema
258
edema
(skin) swelling
259
erythema
(skin) redness
260
fascia
(skin) fibrous membrane of connective tissue supporting and separating muscles and organs
261
fluctuance
(skin) fluid beneath skin due to infection and pus
262
hematoma
(skin) raised area with underlying blood in tissue due to vessel rupture
263
I&D
(skin) incision and drainage, procedure used to drain and abscess to relieve pain
264
induration
(skin) hardened area of tissue, soft tissue that becomes extremely firm
265
keloid
(skin) hypertrophic scar
266
laceration
(skin) splitting of skin due to trauma
267
maculopapular rash
(skin) rash that is both red and raised
268
motttled
(skin) patchy skin color due to poor blood circulation
269
pallor
(skin) pale skin due to anemia
270
papular
(skin) raised bumps
271
petechial rash
(skin) red discolorations that sign meningitis
272
pitting edema
(skin) edema that retains an imprint when touched
273
pruritic
(skin) itchy
274
purulent
(skin) pus
275
serosanguinous
(skin) consisting of serum and blood
276
subungual
(skin) beneath nail
277
tenting
(skin) slow return of skin to normal position after being pinched, sing of dehydration or aging
278
turgor
(skin) skin elasticity, poor turgor sign of age
279
ulcerations
(skin) blisters or open sores
280
urticarial rash, wheals
(skin) patchy red, raised rash, consistent with allergies
281
vesicular rash
(skin) vesicles, fluid filled blisters (herpes)
282
aphasic
(neurological) absence of ability to understand language
283
ataxia
(neurological) loss of coordination
284
cephalgia
(neurological) headache
285
epilepsy
(neurological) seizure disorder
286
facial asymmetry
(neurological) drooping of one side of face
287
hemiparesis
(neurological) weakness of one half of the body
288
hemiplegia
(neurological) paralysis on one side of body
289
LOC
(neurological) loss of consciousness
290
meningitis
(neurological) infection of meninges
291
MAEx4
(neurological) moves all extremities x4, patient moves arms and legs normally, indicating normal motor functions
292
normal DTR
(neurological) normal deep tendon reflexes, rated as 2+
293
oriented x3
(neurological) oriented to Person Place Time
294
paresthesia
(neurological) abnormal tactile sensation, tingling
295
postictal
(neurological) state of somnolesence and decerased responsiveness after seizure
296
syncope
passing out, loss of consciousness, fainting
297
vertigo
(neurological) room spinning dizziness
298
affect
(psychological) observed emotional and social responses
299
auditory hallucinations
(psychological) hearing things that arent real
300
depressed
(psychological) sad unhappy
301
flat affect
(psychological) lack of normal interaction, monotone, unemotional
302
homicidal ideation
(psychological) thoughts of killing another person
303
suicidal ideation
(psychological) thoughts of killing oneself
304
tangential thoughts
(psychological) thought processes that do not follow normal or logical progression
305
visual hallucination
(psychological) seeing things that do not exist
306
-ectomy
removal
307
-itis
inflammation
308
-scopy
viewing with scope
309
asucultation
listening with stethoscope
310
baseline
normal state of being for each patient
311
benign
normal, of no danger to health
312
catheter
tube inserted into vessels to permit injection or withdrawal of fluids
313
DDx
differential diagnosis, different diseases a physician is considering as a reason for patient symptoms
314
grossly
a lot
315
infarct
area of dead tissue after loss of blood supply
316
ischemia
lack of blood to a specfic area
317
