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INTRODUCTION
When you encounter patients with positive symptoms, you will need to perform a symptom analysis to thoroughly
assess your patient’s presenting symptoms. Although many questions come to mind, your patient’s condition and
time constraints may preclude you from going into too much detail. If so, you’ll need to zero in on several key areas
to evaluate your patient’s symptoms.
As you perform the symptom analysis, try to determine how disabling this problem is for your patient. Also ask if he
or she has any medical problems related to the current problems and if he or she is taking any medications for this
current problem.
WHAT IS PQRST?
The helpful mnemonic PQRST provides key questions that will give you a good overview of any symptom. Although
you can ask additional questions, the following ones provide a thorough analysis of any presenting symptom:
P = Precipitating/Palliative Factors
Ask: What were you doing when the problem started? Does anything make it better, such as medications
or certain positions? Does anything make it worse, such as movement or breathing?
Q = Quality/Quantity
Ask: Can you describe the symptom? What does it feel like, look like, or sound like? How often are you
experiencing it? To what degree does this problem affect your ability to perform your usual daily activities?
R = Region/Radiation/Related Symptoms
Ask: Can you point to where the problem is? Does it occur or spread anywhere else? (Take care not to
lead your patient.) Do you have any other symptoms? (Depending on the chief complaint, ask about
related symptoms. For example, if the patient has chest pain, ask if she or he has breathing problems
or nausea.)
S = Severity
Ask: Is the symptom mild, moderate, or severe? Grade it on a scale of 0 to 10, with 0 being no symptom
and 10 being the most severe. (Grading on a scale helps objectify the symptom.)
T = Timing
Ask: When did the symptom start? How often does it occur? How long did it last?
The symptom analysis tables below will help you in assessing your patients with positive symptoms using the
PQRST method.
Q What does the mole or lesion look like? Basal cell carcinoma is often a pink, pearly, translucent, smooth
How big is it? papule with telangiectasis.
Can you show me? Squamous cell carcinoma is often a scaly plaque or ulceration
with an irregular translucent border.
Melanoma depends on type:
Lentigo maligna: Flat, hyperpigmented, variegated, with
irregular border.
Superficial spreading: Irregular border and color, found close
to existing nevi.
Nodular: Papular, arises in nevus; blue, black, or gray nodule
with discrete, sharp borders.
Acral lentiginous: Similar to lentigo maligna but with one or
more dark papules against an uneven, pigmented, speckled
background.
R Where is the mole or lesion? Basal cell carcinoma is usually found on sun-exposed areas
of the face and ears.
Squamous cell carcinoma is usually found on sun-exposed
areas of the face, ears, arms, and hands.
Melanoma depends on type:
Lentigo maligna: Sun-exposed areas, especially face and neck.
Superficial spreading: Men’s backs, women’s legs, trunk of
both sexes.
Nodular: On or within a nevus.
Acral lentiginous: Palms, soles, subungual areas. and
mucous membranes.
S Does it seem to be getting worse, getting Helps determine progression of ulcer and its impact on
better, or staying the same? patient’s activities of daily living (ADLs).
Has it affected your ability to do what you
usually do?
T When did you first notice the sore? Helps determine an acute vs. a chronic problem.
How long has it been there?
R Is the itching generalized or confined to a Generalized itching is more likely systemic in origin
specific area? Eyes: Allergic, viral, bacterial, or fungal conjunctivitis.
If confined to a specific area where? Head: Tinea capitis, pediculosis capitis.
Do you have a rash? Genitals: Vaginitis, tinea cruris, pediculosis pubis.
Do you have a runny nose, tearing of eyes, Chest: Tinea corporis, pediculosis corporis, herpes zoster,
itching of nose and eyes? pityriasis rosea.
Have you noticed any changes in your skin Extremities: Pityriasis rosea, herpes zoster, psoriasis.
color? Ankles, lower legs: Cimex lectularius (bedbugs) or fleas.
Do you have nausea and vomiting, loss of Feet: Tinea pedis.
appetite? The distribution of a rash often helps to identify its source:
Do you have abdominal pain? Generalized rash: More likely systemic in origin.
Is there pain or burning along with the itch- Burrowing-induced skin lesions: Scabies.
ing? Christmas tree pattern on trunk: Pityriasis rosea.
Have you noticed a change in your energy Vesicles in a linear pattern: Herpes.
level? Are you nervous or “hyper?” Or do Transient rash/wheal: Urticaria.
you have decreasedenergy and fatigue? The lesion characteristics also help to identify the source:
Vesicles: Herpes.
Patches: Pityriasis rosea.
Papules: Pediculosis corporis.
Red elevated plaques with silver scales: Psoriasis.
Scales and blisters: Tinea pedis.
Sinus pressure and nasal congestion suggest allergies.
Yellow: Renal disease, liver disease, other systemic problems
associated with itching.
Redness: Infection or inflammatory process.
Pallor: Anemia.
If anorexia, nausea, and/or vomiting, must consider hepatitis or
other form of liver disease.
Right upper quadrant (RUQ) pain is seen in some liver diseas-
es with bile obstruction disorders and with increased bilirubin
levels. The elevated bilirubin causes itching.
Herpes zoster.
If energy is altered, consider thyroid disease or .
diabetes.
Fatigue may also be associated with anemia, malignancy, HIV,
renal or liver disease.
S How severe is the itching? (Grade it on a Severity may help determine the progression of the problem.
scale of 0 to 10, with 10 being the most se-
vere.) Is it worse, the same, or better?
T When did it start? Determining acute vs. chronic onset may help identify underly-
ing cause. For example, allergies usually have an acute onset;
pruritus associated renal disease or liver disease may be more
insidious.
Is it worse at certain times? Pruritus associated with xerosis (dry skin), common in elderly
people, is worse in the winter months.
Do you have other symptoms along Migraines often occur with nausea, vomiting, or visual dis-
with the pain? turbances. Nasal discharge and fever occur with sinusitis.
Sensory changes may accompany intracranial hemorrhage or
temporal arteritis, which often causes unilateral vision loss.
S How severe is the pain at its worst? At its Migraine is usually quite severe, whereas tension headache
least severe? varies from mild to severe. Headache with meningitis is very
severe. Trigeminal neuralgia pain is also very severe. The
“worst headache ever” may indicate subarachnoid bleeding.
T Was the onset of pain sudden or gradual? Sudden-onset pain may be caused by injury or hemorrhage.
Was the pain an isolated event, or does it Migraines and tension headaches often evolve over minutes
recur? Does anything seem to trigger it? or hours and are recurrent. Trigeminal neuralgia pain often
occurs with eating or smiling, is paroxysmal, and causes recur-
rent episodes of extreme pain. Temporal arteritis pain may be
most evident when the temporal area is palpated.
T Is the tightness or discomfort constant? Constant jaw discomfort may be associated with dental pain,
Intermittent? whereas intermittent pain related mostly to chewing action may
How has it progressed since you first be associated with TMJ syndrome.
noticed it?
