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Abrasion - ✔✔superficial wound to the top most layer of the skin (scratch) Afebrile - ✔✔without fever Ambulation - ✔✔to walk Analgesics - ✔✔pain medications Antiemetics - ✔✔nausea medication Antipyretics - ✔✔fever reducing medication Apnea - ✔✔without breath Atelectasis - ✔✔collapse of the alveoli in the lungs Avulsion - ✔✔forcible tearing away of skin from the body Bradycardia - ✔✔slow heart rate (under 60 bpm) Cerumen - ✔✔earwax Cholecystectomy - ✔✔surgical removal of the gall bladder
Claudicaiton - ✔✔limping Colectomy - ✔✔surgical removal of the large intestine/colon Contusion - ✔✔blunt force trauma to tissue under the skin (deep bruise) Cyanosis - ✔✔blue skin due to lack of oxygen Debridement - ✔✔removal of foreign matter or dead tissue form the wound Dyspnea - ✔✔difficulty breathing Dyspnea on exertion - ✔✔difficulty breathing upon movement/ambulation Dysuria - ✔✔difficulty/painful urination Ecchymosis - ✔✔large area of ruptured blood vessels (superficial bruise) Emesis - ✔✔vomitting Epistaxis - ✔✔nose bleed Erythema - ✔✔redness Febrile - ✔✔fever Gait - ✔✔manner of walking
Melena - ✔✔black tarry stools Nephrectomy - ✔✔surgical removal of the kidneys Oophorectomy - ✔✔surgical removal of the ovaries Orthopnea - ✔✔difficulty breathing when lying down Palpable - ✔✔able to be touched or easily perceived Photophobia - ✔✔abnormal intolerance of light, sensitivity to light Pleurisy - ✔✔inflammation of pleural lining of the lungs (pain upon deep inspiration) Polydipsia - ✔✔excessive thirst Polyuria - ✔✔excessive urination Priapism - ✔✔erect penis that does not return to flacid state within 4 hours Pruritis - ✔✔itchiness Puncture - ✔✔object piercing the skin causing small hole Purulent - ✔✔puss Rhinorrhea - ✔✔runny nose
Salpingectomy - ✔✔surgical removal of the fallopian tubes Salpingoophorectomy - ✔✔surgical removal of the ovaries and fallopian tubes Syncope - ✔✔faiting Tachycardia - ✔✔rapid heart rate (above 100 bpm) Tinnitus - ✔✔ringing int he ears Tonsillectomy - ✔✔surgical removal of the tonsils Transient - ✔✔passing into and out of existence Tubal ligation - ✔✔tying of fallopian tubes Vertigo - ✔✔room spinning Waxing and waning - ✔✔gradual increase or decrease of severity of constant pain Ab - ✔✔abortion Abd - ✔✔abdominal Abx - ✔✔antibiotics AKA - ✔✔above knee amputation
cath - ✔✔catheter c.c - ✔✔chief complaint CHI - ✔✔close head injury CP - ✔✔chest pain, cerebral palsy CPR - ✔✔cardiopulmonary resuscitation CSF - ✔✔cerebral spinal fluid CT - ✔✔computerized topography scan CTA - ✔✔clear to auscultation CXR - ✔✔chest x-ray C/S - ✔✔cesarean section DC - ✔✔discharged D&C - ✔✔dilation and curettage DNR - ✔✔do not resuscitate DTR - ✔✔deep tendon reflexes
Dx - ✔✔diagnosis ED - ✔✔emergnecy department EENT - ✔✔eyes, ear, nose, throat EKG - ✔✔electrocardiogram EPI - ✔✔epinephrine EtOH - ✔✔alcohol intoxication Ext - ✔✔extremity FB - ✔✔foreign body FFP - ✔✔fresh, frozen plasma freq - ✔✔frequently From - ✔✔full range of motion F/U - ✔✔follow-up Fx - ✔✔fracture GB - ✔✔gall bladder
IV - ✔✔intravenous I&D - ✔✔incision and drainage K+ - ✔✔potassium Lat - ✔✔lateral LBBB - ✔✔left bundle branch block LLE - ✔✔left lower extremity LLL - ✔✔left lower lobe LLQ - ✔✔left lower quadrant LMP - ✔✔last mentrual period LOC - ✔✔loss of consciousness LP - ✔✔lumbar puncture LUE - ✔✔left upper extremity LUL - ✔✔left upper lobe LUQ - ✔✔left upper quadrant
LVH - ✔✔left ventricular hypertrophy MAE - ✔✔moves all extremities MCA - ✔✔motorcycle accident MS - ✔✔morphine sulfate MVA - ✔✔motor vehicle accident NAD - ✔✔no acute disease NG - ✔✔nasogastric NKA - ✔✔no known allergies nl - ✔✔nomral NPO - ✔✔nothing per os NSR - ✔✔normal sinus rhythim NS - ✔✔normal saline O2 - ✔✔oxygen OD - ✔✔overdose