palpation
examination by touch
318
standing erect with arms at sides and palms of hands turned forward
anatomical position
319
situated towards front
anterior
320
cervical spine (C1-C7)
C-spine
321
generalized, not localized to any specific location
Diffuse
322
farther from the trunk of body
distal
323
upper central region of the abdomen
epigastric
324
anatomical feature of an infant's skull, the "soft-spot"
fontanel
325
lower on the body farther from the head
Inferior
326
lumbar spine (L1-L5)
L-spine
327
farther from the midline
lateral
328
Left Lower Extremity, or Left leg
LLE
329
Left Lower Quadrant, Left Lower Quadrant of the abdoment
LLQ
330
Left Upper Extremity, Left arm
LUE
331
Left Upper Quadrant of hte abdomen
LUQ
332
nearer to the midline
medial
333
palm side of hand or body
palmar, or volar
334
sole of foot
Plantar
335
rear or back
posterior, or dorsal
336
body position lying face down with forearms and hands turned palm side
prone
337
nearer to the trunk of the body
proximal
338
Right Lower Extremity, or right leg
RLE
339
Right Lower Quadrant of the abdomen
RLQ
340
Right Upper Extremity, or right arm
RUE
341
Right Upper Quadrant of the abdomen
RUQ
342
nearer to the surface
Superficial
343
higher on the body, nearer to the head
superior
344
body position lying face up
supine
345
lower central region on the abdomen
suprapubic
346
Thoracic spine (T1-T12)
T-spine
347
(Timing) new onset, likely concerning
Acute
348
(Timing) new exacerbation of a chronic condition
acute on chronic
349
(Timing) long standing, constant.
chronic
350
(Timing) Symptoms that are always present but changing in severity, never fully resolving
Fluctuating
351
(Timing) Symptoms that completely resolve at times, but continue to return repeatedly
Intermittent
352
(Timing) occasional, sporadic, transient
Paroxysmal
353
(Timing) Gone, no longer existing
Resolved
354
(Timing) Resolving spontaneously after onset
Transient
355
(Timing) symptoms going in and out
waxing and waning
356
Family history, a part of the medical chart that lists diseases and health conditions in the family that may put the patient at increased risk
FHx
357
Health Insurance Portability and Accountability Act. Federal law that protects sensitive patient information
HIPAA
358
patient
pt
359
rule out
r/o
360
review of system. A part of the medical chart that is a checklist of the symptoms the patient has, grouped by body system
ROS
361
status post (after). (e.g., headache s/p fall, headache after fall)
s/p
362
social history, a part of the chart that addresses lifestyle contributing factors to illness
SHx
363
symptoms
Sx
364
treatment
Tx
365
up to date
UTD
366
within normal limits (normal, not of concern)
WNL
367
diagnosis
dx
368
collection of pus beneath the skin
abscess
369
dangerous infection of the appendix
appendicitis
370
inflammation of the joints
arthritis
371
atrial fibrillation, irregular and very rapid heart rhythm. arrythmia
A fib
372
localized facial nerve dysfunction that causes facial droop and numbness
Bell's Palsy
373
inflammation or infection of the bronchi, or upper airway
bronchitis
374
cancer, carcinoma
CA
375
infection of skin cells
cellulitis
376
cerebrovascular accident, or stroke. hemorrhagic or ischemic in nature
CVA
377
inflammation of the gallbladder
Cholecystitis
378
production of gallstones
Cholelithiasis
379
chronic obstructive pulmonary disease, causes obstructed airflow to the lungs
COPD
380
chronic renal failure, chornic kidney disease Decreased ability for kidneys to filter waste and fluid from the blood.