T Has the sore progressed at all since you Most lesions—including those associated with various types
first noticed it? Did it gradually reach its of stomatitis, herpes, syphilis, or trauma—tend to develop and
current size and state, or did it form heal rather abruptly.
abruptly? Is this the first sore you’ve had, However, there may be some early symptoms, such as a
or have they been recurrent? prodromal period of discomfort or progression from nodular
area to vesicles and ulcers that might be present with herpes
simplex or herpes zoster. Recurrent episodes could be related
to herpes simplex, allergies to foods or medications, or trauma,
such as might occur with tongue biting. Persistent nonhealing
lesions are often associated with malignancy.
S How severe is the sensation on a scale Provides a baseline assessment for evaluating improvement
of 0 to 10? or worsening of condition.
T How long have you had the dryness in your Constant dryness is more common with advanced age or
eyes? Is it constant or does it come and go? systemic disease, such as Sjögren’s syndrome or disease
of the lacrimal gland.
R Do you have mucus with your cough? If so, Small amount, thin, clear-to-white, odorless, tasteless: Normally
what is the mucus like? present to maintain patent airway and remove debris.
What color is it? Increased amount, thin, clear, or white: Postnasal drip, allergy,
What does it smell/taste like? sinus
What other symptoms do you have? inflammation, viral cold or flu, bronchitis/asthma without infection
(emphysema does not have sputum).
Thick, tenacious: Usually related to dehydration or inadequate
fluid intake. If difficult to expectorate, may develop mucus plugs.
Gray or tan: Smoking, bronchitis.
Yellow or green: Bacterial infection, Pseudomonas: Infection with
emphysema or chronic bronchitis. With asthma, mucus may be
from increased eosinophils rather than infection.
Apple green, thick: Haemophilus influenzae, pneumonia.
Rust colored: Pneumococcal pneumonia, pulmonary infarction,
tuberculosis (TB), lung cancer.
Pink, either thin, streaked, or frothy/bubbly: Streptococcal or
staphylococcal pneumonia, pulmonary edema.
“Red currant jelly” appearance: Klebsiella pneumoniae.
Blood-streaked mucus or frank bleeding (hemoptysis): Violent
coughing, TB, pneumonia, lung cancer, lung abscess with infarc-
tion, pulmonary emboli, bronchiectasis, coagulation disorders,
sarcoidosis.
HELPFUL HINT
If patient reports hemoptysis, determine if source of bleeding
is from lungs or stomach. Hematemesis (bloody emesis from
stomach) is usually dark red or coffee ground colored if blood is
partially digested. Blood tests positive for acid in a litmus test.
Bright red, thick blood is usually from ruptured esophageal vari-
ces (dilated esophageal blood vessels). Hemoptysis (coughed-
up blood) is usually light to bright red, thin, and possibly mixed
with mucus.
ALERT
Persistent hemoptysis in a middle-aged smoker usually indicates
bronchial carcinoma.
Foul odor or taste: Bacterial infection, especially anaerobic
bacteria. “Tickle” in throat: Cough localized above or below larynx.
Sneezing, nasal blockage: Rhinitis. Hoarseness: Laryngitis.
Ineffective cough, hoarse voice: Recurrent laryngeal nerve palsy.
Dry, painful cough: Tracheiti
S Is the cough getting worse? Persistent cough for more than 3 weeks is considered chronic
and warrants investigation.
T How long have you had the cough? More than 3 weeks: Often associated with smoking.
When does it occur? Upon arising: Bronchitis or cigarette smoking.
Late afternoon: Allergies or occupational exposure to irritants.
After eating: GERD.
Evening or after going to bed: Postnasal drip, sinusitis, GERD
with nocturnal aspiration.
During the night: Asthma, pulmonary edema.
After exercise: Asthma.
No specific time: COPD, lung cancer, pneumonia, TB.
DESCRIPTION SIGNIFICANCE
P What precipitates the SOB? Dyspnea on exertion (DOE) with little or no SOB at rest: Physi-
Activity or exercise? cal decompensation (being out of shape), inadequate ventila-
What makes it better? tion and perfusion, inefficient breathing mechanism, slowly
Sitting upright? Sleeping propped on pil- progressive lung disorders in early stages.
lows? Resting? Paroxysmal nocturnal dyspnea (awakening at night with SOB):
Pulmonary edema secondary to cardiac disorders/failure or
advanced chronic lung disease (cor pulmonale).
Orthopnea (must be in upright position to breathe comfortably):
Pulmonary edema, asthma, pulmonary HTN.
Nonrespiratory causes: Obesity, high spinal cord injury, pain.
Q How would you describe your breathing Helps determine degree of functional disability.
problem? (Often described as SOB, inabil- “Tight chest”: Associated with pain, as with angina or pleurisy.
ity to “catch breath,” feeling short-winded, Dyspnea is the result of pain, as with angina or pleurisy.
“tight chest,” inability to do housework.)
Does it keep you from performing your
usual activities?
R Aside from the SOB, do you have any other Chest pain: Angina, myocardial infarction (MI), pulmonary
symptoms? embolus.
Dyspnea with deep inspiration: Associated with pleuritic pain or
abdominal surgery.
S On a scale of 1 to 4, how would you rate If patient with COPD is compensating, dyspnea may be mild
your shortness of breath (1 = mildly dis- (1–2). If patient has decompensated, with decreased PaO2 or
abling; 4 = very disabling)? increased PaCO2 levels, dyspnea will be disabling (3–4).
Can also assess severity by functional
measure.
T When did the SOB start? Onset/duration:
How long does it last? Immediate (minutes): Pulmonary edema, pulmonary emboli,
pneumothorax, or acute asthma.
Short (hours to days): Pulmonary edema, pneumonia, asthma,
pleural effusion, anemia.
Long (weeks to years): Chronic lung disease, restrictive lung
disease, anemia, chronic congestive heart failure (CHF).
When duration is prolonged, gradual changes in functional
ability often occur.
Note if accompanied by pain, anxiety/panic, or change in level
of consciousness. Changes in level of consciousness may
indicate hypoxia.
DESCRIPTION SIGNIFICANCE
P Have you had recent respiratory prob- Pneumonia, pulmonary infarction from pulmonary emboli, and
lem? pneumothorax can cause pleuritic pain.
Is the pain worse with deep breathing Pleuritic pain intensifies with breathing, coughing, muscle strain,
and coughing? With movement? or rib fractures.
ALERT
Pleuritic pain that subsides does not
necessarily indicate an improvement, but
may indicate that an effusion has devel-
oped.
Q What does the pain feel like? Aching: Muscle tenderness, possibly cardiac in origin.
HELPFUL HINT
When distinguishing chest pain of respiratory origin from cardiac
pain, be sure to rule out cardiac pain first. (See Chapter 12 for
more information.)
Sharp, stabbing: Spontaneous pneumothorax, pulmonary infarc-
tion, pleurisy, especially with deep breath.
Dull: Lung cancer, from pressure on mediastinal structures.
