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Clinical Vocab
vocabulary for Clinical Assessment
| Question | Answer |
|---|---|
| aneroid | no liquid: without liquid |
| antecubital | of or relating to the inner forearm region |
| ataxia | lack of voluntary muscle coordination |
| coma | a state characterized by an extremely deep unconsciousness |
| cyanosis | blue color of the skin due to a lack of oxygen |
| diastolic | pressure in blood vessels when heart muscle is relaxed (between beats) |
| febrile | characterized by fever |
| gait | manner of walking |
| Hx | history |
| hypothermic | low core temperature |
| jaundice | yellow color of the skin due to a build up of bilirubin |
| kyphosis | excessive outward curvature of the spine (thoracic region) |
| lordosis | excessive inward curvature of the spine (lumbar and cervical regions) |
| pallor | pale skin color |
| stupor | a state of near-unconsciousness and confusion |
| Sxs | symptoms |
| systolic | pressure in blood vessels when heart muscle is contracted (during beats) |
| tachypnea | abnormally rapid respiration |
| CC | Chief Complaint; main reason that patient has presented |
| HPI | History of Present Illness; further details concerning CC; duration/description of SSX |
| ROS | Review Of Systems; starting at head and working down, diagnostic questions concerning body systems (head, eyes, lungs) |
| PMH | Past Medical History; past medical problems, past diagnoses, hospitalizations, surgeries |
| SH | Social History; occupation (possible hazards), habits such as smoking/use of alcohol or other drugs, intensity and frequency of physical activity |
| FH | Family History; diabetes, heart problems of direct blood relatives |
| PE | Physical Exam; VS, wt, ht, BMI; head-to-toe examination to gain objective data to evaluate health status of pt |
| EKG | Electro(K)ardioGram; measurement of electrical activity of heart |
| LAB | laboratory values; numerical results returned from laboratory tests |
| Assessment (SOAP) | assess the subjective and objective information; impressions, possibly Dx or working Dx |
| Plan (SOAP) | plan of action, suggestions, recommendations |
| cachectic | weight loss, muscle atrophy, fatigue, weakness, and significant loss of appetite |
| afebrile | "afebrile"; not characterized by high core body temperature |
| emesis | "emesis"; forceful, involuntary expulsion of stomach contents |
| NAD | "no abnormalities detected" or "no acute distress" in neonates |
| papule | hard, raised spot on the skin |
| macular | discoloration of skin |
| hematochezia | (red) blood in the stool (undigested; LOWER GI bleed) |
| paresthesia | numbness or tingling; "pins and needles" |
| bradycardia | slow heart rate |
| cephalgia | headache |
| dysphagia | difficulty swallowing |
| aphasia | inability to speak |
| induration | hardening, stenosis |
| pruritic | intense itching |
| tinnitus | ringing in the ears |
| myalgia | muscle pain |
| hepatosplenomegaly | enlargement of the spleen AND liver |
| heart murmur | abnormal heart sound(s) caused by turbulent blood due to incompetent valves |
| oliguria | low urine output |
| R/O | Rule Out |
| C/O | Complains Of |
| Tx | treatment |
| Dx | diagnosis |
| confluent | grouping together of bumps or sores |
| melena | (brown) hard, blood in the stool (partially digested; UPPER GI bleed) |
Created by:
ianray42
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