CRF, CKD
381
inflammation of an organ by degenerative changes, especially the liver
cirrhosis
382
congestive heart failure, serious condition which the heart does not pump blood as efficiently
CHF
383
infection of the outer layer of the eye
conjuctivitis
384
coronary artery bypass graft, invasive procedure used to treat coronary artery disease
CABG
385
coronary artery disease, buildup of plaque in the arteries
CAD
386
inflammation of rib cartilage
Costochondritis
387
viral infection of the upper airway with barking cough, stridor
croup
388
deep vein thrombosis, blood clot forming deep in body, usually in leg
DVT
389
inflammation of the skin
dermatitis
390
acute inflammation of the diverticula pouches
diverticulitis
391
egg developing outside of the uterus extremely dangerous due to rupture
ectopic pregnancy
392
presence of functioning endometrial tissue outside of the uterus
endometriosis
393
inflammation of the GI tract
gastroenteritis
394
gastrointestinal reflux disease, when stomach acids go from stomach into esophagus
GERD
395
type of arthritis, diagnosed by ordering a uric acid level
gout
396
inflammation of the liver
hepatitis
397
high blood sugar due to diabetes
hyperglycemia
398
hyperlipidemia, high cholesterol
HLD
399
hypertension, high blood pressure (>140/90)
HTN
400
low blood sugar
hypoglycemia
401
low blood sugar (<100/65)
hypotension
402
insulin-dependent diabetes mellitus. Diabetes requiring the use of insulin injections
IDDM
403
Inflammation of a lymphatic vessel, appears as red streaking
Lymphangitis
404
multiple sclerosis, autoimmune disease affective brain and spinal cord
MS
405
myocardial infarction, heart attack
MI
406
kidney stone
nephrolithiasis / renal calculi
407
non-insulin dependent diabetes mellitus, diabetes not requiring the use of insulin injections
NIDDM
408
otitis media, inner ear infection
OM
409
inflammation of the pancreas
pancreatitis
410
pelvic inflammatory disease
PID
411
peptic ulcer disease
PUD
412
inflammation of the pericardium
pericarditis
413
peripheral vascular disease. blood circulation disorder that causes the blood vessels to narrow, block, or spasm
PVD
414
throat infection
pharyngitis
415
pneumonia, infection inside lung tissue
PNU
416
presence of air or gas in the pleural space
pneumothorax
417
autoimmune skin disease, dry, scaly, red patches of skin
psoriasis
418
pulmonary embolism. blockage of pulmonary artery due to clot
PE
419
presence of air or gas in the pleural space, collapsed lung
pneumothorax
420
infection on the kidneys
pyelonephritis
421
compression of the sciatic nerve causing back pain with radiation to posterior leg
sciatica
422
dangerous infection of the blood
sepsis
423
infection/inflammation of the sinuses
sinusitis
424
fungal rash
tinea
425
transient ischemic attack. mini stroke, neurological function restored over time
TIA
426
upper respiratory infection
URI
427
urinary tract infection, kidneys, ureters, bladder, urethra
UTI
428
basic metabolic panel. blood test that measures lots of things
BMP
429
chest x-ray
CXR
430
complete blood count, blood test used to evaluate overall health, wide range of disorders
CBC
431
complete metabolic panel, blood test that measures 14 different substances
CMP
432
computerized assisted tomography. XR procedure that does cross section scans of the body
CT/CAT
433
electrocardiogram
EKG/ECG
434
hemoglobin and hematocrit, rd blood cell measurements to evaluate anemia
H&H
435
urinalysis, urine test to detect a wide range of disorders
UA
436
antibiotics
abx
437
acetylsalicylic acid (aspirin)
ASA
438
acetylsalicylic acid
aspirin
439
(bis in die) twice daily
B.I.D
440
intramuscular
IM
441
no known drug allergies
NKDA
442
non-steroidal anti-inflammatory drug (ibuprofen, motrin)
NSAID
443
per os (by mouth)
PO
444
