Term
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Definition
| Altered state of consciousness which a person enters after experiencing an epileptic seizure |
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Term
| (+) NV Distal to Injury (MS/extremity) |
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Definition
| Neurovascular intact distal to the injury |
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Term
| (-) CMT (GU: Pelvic Exam) |
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Definition
| No Cervical Motion Tenderness |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Fluid filled space inside th eye between the iris and the cornea (examined in a Slit Exam) |
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Term
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Definition
Expressive: difficulty speaking, cannot get the words out
Receptive: difficulty understanding others |
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Term
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Definition
| Additional symptoms related to the cheif complaint |
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Term
| Asystole (Cardiovascular) |
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Definition
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Term
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Definition
| Unsteady, staggering or irregular gait |
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Term
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Definition
| Tearing away (commonly refered to as a skin tear) |
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Term
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Definition
| Missing teeth, partially or completely |
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Term
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Definition
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Term
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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 |
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Term
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Definition
| Bloody discharge (from the ears) |
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Term
| Bradycardia (Cardiovascular) |
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Definition
| Slow heart rate, heart rate under 60 |
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Term
| C-Collar / Backboard PTA (Neck) |
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Definition
| Cervical Collar and/or Backboard Prior to Arrival |
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Term
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Definition
| complaints/complains of... |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Cerebral Spinal Fluid nasal discharge |
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Term
| CVA Tenderness (Back & GU) |
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Definition
| Costovertebral Angle Tenderness |
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Term
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Definition
| Cerberal Vasulcar Attack / Transient Ischemic Attack, stroke and "mini" stroke |
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Term
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Definition
| Erythematous inflammation of the skin |
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Term
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Definition
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Term
|
Definition
| Swelling of the conjunctiva |
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Term
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Definition
| Thin, clear membrane that coats the outer surface of the eye |
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Term
| Contusion (Multiple Systems) |
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Definition
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Term
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Definition
| The transparent front part of the eye that covers the iris, pupil, and anterior chamber |
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Term
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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. |
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Term
| Crepitus (Neck & Chest/axilla) |
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Definition
| Grating, crackling, or popping sounds experienced under the skin and in the joints |
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Term
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Definition
| Dyspnea on Exertion: shortness of breath with exertion |
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Term
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Definition
| Deep Tendon Reflexes, measured from 0-5+ with 2+ being normal |
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Term
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Definition
| Deep Vein Thrombosis Exam |
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Term
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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 |
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Term
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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 |
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Term
| Decreased ROM (MS/extremity) |
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Definition
| Decreased Range of Motion |
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Term
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Definition
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Term
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Definition
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Term
| Dialysis Shunt (Cardiovascular) |
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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? |
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Term
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Definition
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Term
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Definition
| Poor articulation of speech |
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Term
| Dysmetria (Neuro: Finger to nose test) |
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Definition
| A lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| Edema (Cardiovascular, MSE, & Skin) |
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Definition
| Swelling. Graded 1+, 2+, 3+, and 4+ pitting edema |
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Term
| Emaciated (Constitutional) |
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Definition
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Term
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Definition
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Term
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Definition
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Term
| Erythema (Multiple Systems) |
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Definition
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Term
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Definition
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Term
| Excoriated (GU: Pelvic exam) |
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Definition
| To tear or wear off the skin; abrade; chafe |
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Term
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Definition
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Term
| FB Sensation (ENT & Eyes) |
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Definition
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Term
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Definition
| With fever (opposite is "afebrile", without fever) |
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Term
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Definition
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Term
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Definition
| A strip of dye used to stain the eye and examine for abrasions or foreign bodies |
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Term
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Definition
| Back portion of the interior of th eeyeball, visible through the pupil |
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Term
| Glascow Coma Scale (Neuro) |
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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) |
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Term
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Definition
| Swelling of the thyroid gland |
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Term
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Definition
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Term
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Definition