Localized chest-wall tenderness: Infection; inflammation of chest
wall, intercostal nerves or muscles; fractured ribs.
Referred pain: Possible cardiac or abdominal causes, depending
on pattern of referral.
R Can you point to where it hurts? Localized: Pleural pain, fractured ribs, muscle strain.
Poorly localized: Lung cancer.
S How severe is the pain on a scale of 0 to Severity associated with breathing: Pleuritic pain.
10, with 0 being no pain and 10 being the Severity associated with movement: Musculoskeletal pain.
worst possible pain? Severe, constant pain unrelated to breathing and interfering with
sleep: Malignant disease involving chest wall.
T When does the pain occur? Pain associated with breathing: Pleuritic pain.
Pain with movement: Musculoskeletal pain.
Continual pain: Malignancy of chest wall.
S On a scale of 0 to 10, with10 being the Mild to severe: MI, angina, pericarditis, pulmonary emboli,
worst, how severe is the pain? pneumothorax, pneumonia, esophageal reflux, esophageal
spasm.
Severe: Dissecting aortic aneurysm, pulmonary HTN,
esophageal rupture.
T When did the pain start? Cardiac origin:
How long did it last? Sudden onset lasting 30 minutes to 1 hour, may not have
Have you had this before? precipitating factor: Acute MI.
Sudden onset lasting a few minutes, usually with a precipitating
factor: Angina pectoris.
Acute onset: Dissecting aortic aneurysm.
Acute or variable onset: Pericarditis.
Respiratory origin:
Acute onset: Pulmonary emboli, pneumothorax, pleurisy,
pneumonia, bronchitis, asthma.
Insidious onset: Lung cancer, lung abscess.
Musculoskeletal origin:
Acute: Degenerative disc disease in cervical or thoracic spine,
costochondritis.
GI origin:
Acute: Pancreatitis, cholecystitis peptic ulcer, esophageal
reflux disease.
Neurologicl origin:
Acute: Herpes zoster, nerve root compression.
Psychogenic origin:
Acute: Anxiety or panic attack resulting in hyperventilation.
Q What does the pain feel like? Cramping: Thrombophlebitis, occlusive vascular disease.
Is it deep or superficial? Dull aching: Varicose veins.
T When did the pain start? Was it sudden or Gradual onset: Venous or arterial insufficiency.
gradual? Is it intermittent or continuous? Sudden onset: Thrombophlebitis, acute arterial occlusion.
How long does it last? ALERT
Sudden onset of pain with cold extremity and absent pulse may
indicate acute arterial occlusion, a surgical emergency.
P Does anything make the pain worse? Eating fatty foods: Precipitates gallbladder symptoms.
Does anything make it better? Changing body position: Intensifies parietal pain associated
HELPFUL HINT with appendicitis or perforated ulcer.
Identifying what relieves symptoms has Deep inspiration: Worsens RUQ pain in acute cholecystitis
diagnostic value. and peritonitis.
Eating: Improves symptoms of gastric ulcer.
Sitting up after eating: Improves symptoms of hiatal hernia
and GERD.
T When was your last bowel movement? May identify onset and duration of problem.
How often do you have them? Normal frequency of bowel movements is from 2/day
What is your usual bowel pattern? to 2 to 3/wk.
Has it changed? How long have you had
constipation problems?
Do you have ear problems such as Mé- Inner ear problems may cause nausea.
nière’s disease?
Do you have motion sickness? Nausea is associated with motion sickness.
Do you have a history of heart failure? Nausea can be associated with heart failure, especially
right-sided heart failure.
What have you done to relieve the nausea? Depending on the cause, helps determine if medication or
How has it worked? other interventions will be effective at relieving nausea.
Q How would you describe the nausea? Does Description of nausea depends on cause.
it come over you in a wave and then dis-
sipate, or is it constant?
R Do you have any other symptoms, such as Associated with food poisoning.
fever, chills, cramps, vomiting, or diarrhea?
Vomiting and headache? Typical of migraine headaches.
Malaise and joint pain (arthralgia)? Associated with glomerulonephritis.
Malaise, anorexia, pain in RUQ, and jaun- Associated with hepatitis.
dice?
Anorexia, pain in umbilical region or right Associated with appendicitis.
lower quadrant (RLQ)?
Weight loss? Associated with malabsorption disorders, cancer, food intoler-
ance.
S Is the nausea getting better or worse? Reflects the progression of the problem. For example, nausea
Has the nausea prevented you from doing associated with pregnancy usually subsides by the second
your regular activities? trimester.
Nausea associated with underlying malignancy does not
subside.
Identifies the impact of symptom on patient’s life.
R Do you have any pain? Abdominal discomfort is associated with gastric cancer. Epi-
gastric pain is associated with gastritis.
Periumbilical pain progressing to RLQ pain is associated with
appendicitis.
Do you have diarrhea? Associated with food poisoning and gastroenteritis.
Do you have a fever? Associated with hepatitis, gastroenteritis, and pancreatitis.
Have you lost weight? Associated with gastric cancer.
Are you dizzy? Associated with motion sickness and labyrinthitis.
Are your eyes sensitive to light Associated with migraines.
(photophobia)?
Do you have a headache and stiff neck? Associated with meningitis.
Is your abdomen swollen? Associated with bowel obstruction.
S Is the vomiting getting better or worse? Determining the severity will reflect the progression and acuity
Have you been able to keep any food or of the symptom.
fluids down?
T When did the vomiting start? Identifying the duration of the problem is important in
identifying possible electrolyte imbalance.
HISTORY
Remember to look at each history component as it relates to the integumentary system. Ask the patient the following:
Do you have:
Changes in moles or other lesions? Nonhealing sore or chronic ulceration?
Pruritus/itching? Rashes?
Changes in skin, hair, or nails?
Do you have any food, drug, or environmental allergies?
Do you have any medical problems?
Are you on any medications, prescribed or over the counter (OTC)?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Gloves Penlight
Ruler Marker
Magnifier
POSITION
Assess all areas, changing position as needed.
TECHNIQUE
First, scan your patient, checking for specific signs of diseases affecting other organ systems that might
alter the skin, hair, or nails.
INSPECTION/PALPATION
Skin
Inspect:
Color Odor
Integrity Lesions, if any (if found, describe morphology,
distribution, pattern, and location).
Palpate:
Temperature Turgor
Texture Moisture
If lesions found on inspection, palate them for texture, tenderness, pulsations, blanching.
Hair
Inspect:
Color Quantity
Distribution Condition of scalp
Lesions Pediculosis
Palpate:
Texture Scalp for tenderness, mobility
Nails
Inspect:
Color Condition
Shape Angle of attachment
Palpate:
Texture Capillary refill
DOCUMENTATION
Document your findings.
HISTORY
Remember to look at each history component as it relates to the head, face, and neck. Ask the patient the following:
Do you have:
Head pain/headaches? Jaw tightness and pain?
Neck pain and stiffness? Neck mass?
Nasal congestion? Nosebleed?