(pro re nata) as needed
p.r.n
445
(quaque hora somni) at every bedtime
q.h.s
446
(quater in die) four times a day
q.i.d
447
prescription (as in 'recipe')
rx
448
(ter in die), three times a day
t.i.d
449
(constitutional) without fever
afebrile
450
(constitutional) able to move about, not confined to a bed
ambulatory
451
(constitutional) extremely bony, malnourished
cachetic
452
the general appearance of the patient
constitutional
453
(constitutional) inability to tolerate their body state due to pain, or respiratory failure
distress
454
(constitutional) no acute distress, patient is comfortable
NAD
455
(constitutional) feverish
febrile
456
(constitutional) septic, very sick, about to die
lethargic
457
(constitutional) generalized discomfort or weakness
malaise
458
(constitutional) appearing stable, no risk of deterioration
non-toxic
459
(constitutional) appearing drowsy
somnolent
460
(constitutional) poor self hygiene
unkempt
461
(constitutional) normal state of mental and body development
well developed
462
(eye) thin outer lining of the eye and eyelid
conjunctiva
463
(eye) transparent frontal aspect of the eye, covering both the iris and pupil
cornea
464
(eye) extraocular muscles intact, testing that examines the function of the eye muscle
EOMI
465
use of ophthalmoscope to look through pupil and examine interior surface of posterior eye
fundoscopic exam
466
(eye) involuntary shaking eye movements
nystagmus
467
(eye) pain in eye
ophthalmalgia
468
(eye) pale inner aspect of the eyelid most often due to anemia
pale conjunctiva
469
(eye) bruising around the eyes, indicative of trauma
periorbital ecchymosis
470
(eye) light sensitivity
photophobia
471
(eye) pupils equal, round reactive to light. common normal exam finding
PERRL
472
(eye) yellowing of the sclera (whites of the eye) due to jaundice
scleral icterus
473
(eyes) sclera is white and normal
sclerae anicteric
474
(eye) blood in white part of the eye
subconjunctival hemorrhage
475
(ENT) earwax
cerumen
476
(ENT) teeth
dentition
477
(ENT) dry tongue, mouth, and lips indicating dehydration
dry mucosa
478
(ENT) without teeth
edentulous
479
(ENT) nosebleed
epistaxis
480
(ENT) gums
gingiva
481
(ENT) nostril
nare
482
(ENT) back of mouth where it meets the throat
oropharynx
483
(ENT) earache
otalgia
484
(ENT) redness of the pharynx, indicating throat infection
pharyngeal erythema
485
(ENT) clear nasal discharge, runny nose
rhinorrhea
486
(ENT) ringing in ears
tinnitus
487
(ENT) redness of the TM, infection sign
TM erythema
488
(ENT) pus on tonsils, indicating infection of tonsils
tonsillar exudate
489
(ENT) tonsillectomy and adenoidectomy, tonsils and adenoids removed in surgery
T&A
490
(ENT) tympanic membrane
TM
491
(neck) whooshing blood flow heard with auscultation. often because of plaque narrowing
carotid bruit
492
(neck) enlarged lymph nodes
lymphadenopathy
493
(neck) stiff neck as sign of meningitis
meningismus
494
(neck) flexible, not stiff
supple
495
(neck) enlarged thyroid
thyromegaly
496
(neck) jugular vein distention, enlarged bulging jugular vein, sign of heart distention due to blood volume increase
JVD
497
cardiovascular
CV
498
(CV) localized ballooning of a vessel due to a weakened vessel wall
aneurysm
499
(CV) blood vessel carrying blood away from the heat
artery
500
(CV) slow heart rate HR<60
bradycardia
501
(CV) enlarged heart
cardiomegaly
502
(CV) artery that supplies heart with blood
coronary artery
503
(CV) pulse found on dorsum (top) of foot
dorsalis pedis pulse
504
(CV) abnormal heart sound, rated on 1-6 scale
murmur
505
(CV) normal sinus rhythm, rhythm of a healthy heart
NSR
506
(CV) to beat rapidly, irregularly, forcefully on heart
palpitation
507
(CV) on carotid, brachial, radial, femoral, etc. arteries
pulse exam
508
