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MEDHOST Specific Flashcards
Flashcards with words and abbreviations commonly used by MEDHOST (EMR)
179
Medical
Not Applicable
03/23/2010

Additional Medical Flashcards

 


 

Cards

Term
"Post-ictal" (Neuro)
Definition
Altered state of consciousness which a person enters after experiencing an epileptic seizure
Term
(+) NV Distal to Injury (MS/extremity)
Definition
Neurovascular intact distal to the injury
Term
(-) CMT (GU: Pelvic Exam)
Definition
No Cervical Motion Tenderness
Term
AMS
Definition
Altered Mental Status
Term
Anorexia (Abdomen/GI)
Definition
Loss of appetite
Term
Anterior Chamber (Eyes)
Definition
Fluid filled space inside th eye between the iris and the cornea (examined in a Slit Exam)
Term
Aphasia (Neuro)
Definition
Expressive: difficulty speaking, cannot get the words out
Receptive: difficulty understanding others
Term
Associated S/S
Definition
Additional symptoms related to the cheif complaint
Term
Asystole (Cardiovascular)
Definition
No pulse
Term
Ataxic Gait (Neuro)
Definition
Unsteady, staggering or irregular gait
Term
Avulsion (Skin)
Definition
Tearing away (commonly refered to as a skin tear)
Term
Avulsion (teeth) (ENT)
Definition
Missing teeth, partially or completely
Term
Axilla (Chest/axilla)
Definition
The armpit or underarm
Term
Babinski (Neuro)
Definition
Neurological test based upon what the big toe does when the sole of the foot is stimulated. A down going big toe is normal
Term
Bloody D/C (ENT)
Definition
Bloody discharge (from the ears)
Term
Bradycardia (Cardiovascular)
Definition
Slow heart rate, heart rate under 60
Term
C-Collar / Backboard PTA (Neck)
Definition
Cervical Collar and/or Backboard Prior to Arrival
Term
C/o
Definition
complaints/complains of...
Term
CC Statement
Definition
Cheif Complaint
Term
CP
Definition
Chest pain
Term
CSF Rhinorrhea (ENT)
Definition
Cerebral Spinal Fluid nasal discharge
Term
CVA Tenderness (Back & GU)
Definition
Costovertebral Angle Tenderness
Term
CVA/TIA
Definition
Cerberal Vasulcar Attack / Transient Ischemic Attack, stroke and "mini" stroke
Term
Cellulitis (Skin)
Definition
Erythematous inflammation of the skin
Term
Cerumen Impaction (ENT)
Definition
Impaction of earwax
Term
Chemosis (Eyes)
Definition
Swelling of the conjunctiva
Term
Conjunctiva (Eyes)
Definition
Thin, clear membrane that coats the outer surface of the eye
Term
Contusion (Multiple Systems)
Definition
A minor bruise
Term
Cornea (Eyes)
Definition
The transparent front part of the eye that covers the iris, pupil, and anterior chamber
Term
Cranial Nerves (Neuro)
Definition
Physical exam used to test cranial nerves, only nerves II-XII are tested. (Nerve I is taste) The exam includes testing the EOM's, testing the sensation to the face, squeezing the eyes shut, sticking out the tongue, puffing out the cheeks, smiling, etc.
Term
Crepitus (Neck & Chest/axilla)
Definition
Grating, crackling, or popping sounds experienced under the skin and in the joints
Term
DOE (Respiratory)
Definition
Dyspnea on Exertion: shortness of breath with exertion
Term
DTR's (Neuro)
Definition
Deep Tendon Reflexes, measured from 0-5+ with 2+ being normal
Term
DVT Exam (MS/extremity)
Definition
Deep Vein Thrombosis Exam
Term
Decerebrate (Neuro)
Definition
Abnormal body posture which involves the arms and legs held straight out, toes pointed downward, and th ehead and neck arching backward. The muscles are tightened and held rigidly. Usually indicative of severe damage to the brain
Term
Decorticate (Neuro)
Definition
Abnormal body posture which involves rigidity, flexion of the arms, clenched fists, and extended legs. The arms are bent inward toward the body with the wrists and fingers bent and held on the chest
Term
Decreased ROM (MS/extremity)
Definition
Decreased Range of Motion
Term
Decubitus Ulcer (Skin)
Definition
Bedsore, graded from 1-4
Term
Dental Caries (ENT)
Definition
Tooth decay, cavity
Term
Dialysis Shunt (Cardiovascular)
Definition
MEDHOST will ask 1) Location, 2) Palpable pulse, 3) Ascultated thrill, 4) Erythema, 5) Edema, and 6) Bleeding. Where is it? Can the MD feel a pules? Can the MD hear a thrill? Is there any redness, swelling, or bleeding?
Term
Diaphoresis (Skin)
Definition
Profuse perspiration
Term
Dysarthric (Neuro)
Definition
Poor articulation of speech
Term
Dysmetria (Neuro: Finger to nose test)
Definition
A lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye
Term
Dysphagia (ENT)
Definition
Difficulty Swallowing
Term
EOM's (Eyes)
Definition
Extraocular Movements
Term
ETOH Dependence (Psych)
Definition