Mouth and dental pain? Sore throat?
Hoarseness?
Do you have problems or complaints related to your head, face, nose, mouth, throat, or neck?
Do you have allergies to any medications, foods, or environmental factors?
Do you have any health problems?
Are you taking any medications, prescribed or OTC?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Glove Penlight
Tongue blade Gauze
Stethoscope Otoscope
Transilluminator Cup of water
POSITION
Sitting
TECHNIQUE
First, scan your patient from head to toe, checking for specific signs of diseases affecting other organ
systems that might alter the head, face, and neck.
Nose
Inspect:
Position, septal deviation, discharge, flaring
Nasal mucosa color, intact septum, turbinates, polyps
Palpate:
Patency
Mouth And Throat
Inspect:
Lips: Color, lesions, purse-lip, odor Oral mucosa: Color, lesions
Gingivae: Color, bleeding, retraction, Teeth: Occlusion, number, condition, color
hypertrophy
Tongue: Color, lesions, texture, Oropharynx/soft and hard palate/tonsils: Color,
position, mobility condition lesions, drainage, exudates
Palpate:
Lips and tongue: Tenderness, muscle tone, lesions
Oropharynx: Test gag reflex
Neck
Inspect:
Neutral position, hyperextended, and as patient swallows
Note range of motion (ROM), symmetry, condition of skin.
Palpate:
Cervical lymph nodes: Occipital, postauricular, preauricular, tonsillar, submandibular, submental,
superficial, deep, posterior, supraclavicular, infraclavicular
Thyroid gland: Anterior or posterior approach
Auscultate:
Thyroid: If palpable, listen for bruits with the bell over the thyroid.
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the eyes. Ask the patient the following:
Do you have:
Vision loss? Eye pain?
Double vision? Eye tearing?
Dry eyes? Eye drainage?
Eye appearance changes? Blurred vision?
Have you noticed any changes in your vision?
Do you wear glasses or corrective lenses?
Have you ever had eye surgery? Injury?
Have you ever seen spots or floaters, flashes of light, or halos around lights?
Do you have a history of recurrent eye infections, styes?
When was your last eye exam?
Do you have a history of diabetes or hypertension (HTN)?
What medications are you currently taking?
Do you take any prescribed or OTC eye drops?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Visual acuity chart (Snellen) Color vision chart
Ophthalmoscope Penlight
Cotton swab/ball Gloves if indicated
POSITION
Sitting
TECHNIQUE
First, scan your patient from head to toe, checking for specific signs of diseases affecting other organ
systems that might alter the eyes.
Visual Acuity
Test far (distant) vision. Test near vision.
Test peripheral vision. Test color vision.
Extraocular Muscles
Check parallel alignment and corneal Check for lid lag.
light reflex.
Test six cardinal fields. Perform cover-uncover test.
External Structures
Inspect:
General appearance Eyelids and lashes: Position and distribution
Eyeballs: Protrusion Lacrimal glands and ducts: Swelling, redness,
or drainage
Conjunctiva (bulbar and palpebral): Sclera: Color
Color, foreign objects
Cornea: Clarity, abrasions, corneal reflex Iris: Color, size, equality
Pupils: Size, equality, reaction to light,
and accommodation
Palpate:
Eyeballs: Consistency
Lacrimal glands and ducts: Tenderness
Ophthalmoscopy
Inspect:
Red light reflex Optic disc: Color, shape, borders
Physiological cup: Color, size Vessels (arteries and veins): Color, size, crossings
Retina (fundus): Color, lesions Macula: Color, fovea centralis, lesions
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the ears. Ask the patient the following:
Do you have:
Hearing loss? Vertigo?
Tinnitus? Ear drainage?
Earache?
Do you have problems with your ears, such as ringing? Do you have hearing problems?
Do you have balance problems?
Do you have drainage from your ears? If yes, how much and what color?
Have you had recent head trauma?
Do you have any health problems?
Are you exposed to noise pollution at work or in your home environment?
Are you on any prescribed or OTC medications?
Do you have allergies?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Tuning fork Otoscope with pneumatic attachment
Thermometer Watch
Gloves if indicated
POSITION
Sitting for adult; supine for infant or toddler to stabilize head
TECHNIQUE
First, scan your patient from head to toe, checking for specific signs of diseases affecting other organ
systems that might alter the ear.
Otoscopic Exam
External Ear Canal
Inspect:
Color, drainage, foreign objects, lesions
Tympanic Membrane
Inspect:
Color, position of landmarks, integrity of tympanic membrane ™, mobility of TM
Hearing Tests (Test Each Ear Separately)
Whisper Voice Test Ticking Watch Test
Weber Test Rinne Test
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the respiratory system. Ask the patient the following:
Do you have:
Cough? Dyspnea?
Chest pain? Related symptoms, such as edema and fatigue?
Do you have any history of respiratory disease? If so, are you taking any medication? What are they,
and why are you taking them?
Do you have any other medical problems?
Do you use tobacco? If so, what kind? How much tobacco do you use? How long have you been using it?
What is your occupation?
Where do you live?
When was your last purified protein derivative (PPD)? What was the result?
Have you ever had a chest x-ray? If so, what were the results?
Have you ever been immunized for influenza or pneumonia?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Stethoscope Marker
Ruler
POSITION
Sitting
TECHNIQUE
First, scan your patient from head to toe, checking for specific signs of diseases affecting other organ
systems that might alter the respiratory system.
INSPECTION, PALPATION, PERCUSSION, AUSCULTATION
Apply techniques:
Anterior, posterior, lateral Side to side
Apex to base
Chest
Inspect:
Shape and symmetry Muscles for breathing
Anteroposterior:lateral ratio Respiratory rate, rhythm
Costal angle Spinal deformities
Condition of the skin
Palpate:
Tenderness, masses, crepitus Excursion
Fremitus
Percuss:
Identify percussion sound. Note diaphragmatic excursion.
Auscultate:
Note breath sounds. Note abnormal sounds.
Notes adventitious sounds. Note abnormal voice sounds.
Trachea
Palpate:
Position
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the cardiovascular (CV) system. Ask the patient the following:
Do you have:
Chest pain? Palpitations?
Syncope? Edema?
Fatigue? Extremity changes?
Dyspnea and cough?
Are you having any chest discomfort? If yes, when did it start?
What were you doing before the pain started? Did anything make it better or worse?
Have you ever had this pain before? What does it feel like? Where does it hurt? On a scale from 1 to 10,
with 10 being the worst, how severe is the pain?
Do you have a history of CV disease? If yes, are you taking any medications? If yes, what are you taking
and why?
Do you have any other medical problems?
Are you having any breathing difficulties?
Do you have any allergies? If, yes, describe reaction.
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Stethoscope with the ability to detect Sphygmomanometer
high- and low-pitched sounds
Marker Ruler
POSITION
Supine, sitting, left lateral recumbent
TECHNIQUE
First, scan your patient from head to toe, looking for signs related to the CV system.