(CV) regular rate and rhythm, normal heart sounds at a regular rate (60-100 bpm)
RRR
509
(CV) narrowing of a body opening or passage
stenosis
510
(CV) fast heart rate >100 bpm
tachycardia
511
(CV) blood clot or blockage
thrombus
512
(CV) vessel carrying blood towards the heart
vein
513
(respiratory/pulmonary) decreased RR
bradypnea
514
(respiratory/pulmonary) clear to auscultation
CTA
515
(respiratory/pulmonary) difficulty or shortness of breath
dyspnea
516
(respiratory/pulmonary) dyspnea on exertion, dypsnea during light exercise such as walking
DOE
517
(respiratory/pulmonary) coughing up gross amounts of blood
hemoptysis
518
(respiratory/pulmonary) low SaO2 of body, not enough oxygen in the blood
hypoxia
519
(respiratory/pulmonary) pain with breathing
pleurisy
520
(respiratory/pulmonary) wet crackling in lungs
rales crackles
521
(respiratory/pulmonary) mucous rolling around in bronchi
rhonchi
522
(respiratory/pulmonary) shortness of breath
SOB
523
(respiratory/pulmonary) mixed matter with saliva passed through the mouth
sputum
524
(respiratory/pulmonary) upper airway noise, common sign in croup
stridor
525
(respiratory/pulmonary) increased respiratory rate
tachypnea
526
(respiratory/pulmonary) high pitched sound heard in the lungs with asthmatics or lung disease
wheezing
527
(GI) indigestion
dyspepsia
528
(GI) difficulty swallowing
dysphagia
529
(GI) vomiting
emesis
530
(GI) gross amounts of blood in vomit
hematemesis
531
(GI) bright red blood in the stool
hematochezia
532
(GI) enlarged liver
hepatomegaly
533
(GI) protrusion of part of an internal organ or tissue through weak area of muscle
hernia
534
(GI) RLQ point tenderness, appendicitis
McBurney's point
535
(GI) black tarry stool indicative of upper GI bleed
melena
536
(GI) RUQ point tenderness, cholecystitis
Murphy's sign
537
(GI) nausea, vomiting, diarrhea
N/V/D
538
(GI) enlarged organ
organomegaly
539
(GI) rebound, guarding, rigidity, signs of peritonitis
peritoneal signs
540
(GI) enlarged spleen
splenomegaly
541
tenderness of ovaries during pelvic exam, indicative of ovarian cyst
adnexal tenderness
542
(GU) opening of cervix
cervical os
543
(GU) costovertebral angle tenderness, tenderness over kidneys
CVA tenderness
544
(GU) painful menstruation
dysmenorrhea
545
(GU) painful urination
dysuria
546
(GU) tube inserted through urethra to drain urine, often left in place
Foley catheter
547
(GU) tube inserted through urethra to drain urine, often left in place
Foley catheter
548
(GU) urinating often
frequency
549
(GU) gravida, para, abortion. #times pregnant, #live children born, #failed pregnancies
G/P/Ab
550
(GU) the state of being pregnant
gravid
551
(GU) blood in urine
hematuria
552
(GU) intrauterine pregnancy. normal egg fertilization
IUP
553
(GU) last normal menstrual period, first day of ones period
LNMP
554
obstetrics and gynecology
OB/GYN
555
passing small amounts of blood from the vagina
spotting
556
abrupt urge to urinate
urgency
557
(musculoskeletal) joint aches
arthralgias
558
(musculoskeletal) showing signs of tissue breakdown
atrophic
559
(musculoskeletal) tenderness of bone indicating fracture
bony tenderness
560
(musculoskeletal) visual abnormality of bone or anatomical structure
deformity
561
(musculoskeletal) disconnected joint
dislocation
562
(musculoskeletal) fracture
Fx
563
(musculoskeletal) hunchback, rounded thoracic cavity of spine
kyphosis
564
(musculoskeletal) bony prominence on each side of the ankle
malleolus
565
(musculoskeletal) muscular pain
myalgia
566
(musculoskeletal) tenderness of muscles beside the spine
paraspinal tenderness
567
(musculoskeletal) range of motion of join
ROM
568
(musculoskeletal) tenderness directly over the vertebra
vertebral point tenderness
569
(skin) scrape
abrasion
570
(skin) forcible pulling away of a part