| Tensing of the abdominal wall muscles to guard inflamed organs, can be voluntary or involuntary |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Collection of blood outside the blood vessels |
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Term
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Definition
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Term
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Definition
| Coughing up of blood-stained sputum |
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Term
| Hemotympanum (Head/face & ENT) |
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Definition
| Blood in the tympanic cavity of the middle ear |
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Term
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Definition
| The patients history is obtained from someone other than the patient. (Spouse, child, caregiver, ect.) |
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Term
| Homan's Sign (MS/extremity: DVT Exam) |
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Definition
| Pain in the calf of popliteal region with abrupt dorsiflexion |
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Term
| Homicidal Ideation (Psych) |
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Definition
| Thoughts or desires to harm another person |
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Term
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Definition
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Term
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Definition
| Blood in the anterior chamber of the eye |
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Term
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Definition
| Incision and Drainage (usually and abscess) |
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Term
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Definition
| Yellowing of the whites of the eyes |
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Term
| Incarcerated Hernia (Abdomen/GI) |
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Definition
| An abdominal hernia which cannot be reduced |
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Term
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Definition
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Term
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Definition
| Redness of the conjunctiva, bloodshot eyes, "pink eye" |
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Term
| Irregularly Irregular (Cardiovascular) |
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Definition
| A heart rhythm more commonly refered to as Atrial Fibulation or A-Fib |
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Term
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Definition
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Term
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Definition
| Yellowish discoloration of the skin |
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Term
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Definition
| Curving of the spine which causes bowing of the back, hunchback |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Almost any abnormality involving any tissue or organ due to disease or any injury. |
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Term
| Lethargic (Constitutional) |
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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) |
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Term
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Definition
| Inward curvature of a portion of the spine, swayback |
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Term
| Lymphadenopathy (Neck & Chest/axilla) |
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Definition
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Term
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Definition
| A skin rash in which the lesions are flat and less than 1cm in diameter |
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Term
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Definition
| Generalized feeling of discomfort, illness, or lack of well being |
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Term
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Definition
| Misalignment of the teeth/jaw |
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Term
| McBurney's Sign (Abdomen/GI) |
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Definition
| Right lower quadrant (RLQ) tenderness |
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Term
| Moderate Sedation (Procedure) |
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Definition
| Temporarily sedating a patient in order to perform another procedure. Commonly called Conscious Sedation |
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Term
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Definition
| Does anything make the patients symptoms better/worse? |
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Term
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Definition
| Extra or unusual sound heard during a heartbeat. Can be Systolic, Diastolic, Crescendo, Decrescendo or Crescendo-Decrescendo and are graded from 1-6 |
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Term
| Murphy's Sign (Abdomen/GI) |
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Definition
| Right upper quadrant (RUQ) tenderness |
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Term
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Definition
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Term
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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)
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Term
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Definition
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Term
| Nystagmus (Verticle/Rotary) (Eyes) |
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Definition
| Involuntary movement of the eye, in a vertical or circular pattern |
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Term
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Definition
| Over the Counter medications |
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Term
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Definition
| Mentally dulled (an acceptable caviat for not obtaining HPI/ROS) |
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Term
| Obturator Sign (Abdomen/GI) |
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Definition
| Abdominal pain with flexion and internal rotation of the hip |
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Term
| Odor - ETOH (Constitutional) |
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Definition
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Term
| Odor - ketotic (Constitutional) |
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Definition
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Term
| Organomegaly (Abdomen/GI) |
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Definition
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Term
| Orientation x1, x2, x3, or x4 (Neuro) |
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Definition
| Oriented to person, place, time, and situation |
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Term
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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 |
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Term
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Definition
| Pupils Equal, Round, and Reactive to Light and Accomodation |
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Term
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Definition
| Paroxysmal Nocturnal Dyspnea: respiratory distress which awakens the patient from sleep |
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Term
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Definition
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Term
| Palpitations (Cardiovascular) |
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Definition
| Abnormailty of heartbeat (often described as the heart "racing" or "skipping beats") |
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Term
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Definition
| Optic disc swelling secondary to elevated intracranial pressure |
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Term
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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 |
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Term
| Paresthesias (MS/extremity) |
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Definition
| An abnormal sensation, burning, prickling |
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Term
| Pedal Edmea (Cardiovascular) |
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Definition
| Pitting edema of the feet |
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Term
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Definition