RLL - ✔✔right lower lobe RLQ - ✔✔right lower quadrant RML - ✔✔right middle lobe RRR - ✔✔regular rate and rhythm RUE - ✔✔right upper extremity RUL - ✔✔right upper lobe RUQ - ✔✔right upper quadrant Rx - ✔✔prescription Pna - ✔✔pneumonia R/O - ✔✔ruled out SQ - ✔✔subcutaneous SOB - ✔✔shortness of breth SNF - ✔✔skilled nursing facility s/p - ✔✔status post
Sx - ✔✔symptoms TAH - ✔✔total abdominal hysterectomy TURP - ✔✔trans-urethral resection of the prostate Tx - ✔✔treatment UA - ✔✔urinalysis US - ✔✔ultrasounds VS - ✔✔vital signs WNL - ✔✔within normal limits x - ✔✔times/multiplied by yr - ✔✔year y/o - ✔✔year old Somnolent - ✔✔drowsy or sleepy Cachectic - ✔✔physical wasting appearance Large Body Mass Index - ✔✔obses
Subconjuctival hemorrhage - ✔✔bright red patch in whties of eyes Extra Ocular Movements Intact - ✔✔physical exam of eye movement Papilledema - ✔✔swelling fo optic disc due to increase in intercranical pressure Fundi sharp - ✔✔interior surface fo teh eye is harp Visual acuity - ✔✔acuteness/sharpness of vision based off eye cart exam Normal Palpebral Conjunctiva - ✔✔the membrane that coats eyelids is clear Exophthalmos - ✔✔bulging of eyes out fo the sockets Nystagmus - ✔✔involuntary rapid eye movement Erythema of the external - ✔✔redness to outer ear canal Cerumen impaction - ✔✔excessive earwax Tympanic membrane - ✔✔eardrum Hemotympanum - ✔✔blood in eardrum Mastoid tenderness - ✔✔tenderness of the mastoid process Clear rhinorrhea - ✔✔clear nasal discharge
Septal deviation - ✔✔displacement of nasal septum Septal hematoma - ✔✔bruising or bleeding within the nasal septum Pericoronitis - ✔✔infeciton of the gums Parotid mass - ✔✔enlarged parotid glands (mouth( Trismus - ✔✔inability to open mouth normally Malocclusion - ✔✔misalignment of the teeth and dental arches Pharyngeal erythema - ✔✔redness of the throat Exudate - ✔✔oozing fluid from the throat Peritonsilar abscess - ✔✔collection of infected leisions near the tonsils Carotid bruit - ✔✔abnormal blood flow int eh carotid artery Cervical vertebral tenderness - ✔✔pain along cervical spine Anterior cervical lymphadenopathy - ✔✔swollen lymphnodes in the neck Meningismus - ✔✔collection of symptoms including neck stiffness, photophobia and headache Nuchal rigidity - ✔✔neck stiffness
Murphy's sign - ✔✔ 4 fingers under right rib (gall bladder infection) Rovsing's sign - ✔✔palpation of LLQ causing pain in RLQ (appendicitis) Psoas sign - ✔✔put knee to chest McBurney's point tenderness - ✔✔point halfway between belly button and hipbone (appendicitis) Umbilical hernia - ✔✔outward protrusion of abdominal lining Greg-Turner's sign - ✔✔bruising of flank area (pancreatitis or ectopic pregnancy) Cullen's sign - ✔✔brusing around umbilicus (pancreatitis or ectopic pregnancy) Costovertebral angle tenderness (CVA) - ✔✔tap on back (kidney infection) Paraspinal tenderness - ✔✔pain adjacent to spine Lasegue test - ✔✔pain with straight leg raised (herniated disc) Saddle anesthesia - ✔✔loss of sensation near the buttocks Cervical Motion Tenderness (CMT) - ✔✔pain with movement of the cervix Inguinal hernia - ✔✔outward protrusion in the groin Cremasteric reflex - ✔✔superficial reflex of the muscle that pulls up the scrotum
Paraphymosis - ✔✔inability to pull back the ore skin over the head of the penis Guaiac - ✔✔test detecting the presence of fecal occult blood Rectal tone - ✔✔anal elasticity of rectal sphincter Melena - ✔✔dark tarry stools Clubbing - ✔✔deformity of finger/fingernails Snuff box tenderness - ✔✔pain around thumb area (scafford fracture) Valgus/Varus stress test - ✔✔evaluation for knee instability Homans' sign - ✔✔pain in the calf region (blood clot) Ligamentous laxity - ✔✔loose ligaments McMurray's test - ✔✔rotate knee test (meniscus tear) Lachman's test - ✔✔pivot shift test (ACL tear) Bursa - ✔✔small fluid filled sac surrounding the joint Aphasia - ✔✔no speech Dysphasia - ✔✔difficulty with word finding