avulsion
571
(skin) blue color of skin due to hypoxia
cyanosis
572
(skin) sweating
diaphoresis
573
(skin) bruising
ecchymosis
574
(skin) dry, scaly skin consistent with eczema
eczematous rash
575
(skin) swelling
edema
576
(skin) redness
erythema
577
(skin) fibrous membrane of connective tissue supporting and separating muscles and organs
fascia
578
(skin) fluid beneath skin due to infection and pus
fluctuance
579
(skin) raised area with underlying blood in tissue due to vessel rupture
hematoma
580
(skin) incision and drainage, procedure used to drain and abscess to relieve pain
I&D
581
(skin) hardened area of tissue, soft tissue that becomes extremely firm
induration
582
(skin) hypertrophic scar
keloid
583
(skin) splitting of skin due to trauma
laceration
584
(skin) rash that is both red and raised
maculopapular rash
585
(skin) patchy skin color due to poor blood circulation
motttled
586
(skin) pale skin due to anemia
pallor
587
(skin) raised bumps
papular
588
(skin) red discolorations that sign meningitis
petechial rash
589
(skin) edema that retains an imprint when touched
pitting edema
590
(skin) itchy
pruritic
591
(skin) pus
purulent
592
(skin) consisting of serum and blood
serosanguinous
593
(skin) beneath nail
subungual
594
(skin) slow return of skin to normal position after being pinched, sing of dehydration or aging
tenting
595
(skin) skin elasticity, poor turgor sign of age
turgor
596
(skin) blisters or open sores
ulcerations
597
(skin) patchy red, raised rash, consistent with allergies
urticarial rash, wheals
598
(skin) vesicles, fluid filled blisters (herpes)
vesicular rash
599
(neurological) absence of ability to understand language
aphasic
600
(neurological) loss of coordination
ataxia
601
(neurological) headache
cephalgia
602
(neurological) seizure disorder
epilepsy
603
(neurological) drooping of one side of face
facial asymmetry
604
(neurological) weakness of one half of the body
hemiparesis
605
(neurological) paralysis on one side of body
hemiplegia
606
(neurological) loss of consciousness
LOC
607
(neurological) infection of meninges
meningitis
608
(neurological) moves all extremities x4, patient moves arms and legs normally, indicating normal motor functions
MAEx4
609
(neurological) normal deep tendon reflexes, rated as 2+
normal DTR
610
(neurological) oriented to Person Place Time
oriented x3
611
(neurological) abnormal tactile sensation, tingling
paresthesia
612
(neurological) state of somnolesence and decerased responsiveness after seizure
postictal
613
passing out, loss of consciousness, fainting
syncope
614
(neurological) room spinning dizziness
vertigo
615
(psychological) observed emotional and social responses
affect
616
(psychological) hearing things that arent real
auditory hallucinations
617
(psychological) sad unhappy
depressed
618
(psychological) lack of normal interaction, monotone, unemotional
flat affect
619
(psychological) thoughts of killing another person
homicidal ideation
620
(psychological) thoughts of killing oneself
suicidal ideation
621
(psychological) thought processes that do not follow normal or logical progression
tangential thoughts
622
(psychological) seeing things that do not exist
visual hallucination
623
removal
-ectomy
624
inflammation
-itis
625
viewing with scope
-scopy
626
listening with stethoscope
asucultation
627
normal state of being for each patient
baseline
628
normal, of no danger to health
benign
629
tube inserted into vessels to permit injection or withdrawal of fluids
catheter
630
differential diagnosis, different diseases a physician is considering as a reason for patient symptoms
DDx
631
a lot
grossly
632
area of dead tissue after loss of blood supply
infarct
633
lack of blood to a specfic area
ischemia
634
examination by touch
palpation