Precordium
Inspect:
Apex for pulsations Precordium for pulsations or movement
Palpate:
Locate point of maximum impulse (PMI; left ventricular impulse [LVI]).
Pulsations, lifts, heaves, thrusts, thrills
Percuss: Cardiac dullness
Auscultate (With Diaphragm and Bell):
Each auscultatory site: apex, left lower sternal border, base left, base right
Apex
Auscultate (With Diaphragm and Bell):
Rate, rhythm, S1, S2, extra sounds
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the peripheral-vascular (PV) and lymphatic systems.
Ask the patient the following:
Do you have:
Swelling? Limb pain?
Changes in sensation? Fatigue?
Have you noticed pain, pallor, pulselessness, polar sensation (coldness), paresthesias, or paralysis in
an extremity (the “six Ps” of acute occlusion)?
Do you have aching, heaviness, throbbing or burning pain, itching, or cramping in your legs?
Are your ankles swollen? Is it difficult to fit into your shoes or wear your wedding band lately?
Do you have leg pain when walking or at rest? What makes the leg pain better?
Have you noticed any sores or ulcers on your feet or legs? How long have they been there? What have
you used to treat them?
Do you have a history of high blood pressure, high cholesterol, CV or PV disease, or diabetes mellitus?
Do you smoke? If so, how long and how much?
Have you noticed any swelling in your neck, armpits, or groin? If so, are the swollen areas sore, hard, or red?
Do they appear on both sides of your body?
Are you unusually tired? If so, are you tired all the time or only after exertion? Do you need frequent naps,
or do you sleep an unusually long time at night?
Have you had a fever recently? If so, how high was it? Was it constant or intermittent? Did it follow a pattern?
Do you ever have joint pain? If so, which joints are affected? Does swelling, redness, or warmth accompany
the pain? Do your bones ache?
Have you noticed any sores that heal slowly?
Do you have a history of blood transfusions?
Have you ever been diagnosed with a chronic infection?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Stethoscope with the ability to detect Sphygmomanometer
high- and low-pitched sounds
Marker Ruler
POSITION
Supine, sitting, standing
TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to the PV/lymphatic systems.
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the breasts. Ask the patient the following:
Do you have:
Lump or mass? Pain or tenderness?
Nipple discharge?
Do you have a lump or thickening in or near your breast or under your arm that persists through the
menstrual cycle?
Is the skin on your breast or nipple red, dimpled, puckered, scaly, or inflamed?
Do you have nipple changes? For example, a change in the direction in which one nipple points,
inversion, eversion, or discharge?
Has your breast changed in size, shape, or contour?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Small pillow Mirror
Gloves Ruler
Specimen slide and culture swab
POSITION
Supine with small pillow under shoulder of breast being examined.
Sitting arms at side, arms over head, hands on hips, leaning forward.
TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to the breasts.
INSPECTION, PALPATION
Breasts
Inspect (Different Positions):
Size, shape, symmetry Condition of skin, lesions, venous pattern
Palpate (Vertical Strip, Pie Wedge, or Concentric Circles Methods):
Consistency Tenderness
Masses
Nipple
Inspect:
Inversion/eversion Direction
Discharge Axilla
Condition of skin Lesions
Palpate:
Elasticity Tenderness
Discharge
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the abdomen. Ask the patient the following:
Do you have:
Abdominal pain? Change in bowel patterns?
Nausea? Indigestion?
Vomiting? Weight changes?
Have you ever had the following: stomach ulcer, hemorrhoids, hernia, bowel disease, cancer, hepatitis,
cirrhosis, or appendicitis?
Have you had abdominal surgery? If so, when, what type, and were there any subsequent problems?
Do you have a family history of ulcer, gallbladder disease, bowel disease, or cancer?
Do you have any problems with swallowing, heartburn, yellowing of your skin, gas, or bloating?
Do you have any food allergies or lactose intolerance?
What is your usual weight and height?
How is your appetite? What did you eat in the last 24 hours?
How is your health usually?
Are you currently being treated for a health problem? If so, what?
How often do you usually have a bowel movement?
Are you having problems with diarrhea, constipation, hemorrhoids, or fecal incontinence? Have you
ever noticed blood in your stool or had black, tarry stools?
How often do you urinate? Do you have incontinence or burning when you urinate?
When was your last menstrual period?
Do you smoke? How many packs a day? (Calculate pack-years.)
Do you drink alcohol? If so, how often? Do you use street drugs?
How many cups of coffee, tea, or caffeinated soda do you drink every day?
Have you been exposed to an infectious disease recently?
What is your occupation?
Have you been immunized against hepatitis B?
Have you ever had a blood transfusion? If so, when?
Do you take any prescribed medications? What are they?
Do you have any allergies to medications?
What OTC medicines or herbal preparations do you use?
Do you use antacids, laxatives, enemas, nonsteroidal anti-inflammatory drugs (NSAIDs), or aspirin?
What home remedies do you use?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Stethoscope with the ability to detect Marker
high- and low-pitched sounds
Ruler Reflex hammer or tongue blade
POSITION
Supine
TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to an abdominal assessment.
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the female genitourinary (GU) system. Ask the patient
the following:
If premenopausal, when as your last menstrual period?
Do you have any pain? Location?
Can you describe your menstrual cycle? What as your age of menarche? What was age at menopause?
Do you have any abnormal vaginal bleeding?
What are your sexual practices? How many partners have you had? What type of sexual activity, oral,
genital, anal? What is your sexual preference, heterosexual, homosexual, or bisexual? Do you practice safe
sex? What do you use? Do you use contraceptives? If, yes, type?
What is your obstetrical history? Have you ever been pregnant? Number of live deliveries? Number of
miscarriages? Abortions? Age of first full-term pregnancy?
Do you have any vaginal discharge? If so, can you describe it?
Do you have a history of GU surgery, sexually transmitted diseases (STDs), or cancer?
Are you currently taking any medications? Hormone replacement therapy (HRT)? Birth control pills (BCP)?
Do you have any urinary symptoms, such as burning, frequency, or dysuria?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Gloves Drape
Lightening Vaginal speculum
Cytological materials for Pap test Culture plates
Reagents Hemoccult test
Warm water Water-soluble lubricant
POSITION
Lithotomy
TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to the female GU system.
Palpate:
External genitalia
Labia Bartholin’s and Skene’s glands
Vaginal introitus Perineum
Internal genitalia
Vaginal wall Cervix
Fornices Uterus
Adnexa Rectovaginal exam: Obtain specimens,
hematest stool if present.
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the GU system. Ask the patient the following:
Do you have penile pain? Do you have any lesions? If yes, please describe.
Could you tell me about your sexual practices? Do you practice oral, genital, or anal sex?
How many partners have you had? What is your sexual preference: heterosexual, homosexual, or bisexual?
Do you practice safe sex? What do you use?
Do you have any discharge? Type?
Did you have a history of GU surgery, STDs, or cancer?
Are you taking any medications? If, yes, what are the medications?
Do you have any medical problems, such as diabetes mellitus, HTN, or PV disease?