Alcohol Dependence
Term
Ecchymosis (Skin)
Definition
Bruising
Term
Edema (Cardiovascular, MSE, & Skin)
Definition
Swelling. Graded 1+, 2+, 3+, and 4+ pitting edema
Term
Emaciated (Constitutional)
Definition
Excessive leanness
Term
Emesis (Abdomen/GI)
Definition
vomit
Term
Epistaxis (ENT)
Definition
Nosebleed
Term
Erythema (Multiple Systems)
Definition
Redness
Term
Excoriated (Eyes)
Definition
Abrasion or scratch
Term
Excoriated (GU: Pelvic exam)
Definition
To tear or wear off the skin; abrade; chafe
Term
Exudate (Eyes & ENT)
Definition
Purulent discharge
Term
FB Sensation (ENT & Eyes)
Definition
Foreign Body Sensation
Term
Febrile (Constitutional)
Definition
With fever (opposite is "afebrile", without fever)
Term
Flatulence (Abdomen/GI)
Definition
Passing gas
Term
Fluoro Strip Used (Eyes)
Definition
A strip of dye used to stain the eye and examine for abrasions or foreign bodies
Term
Fundus
Definition
Back portion of the interior of th eeyeball, visible through the pupil
Term
Glascow Coma Scale (Neuro)
Definition
Scale which aims to give a recording of the conscious state of a person, scores are between 3 (deep unconsciousness) and 15 (awake and alert)
Term
Goiter (Endocrine)
Definition
Swelling of the thyroid gland
Term
Gravida (OB/Gyne)
Definition
Number of pregnancies
Term
Guarding (Abdomen/GI)
Definition
Tensing of the abdominal wall muscles to guard inflamed organs, can be voluntary or involuntary
Term
HA
Definition
Headache
Term
Hematemesis (Abdomen/GI)
Definition
Vomiting blood
Term
Hematoma (Skin)
Definition
Collection of blood outside the blood vessels
Term
Hematuria (GU)
Definition
Blood in the urine
Term
Hemoptysis (Respiratory)
Definition
Coughing up of blood-stained sputum
Term
Hemotympanum (Head/face & ENT)
Definition
Blood in the tympanic cavity of the middle ear
Term
Historian
Definition
The patients history is obtained from someone other than the patient. (Spouse, child, caregiver, ect.)
Term
Homan's Sign  (MS/extremity: DVT Exam)
Definition
Pain in the calf of popliteal region with abrupt dorsiflexion
Term
Homicidal Ideation (Psych)
Definition
Thoughts or desires to harm another person
Term
Hx
Definition
History
Term
Hyphema (Eyes)
Definition
Blood in the anterior chamber of the eye
Term
I&D (Procedure)
Definition
Incision and Drainage (usually and abscess)
Term
Icterus (Eyes)
Definition
Yellowing of the whites of the eyes
Term
Incarcerated Hernia (Abdomen/GI)
Definition
An abdominal hernia which cannot be reduced
Term
Induration (Skin)
Definition
Hardening
Term
Injected (Eyes)
Definition
Redness of the conjunctiva, bloodshot eyes, "pink eye"
Term
Irregularly Irregular (Cardiovascular)
Definition
A heart rhythm more commonly refered to as Atrial Fibulation or A-Fib
Term
JVD (Cardiovascular)
Definition
Jugular Vein Distention
Term
Jaundice (Skin)
Definition
Yellowish discoloration of the skin
Term
Kyphosis (Back)
Definition
Curving of the spine which causes bowing of the back, hunchback
Term
LLQ (Abdomen/GI)
Definition
Left Lower Quadrant
Term
LOC (Neuro)
Definition
Loss of Consciousness
Term
LUQ (Abdomen/GI)
Definition
Left Upper Quadrant
Term
Lesions (Skin)
Definition
Almost any abnormality involving any tissue or organ due to disease or any injury.
Term
Lethargic (Constitutional)
Definition
Minimally responsive (Note: this word is not often used as most Physician's equate lethargic to meaning near death. A better choice might be "somnolent" which means appearing tired or sleepy)
Term
Lordosis (Back)
Definition
Inward curvature of a portion of the spine, swayback
Term
Lymphadenopathy (Neck & Chest/axilla)
Definition
Swollen lymphnodes
Term
Macular (Skin: Rash)
Definition
A skin rash in which the lesions are flat and less than 1cm in diameter
Term
Malaise (Constitutional)
Definition
Generalized feeling of discomfort, illness, or lack of well being
Term
Malocclusion (ENT)
Definition
Misalignment of the teeth/jaw
Term
McBurney's Sign (Abdomen/GI)
Definition
Right lower quadrant (RLQ) tenderness
Term
Moderate Sedation (Procedure)
Definition
Temporarily sedating a patient in order to perform another procedure. Commonly called Conscious Sedation
Term
Modifying Factors
Definition
Does anything make the patients symptoms better/worse?
Term
Murmur(Cardiovascular)
Definition
Extra or unusual sound heard during a heartbeat. Can be Systolic, Diastolic, Crescendo, Decrescendo or Crescendo-Decrescendo and are graded from 1-6
Term
Murphy's Sign (Abdomen/GI)
Definition
Right upper quadrant (RUQ) tenderness
Term
NAD (Constitutional)
Definition
No Acute Distress
Term
NEXUS Criteria (Neck)
Definition