| Color of the skin (pink, warm, abd brisk capillary refill are normal. Cold, dusky, mottled, pale, sluggish capillary refill are abnormal) |
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Term
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Definition
| Vaginal injury (the area between the anus and the vulva) |
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Term
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Definition
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Term
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Definition
| Situated around the orbit of the eye, the outside of the eye |
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Term
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Definition
| A small red or purple spot on the body caused by a minor hemorrhage |
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Term
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Definition
| Excessive sensitivity to light |
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Term
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Definition
| Chest pain with deep breathing |
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Term
| Pleuritic CP (Respiratory) |
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Definition
| Chest pain with deep breathing |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| Poor PO Intake (Constitutional) |
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Definition
| Poor food/fluid intake, from the Latin "per os" or "by mouth" |
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Term
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Definition
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Term
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Definition
| Lying face down (on the stomach) |
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Term
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Definition
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Term
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Definition
| Abdominal pain elicited when the patient is lying on their side and the thigh is hyperextended |
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Term
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Definition
| Drooping of the upper eyelid |
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Term
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Definition
| Measered 1+, 2+, 3+, and 4+. 2+ is considered normal |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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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) |
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Term
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Definition
| Commonly refered to as Crackles, the clicking or rattling noises heard on auscultation of the lungs |
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Term
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Definition
| Where pain is felt on the release of applied pressure upon the abdomen |
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Term
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Definition
| Putting a joint back into place after it has been dislocated |
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Term
| Retractions (Respiratory) |
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Definition
| Visible sinking of the chest wall with inspiration |
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Term
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Definition
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Term
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Definition
| Coarse rattling sound somewhat like snoring, heard on auscultation of the lungs |
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Term
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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 |
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Term
| Rovsing's Sign (Abdomen/GI) |
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Definition
| Palpation of the LLQ results in more pain to the RLQ, indicator of appendicitis |
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Term
| S1 and S2 (Cardiovascular) |
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Definition
| The first and the second heart sounds (the lub and dub) caused by the closing of the AV valves and semilunar valves |
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Term
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Definition
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Term
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Definition
| The white part of the eye |
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Term
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Definition
| The wall dividing the nasal cavity into halves |
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Term
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Definition
| Reduced inspiratory effort |
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Term
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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 |
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Term
| Stool Guaiac (Abdomen/GI) |
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Definition
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Term
| Straight Leg Raise (Back) |
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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) |
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Term
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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 |
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Term
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Definition
| High pitched, harsh, vibratory noise caused by parital airway obstruction |
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Term
| Subconjunctival Hemorrhage (Eyes) |
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Definition
| Bright red patch appearing in the white of the eye |
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Term
| Subungual Hematoma (MS/extremity: Nails) |
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Definition
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Term
| Suicide - gesture (Psych) |
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Definition
| The patient has activly tried to kill him/herslef |
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Term
| Suicide - ideation (Psych) |
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Definition
| the patient has thought of killing him/herself (with or without a plan) |
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Term
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Definition
| Lying face up (on the back) **Think Supine = Spine** |
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Term
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Definition
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Term
| Syncope/Syncope - near (Cardiovascular & Neuro) |
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Definition
| Partial or complete loss of consciousness, "passing out" |
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Term
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Definition
| TM's are not visible due to...(various reasons) |
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Term
|
Definition
| Tympanic Membrabe (ear drums) |
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Term
| Tachycardia (Cardiovascular) |
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Definition
| fast heart rate, heart rate over 100 |
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Term
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Definition
| When pinched and lifted the skin remains tented instead of returning to its normal, flat state. This usually indicates dehydration |
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Term
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Definition
| Yeast infection of the mouth and throat, characterized by patches of white, caused by the fungus Candida albicans |
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Term
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Definition
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Term
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Definition
| Small, shelf-like, bony structures on the inside wall of the nose |
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Term
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Definition
| Abnormaility in the skin's ability to change shape and return to normal (elasticity) |
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Term
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Definition
| The process or fact of being eroded away |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| The small piece of soft tissue which dangles down from the soft palate over the back of the tongue |
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