Do you have any problems with urination, such as burning, frequency, dysuria, or hematuria?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Gloves Penlight
Stethoscope Cotton swab or gauze
Urogenital alginate swabs and Hemoccult test
Thayer-Martin plate
Water-soluble lubricant
POSITION
Supine or standing for genitalia assessment; side-lying or leaning over exam table for rectal exam
TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to male GU assessment
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the motor-musculoskeletal system. Ask the patient
the following:
Do you have:
Pain? Weakness?
Stiffness? Balance or coordination problems?
Other related symptoms?
Do you have a history of musculoskeletal problems, pain, or disease? If yes, are you taking any medications
or undergoing any treatments?
Do you have any other medical problems?
Are you taking any medications, either prescribed or OTC?
Have any accidents or trauma ever affected your bones or joints?
Do your joint, muscle, or bone problems limit your usual activities?
Do you have any occupational hazards that could affect your muscles and joints?
Have you been immunized for tetanus and polio?
Do you smoke or consume alcohol or caffeine? If yes, how much and how often?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Tape measure Goniometer
POSITION
Standing, sitting, supine
TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to a motor musculoskeletal
assessment.
INSPECTION, PALPATION, PERCUSSION
Inspect and Palpate:
Posture
Normal spinal curves (cervical, thoracic, lumbar, sacral)
Test for spinal deformities (kyphosis, scoliosis, lordosis)
Gait
Cerebellar function
Balance (gait, tandem walk, heel-and toe-walk, deep knee bend, hop in place, Romberg test)
Coordination (rapid alternating movements [RAM], finger-thumb opposition, toe tapping, heel down shin)
Accuracy of movements (finger to nose, point-to-point localization)
Measurements
Arm lengths from acromion process to tip of middle finger
Arm circumferences
Leg lengths from anterior superior iliac crest to medial malleolus
Leg circumferences
Muscles
Tone (relaxed and contracted state) of upper and lower extremities
Muscle strength
Joints
ROM, edema, redness, tenderness, crepitus, deformities, stability
Additional tests
Carpal tunnel syndrome: Phalen test or Tinel test
Arm weakness: Pronator drift
Spinal problems: Straight leg raise
Hip problems: Thomas test, Trendelenburg test
Knee problems: Bulge sign, Lachman test, draw sign, McMurray’s test, Apley’s test
Percuss:
Knee for fluid (patellar tap)
DOCUMENTATION
Document your findings and develop your plan of care.
HISTORY
Remember to look at each history component as it relates to the sensory-neurologic system. Ask the patient
the following:
Do you have:
Headache? Mental status change?
Dizziness, vertigo, and syncope? Numbness or loss of sensation?
Deficits in the five senses?
Do you have any neurologic problems?
Do you have any other medical problems?
Are you taking any medications?
Do you have a history of head trauma, loss of consciousness, dizziness, headaches, or seizures?
Do you have memory problems or changes in your senses?
Do you have weakness, numbness, or paralysis?
Do you have problems walking or performing activities of daily living (ADLs)?
Do you have mood problems or depression?
Do you use drugs or alcohol?
Do you have allergies?
Have you ever been treated for a neurologic or psychiatric problem?
When did your symptoms start?
PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Stethoscope Blood pressure cuff
Penlight Gloves
Cotton Tooth pick
Coin Substances to test smell and taste
Tongue blade Reflex hammer
POSITION
Sitting
TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to sensory-neurologic
system assessment.
DOCUMENTATION
Document your findings and develop your plan of care.
A
Abduction
Movement away from the midline.
Acne Vulgaris
Inflammation of the sebaceous glands and hair follicles characterized by papules, pustules, or comedones;
common acne.
Acoustic Neuroma
Benign tumor that grows into the auditory canal involving CN VIII.
Acrochordons
Small, benign polyp growths; skin tags.
Acrocyanosis
Peripheral cyanosis caused by thermoregulation adjustments in newborns.
Acromegaly
Chronic disease in middle-aged adults marked by enlargement of facial bones caused by hyperfunction of the
anterior pituitary, resulting in increased growth hormone.
Actinic Keratosis
Horny, precancerous lesion caused by sun exposure.
Actual Nursing Diagnosis
Identifies an occurring health problem.
Addison Disease
Disease that results in adrenal insufficiency.
Adduction
Movement toward the midline.
Adie’s Pupil
Tonic pupil that responds slowly or not at all with impaired accommodation; affected pupil is frequently larger
than the normal.
Adnexa
Pertaining to the ovaries and fallopian tubes.
Afterload
Volume of blood remaining in the ventricle after contraction; end-systolic pressure.
Agnosia
Inability to recognize an object by sight (visual agnosia), touch (tactile agnosia), or hearing (auditory agnosia).
Agnostic
Person who does not believe in God.
Akathisia
Restlessness, urgent need to move; an extrapyramidal side effect of some antipsychotic medications.
Akinesia
Complete or partial loss of voluntary muscle movement.
Alopecia
Hair loss. Alopecia can be cicatricial (caused by scarring) or noncicatricial (caused by hormonal changes,
medications, infections, or thyroid disease).
Alopecia Areata
Patchy loss of hair.
Alzheimer’s Disease
Chronic, progressive disorder, accounts for 50 percent of all dementias.
Amaurosis Fugax
Temporary loss of vision in one eye, as if a “shade is being pulled down.”
Amenorrhea
Absence or suppression of menstruation.
Anagen
Growth phase of hair development.
Analgesia
Absence of the normal response to pain.
Aneurysm
Abnormal dilatation of a blood vessel.
Angioedema
Development of urticaria and edema of the skin, mucous membranes, or viscera; usually benign.
Angiomas
Vascular spiders, dilated capillaries on the skin, usually seen on neck, chest, face, and arms.
Anisocoria
Inequality in pupil size.
Anorexia Nervosa
Eating disorder characterized by a preoccupation with being thin and dieting, leading to excessive weight loss.
Anosmia
loss of the sense of smell.
Anoxia
Absence of oxygen.
Anthropometry
Measurements of the human body, such as height, weight, skin folds, craiometry, and osteometry.
Apgar
System for evaluating an infant’s physical condition at birth; includes heart rate, respirations, muscle tone,
response to stimuli, and color.
Aphasia
Absence or the impairment of ability to communicate through speech, writing, or signs.
Aphthous Ulcer
A painful oral lesion related to stomatitis cause unknown fever, stress, certain foods may precede lesion.
Apley’s Test
Test for torn meniscus of the knee.
Apnea
Absent breathing.
Apneustic Breathing
Prolonged gasping inspirations followed by extremely short, inefficient expiration.
Appendicitis
Inflammation of the appendix.
Apraxia
Inability to carry out learned sequential movements or commands.
Arcus Senilis
White ring around the cornea from fat deposits; seen in older adults.
Arthritis
Inflammation of the joints, accompanied by pain, swelling, and deformity.
Ascities
Accumulation of serous fluid in the peritoneal cavity.