Used to determine risk of spinal cord injury (*important to document if a patient presents with or is given a c-collar)

 

NEXUS Criteria Measures:

  • Tenderness (vertebral)
  • Intoxication
  • Focal Neuro Defecit
  • Distracting Injury (Ex: the pt has an open fracture)
Term
Nuchal Rigidity (Neck)
Definition
Stiff neck
Term
Nystagmus (Verticle/Rotary) (Eyes)
Definition
Involuntary movement of the eye, in a vertical or circular pattern
Term
OTC Meds
Definition
Over the Counter medications
Term
Obtunded (HPI/ROS)
Definition
Mentally dulled (an acceptable caviat for not obtaining HPI/ROS)
Term
Obturator Sign (Abdomen/GI)
Definition
Abdominal pain with flexion and internal rotation of the hip
Term
Odor - ETOH (Constitutional)
Definition
Smells of alcohol
Term
Odor - ketotic (Constitutional)
Definition
Smells of ketones
Term
Organomegaly (Abdomen/GI)
Definition
Enlarged organ(s)
Term
Orientation x1, x2, x3, or x4 (Neuro)
Definition
Oriented to person, place, time, and situation
Term
Orthopnea (Respiratory)
Definition
The inability to breathe easily unless one is sitting up straight or standing. Will often hear of "3 pillow orthopnea" meaning the patient cannot sleep unless propped up on 3 pillows
Term
P-E-R-R-L-A (Eyes)
Definition
Pupils Equal, Round, and Reactive to Light and Accomodation
Term
PND (Cardiovascular)
Definition
Paroxysmal Nocturnal Dyspnea: respiratory distress which awakens the patient from sleep
Term
Pallor (Skin)
Definition
Pale in color
Term
Palpitations (Cardiovascular)
Definition
Abnormailty of heartbeat (often described as the heart "racing" or "skipping beats")
Term
Papilledema (Eyes)
Definition
Optic disc swelling secondary to elevated intracranial pressure
Term
Papular (Skin: Rash)
Definition
Small, solid, rounded bumps rising from the skin that are usually 0.5cm or less in diameter. Papules may open when scratched and become crusty and infected
Term
Paresthesias (MS/extremity)
Definition
An abnormal sensation, burning, prickling
Term
Pedal Edmea (Cardiovascular)
Definition
Pitting edema of the feet
Term
Perfusion (MS/extremity)
Definition
Color of the skin (pink, warm, abd brisk capillary refill are normal. Cold, dusky, mottled, pale, sluggish capillary refill are abnormal)
Term
Perineal Injury (GU)
Definition
Vaginal injury (the area between the anus and the vulva)
Term
Perineal Itching (GU)
Definition
Vaginal itching
Term
Periorbital (Eyes)
Definition
Situated around the orbit of the eye, the outside of the eye
Term
Petechiae (Skin)
Definition
A small red or purple spot on the body caused by a minor hemorrhage
Term
Photophobia (Eyes)
Definition
Excessive sensitivity to light
Term
Pleurisy (Respiratory)
Definition
Chest pain with deep breathing
Term
Pleuritic CP (Respiratory)
Definition
Chest pain with deep breathing
Term
Polydipsia (Endocrine)
Definition
Excessive thirst
Term
Polyphagia (Endocrine)
Definition
Excessive eating
Term
Polyuria (Endocrine)
Definition
Excessive urination
Term
Poor PO Intake (Constitutional)
Definition
Poor food/fluid intake, from the Latin "per os" or "by mouth"
Term
Posterior Pharynx (ENT)
Definition
Throat
Term
Prone Position
Definition
Lying face down (on the stomach)
Term
Pruritus (Allergy)
Definition
Itching
Term
Psoas Sign (Abdomen/GI)
Definition
Abdominal pain elicited when the patient is lying on their side and the thigh is hyperextended
Term
Ptosis (Eyes)
Definition
Drooping of the upper eyelid
Term
Pulses (Cardiovascular)
Definition
Measered 1+, 2+, 3+, and 4+. 2+ is considered normal
Term
Purulent D/C (ENT)
Definition
Drainage of pus
Term
RLQ (Abdomen/GI)
Definition
Right Lower Quadrant
Term
RUQ (Abdomen/GI)
Definition
Right Upper Quadrant
Term
Racoon Eyes (Head/face)
Definition
Bilateral black eyes
Term
Radiation (of pain)
Definition
Does the pain radiate anywhere else? (Ex: Chest pain which radiates to the left arm or abdominal pain which radiates to the left low back)
Term