Assessment
Data collection phase of the nursing process.
Asthma
Reactive airway disease causing inflammation and obstruction of the airways.
Astigmatism
Corneal irregularity causes diffuse refraction of light rays.
Ataxia
Poor muscle coordination with voluntary movements.
Atheist
Person who denies the existence of God.
Atopic Dermatitis
Inflammation and itching of the skin of unknown cause.
Atrophy
Wasting or decrease in size.
Auscultation
Physical assessment technique that uses the sense of hearing to collect data. Auscultation may be direct or
indirect with use of a stethoscope.
Automaticity
Unique property of cardiac muscle tissue to contract without nervous stimulation.
B
Babinski Reflex
Dorsiflexion of the great toe when the sole of the foot is stimulated.
Ballance Sign
Dullness and tenderness when percussing left upper quadrant is a positive sign of peritoneal irritation or
injury to spleen.
Ballottement
Physical assessment technique that involves bimanual palpation of a partially free-floating object. Deep
palpation is applied in one area, causing the partially attached object to become palpable in another area.
Barlow-Ortalini’s Maneuver
Test for congenital dislocation of the hip.
Barrel Chest
Chest shape in which the anteroposterior-to-lateral diameter ratio is 1:1 rather than the normal 1:2 in an adult;
usually associated with chronic lung disease.
Basal Cell Carcinoma
common form of skin cancer; flesh-colored with rolled borders; usually seen on sun-exposed areas.
Beau’s Lines
White, transverse lines across the nail.
Bell’s Palsy
unilateral facial paralysis involving the facial (VII) cranial nerve.
Benign Prostatic Hypertrophy (BPH)
Benign enlargement of the prostate gland.
Biot’s Breathing
Breathing pattern marked by short breaths followed by long, irregular periods of apnea.
Bipolar Disorder
Disorder marked by manic and depressive episodes.
Blepharoconjunctivitis
Inflammation of the eyelids and conjunctiva.
Blunt or Fist Percussion
Percussion technique used to identify organ tenderness by directly or indirectly striking a body surface with
the ulnar surface of the fist.
Body Mass Index (BMI)
Accurate indicator of body fat; calculated from height and weight measurements.
Bouchard’s Nodules
Bony enlargements or nodules on the proximal interphalangeal joints.
Boutonnière deformity
Flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint.
Bradypnea
Respiratory rates below normal.
Braxton-Hicks contractions
Probable sign of pregnancy; painless, irregular uterine contractions that start after the fourth month of
pregnancy and last through the remainder of the pregnancy.
Bris
Jewish religious ceremony for circumcision of the male that usually occurs 8 days after birth.
C
Café-Au-Lait Spots
Pale brown areas of increased melanin on the skin; appear during infancy but often fade with age.
Callus
Painless thickening of the skin over pressure points.
Candidiasis
Infection of the skin or mucous membranes caused by candida.
Capillary Hemangiomas
Stork bites; benign tumor of dilated blood vessels.
Caput Medusa
Plexus of dilated veins around the umbilicus due to portal vein obstruction; seen in cirrhosis (Cruveilhier-
Baumgarten syndrome).
Caput Succedaneum
Edema of the soft scalp tissue from birth trauma.
Cardiomegaly
Enlarged heart.
Carotenemia
Benign yellow discoloration of the skin caused by carotene.
Carpal Tunnel Syndrome
Compression of the median nerve causing numbness and tingling of the fingers.
Cataract
Opacity of the lens of the eye, the capsule, or both.
Cephalohematoma
Hematoma between the periosteum and the skull.
Cerumen
Ear wax.
Chadwick’s Sign
Bluish discoloration of the cervix; seen at 6 to 8 weeks of pregnancy; probable sign of pregnancy.
Chalazion
Hard cyst on the eyelid; meibomian cyst.
Chancre
Hard, syphilitic, primary, painless ulcer; the first sign of syphilis; appearing 2 to 3 weeks after infection; heals
without leaving a scar.
Chancroid
Highly infectious, painful, nonsyphilitic venereal ulcer; heals leaving a scar.
Chandelier’s Sign
Cervical movement tenderness.
Charcot’s Joint
Deformity, instability, and bony overgrowth of the joint.
Chelitis
Inflammation of the lip.
Cheyne-Stokes Breathing
Breathing pattern marked with gradually increasing then decreasing depth of respirations followed by periods
of apnea.
Cholasma
Mask of pregnancy; increased areas of pigmentation on the face associated with the hormonal changes that
occur during pregnancy.
Cholecystitis
Inflamed gallbladder.
Cholesteatoma
Cystlike sac of keratin caused by a congenital defect or chronic otitis media that may affect hearing.
Chordee
Ventrally curved penis.
Circadian Rhythms
Biological events that occur over a 24-hour period of the sleep-wake cycle of humans.
Circumcision
Surgical removal of the end of the prepuce of the penis.
Circumlocution
Inability to name object verbally, so patient talks around object or uses gesture to define it.
Circumstantiality Thinking
Excessive, irrelevant detail, but eventually gets to the point.
Clang Association
Association of words by sound.
Cleft Lip
Congenital condition, resulting in incomplete fusion of the median nasal process and lateral maxillary processes.
Cleft Palate
Congenital fissure in the palate forming a passageway between the mouth and the nasal cavity.
Clonus
Spasms of alternating muscle contractions between muscle groups caused by hyperactive stretch reflex from
an upper motor neuron lesion.
Clubbing
Condition affecting the fingers and toes; characterized by an increased angle of attachment 180 degrees or
greater and an enlargement of the finger pad.
Colitis
Inflamed colon.
Collaborative Nursing Diagnosis
Identifies a potential medical complication that warrants both medical and nursing intervention.
Colostrum
breast fluid; thin, yellowish fluid that contains proteins, calories, and immunoglobulins.
Concrete Thinking
Unable to abstract; thinks in concrete terms.
Conductive Hearing Loss
Sound transmission through air is affected; caused by a problem with the external or middle ear.
Condylomata Acuminatum
Venereal warts caused by the HPV virus. White, dry, painless lesions.
Conjunctivitis
Inflammation of the conjunctiva.
Contact Dermatitis
Inflammation of the skin due to contact with an irritating substance.
Corns
Horny induration and thickening of the skin extending down into the dermis, causing pain and irritation.
Cor Pulmonale
Hypertrophy or right-sided heart failure due to lung disease.
Crackles
Popping, crackling, discontinuous abnormal breath sound; more predominant on inspiration; more in the
periphery of the lung. Formerly referred to as rales caused by atelectasis, pneumonia, CHF, or interstitial fibrosis.
Craniosynostosis
Premature closure of the sutures.
Crepitus
Crackling sound created when air leaks into tissue, or joint movement with little support.
Crisis
Acute event that stresses a person’s resources and ability to cope or a perceived threat to self.
Critical Thinking
Complex thinking process that involves inquiry, interpretation, analysis, and synthesis.
Crohn’s Disease
Inflammatory bowel disease; regional ileitis.