Rales (Respiratory)
Definition
Commonly refered to as Crackles, the clicking or rattling noises heard on auscultation of the lungs
Term
Rebound (Abdomen/GI)
Definition
Where pain is felt on the release of applied pressure upon the abdomen
Term
Reduction (Procedure)
Definition
Putting a joint back into place after it has been dislocated
Term
Retractions (Respiratory)
Definition
Visible sinking of the chest wall with inspiration
Term
Rhinorrhea (ENT)
Definition
Runny nose
Term
Rhonchi (Respiratory)
Definition
Coarse rattling sound somewhat like snoring, heard on auscultation of the lungs
Term
Romberg (Neuro)
Definition
patients balance is tested while standing with the eyes open and then with the eyes shut. A loss of balabce with the eyes closed is a positive, abnormal test
Term
Rovsing's Sign (Abdomen/GI)
Definition
Palpation of the LLQ results in more pain to the RLQ, indicator of appendicitis
Term
S1 and S2 (Cardiovascular)
Definition
The first and the second heart sounds (the lub and dub) caused by the closing of the AV valves and semilunar valves
Term
SOB (Respiratory)
Definition
Shortness of Breath
Term
Sclera (Eyes)
Definition
The white part of the eye
Term
Septum (ENT)
Definition
The wall dividing the nasal cavity into halves
Term
Splinting (Respiratory)
Definition
Reduced inspiratory effort
Term
Stomatitis (ENT: Mouth)
Definition
Inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, and roof or floor of the mouth. The word "stomatitis" literally means inflammation of the mouth
Term
Stool Guaiac (Abdomen/GI)
Definition
Blood in the stool
Term
Straight Leg Raise (Back)
Definition
A test performed to determine back pain. The patient raises each leg individually until pain is elicited. Test is measured in terms of degrees (pain at 15, 30, 45, 60, 75, or 90 degrees)
Term
Strength (Neuro: Motor)
Definition
Strength is measured from 1-5 over 5, a patient may exhibit 5/5 strength in the left upper extremity but only 4/5 strength in the right. 5/5 in all is normal
Term
Stridor (Respiratory)
Definition
High pitched, harsh, vibratory noise caused by parital airway obstruction
Term
Subconjunctival Hemorrhage (Eyes)
Definition
Bright red patch appearing in the white of the eye
Term
Subungual Hematoma  (MS/extremity: Nails)
Definition
Bleeding under the nail
Term
Suicide - gesture (Psych)
Definition
The patient has activly tried to kill him/herslef
Term
Suicide - ideation (Psych)
Definition
the patient has thought of killing him/herself (with or without a plan)
Term
Supine Position
Definition
Lying face up (on the back) **Think Supine = Spine**
Term
Sx
Definition
Symptoms
Term
Syncope/Syncope - near (Cardiovascular & Neuro)
Definition
Partial or complete loss of consciousness, "passing out"
Term
TM's (-) Visible (ENT)
Definition
TM's are not visible due to...(various reasons)
Term
TM's (ENT)
Definition
Tympanic Membrabe (ear drums)
Term
Tachycardia (Cardiovascular)
Definition
fast heart rate, heart rate over 100
Term
Tenting (Skin: Turgor)
Definition
When pinched and lifted the skin remains tented instead of returning to its normal, flat state. This usually indicates dehydration
Term
Thrush (ENT: Mouth)
Definition
Yeast infection of the mouth and throat, characterized by patches of white, caused by the fungus Candida albicans
Term
Tinnitus (ENT)
Definition
Ringing in the ears
Term
Turbinates (ENT)
Definition
Small, shelf-like, bony structures on the inside wall of the nose
Term
Turgor (Skin)
Definition
Abnormaility in the skin's ability to change shape and return to normal (elasticity)
Term
Ulceration (Skin)
Definition
The process or fact of being eroded away
Term
Urinary Sx's (GU)
Definition
Urinary symptoms
Term
Urticarial (Skin: Rash)
Definition
Hives, itchy wheals
Term
Uvula (ENT)
Definition
The small piece of soft tissue which dangles down from the soft palate over the back of the tongue
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