Cryptorchidism
Undescended testicles; absence of testes and epididymis in the scrotal sac.
Cushing’s Triad
Increase in systolic pressure, widened pulse pressure, and bradycardia seen with increased intracranial pressure.
Cutis Marmorata
Mottled skin.
Cyanosis
Bluish discoloration. Types include central cyanosis, a bluish discoloration due to hypoxia, and peripheral
cyanosis, a bluish discoloration due to vasoconstriction.
Cyst
Primary encapsulated lesion that extends into the dermis; filled with fluid or solid material; less than 2 cm in size.
Cystitis
Inflammation of the bladder.
Cystocele
Prolapse of the bladder into the vagina.
Cystourethrocele
Prolapse of the bladder and urethra of the female.
D
Dacryocystitis
Inflammation of the lacrimal sac.
Decerebrate Posturing (extension)
Extension of the arms with hands clenched and hyperpronated resulting from midbrain (brainstem) lesion.
Decorticate Posturing (flexion)
Arms flexed to chest with hands clenched and internally rotated resulting from a lesion in, at, or above the
brainstem in the cerebral cortex.
Degenerative Joint Disease
Type of arthritis due to “wear and tear” of joints; marked by progressive cartilage deterioration in synovial joints,
also known as osteoarthritis.
Delirium
Acute state of mental confusion and excitement marked by disorientation to time and place, usually with
illusions and hallucinations.
Delusions
False belief (grandiose/persecution/reference/somatic) associated with psychosis.
Dementia
Chronic condition with cognitive deficits, including memory impairment.
Depersonalization
Altered perception or experience that causes temporarily loss of self or personal identity.
Depression
Lowering a body part.
Desquamation
Peeling of the skin.
Dexascan
Scan that tests bone density; screens for osteoporosis.
Dextrocardia
Heart located on the right side of the chest.
Diastasis Recti
Separation of the two halves of the rectus abdominis muscles in the midline at the linea alba.
Diopters
Refractive power of a lens.
Dowager’s Hump
Cervical lordosis with dorsal kyphosis due to slow, painless loss of bone (ostoporosis).
Dullness
Percussion sound that is high-pitched, soft, and short in duration heard over organs.
Dupuytren Contracture
Contracture of the palmar fascia causing contraction of the ring and little finger so they cannot be extended.
Dysarthria
Defective speech; inability to articulate words; impairment of the tongue and other muscles needed for speech.
Dysmenorrhea
Painful menstruation.
Dyspareunia
Painful sexual intercourse.
Dyspepsia
Indigestion.
Dysphagia
Difficulty swallowing.
Dysphasia
Impaired or difficulty with speech.
Dysphonia
Difficulty with quality of voice; hoarseness.
Dysplasia
Abnormal growth of tissue.
Dyspnea
Difficulty breathing.
E
Ecchymosis Bruise
A bluish-black skin discoloration due to bleeding (hemorrhage) into the skin.
Echolalia
Repetition of words spoken by another.
Eclampsia
Coma and convulsive seizures that occur between the 20th week of pregnancy and the end of the 1st week
postpartum.
Ectropion
Eversion of the edge of the eyelid.
Eczema
Acute or chronic inflammation of the skin with erythema, papules, vesicles, pustules, scales, or crusts.
Edema
Local or generalized; the body contains excessive amounts of tissue fluid.
Egophony
Abnormal voice sound; “ee” to “aa” change over affected area.
Ejection Click
Abnormal sound; opening of the aortic or pulmonic valves are heard or a prolapse of the mitral valve, high-
pitched, systolic sound.
Elevation
Raising a body part.
Embolism
Occlusion of a blood vessel by a foreign object or a blood clot within the vessel.
Emphysema
Type of obstructive lung disease with permanent enlargement of the alveoli and destruction of the aveolar wall,
leading to overinflated lungs.
Endocarditis
Inflammation of the endocardium.
Endometriosis
Inflammation of the endometrium.
Enopthalmos
Recession of the eyeball into the orbit.
Entropion
Inversion of the edge of the lower eyelid.
Epicodylitis
Inflammation of the epicondyle of the humerus and the surrounding tissue.
Epididymitis
Inflammation of the epididymis.
Epidural Hematoma
Hematoma above the dura; usually an arterial bleed.
Episcleritis
Inflammation of the sclera.
Epispadias
Male urethral meatus opens on the dorsal side of the glans penis.
Epistaxis
Nosebleed.
Epstein’s Pearls
Small, white, pearl-like epithelial cysts on the palate of newborns that disappear within a few weeks after birth.
Epulis
Raised, red nodules on the gums.
Erectile Dysfunction
Difficulty achieving, maintaining, or completing an erection; inability to achieve satisfactory sexual performance.
Erosion
Secondary lesion; loss of superficial epidermis.
Erythema
Diffuse redness of the skin.
Erythema Toxicum Neonatorum
Firm, red macules and papules on newborns; are benign and resolve without treatment.
Esotropia
Convergent strabismus.
Eupnea
Normal respiratory rates.
Eversion
Turning outward.
Excoriation
Secondary lesion; abrasion of the epidermis.
Excursion
Expansion or movement of the chest.
Exopthalmus
Protrusion of the eyeball.
Exotropia
Divergent strabismus.
Expressive Aphasia (motor aphasia)
Inability to express language even though the person knows what he or she wants to say. Inability to
coordinate the muscles controlling speech. Also called Broca’s aphasia. Frontal lobe affected.
Extension
Straightening, increasing the joint angle.
External Rotation
Turning away from the midline.
Extinction
Tested by simultaneously touching opposite sides of patient’s body and having patient identify points where
she or he was touched.
Extravasation
Escape of fluid into surrounding tissue.
F
Fasciculation
Involuntary contraction or twitching of muscle fibers.
Fetal Alcohol Syndrome
Birth defects in an infant born to a mother whose chronic alcoholism persisted during pregnancy; physical and
mental deficits are noted.
Fibrocystic Disease
Tender, thick, nodular areas in the breast influenced by hormones and diet.
Fibroidadenoma
Benign, well-defined adenoma of fibrous tissue.
Fissure
Secondary lesion; linear break in the skin.
Flaccidity
Loss of muscle tone.
Flat
Percussion sound that is very high pitched, very soft, and very short in duration; heard over soft tissue.
Flexion
Bending; decreasing the joint angle.
Flight of Ideas
Rapidly going from one topic to another.
Fluent Aphasia
Words can be spoken but are used incorrectly.
Fluorosis
Chronic fluorine poisoning causing mottling of the tooth enamel.
Fontanel
Unossified space or soft spot lying between the cranial bones of the infant’s skull.
Fordyce’s Granules
Enlarged ectopic sebaceous glands on the oral mucosa or genitalia that appear as small yellow spots.
Fremitus
Palpable vibration created by the movement of air when the patient speaks.
Friction Rub
High-pitched, scratchy sound caused by inflamed layers rubbing together as with a pleural friction rub of
pleuritis or a pericardial friction rub of pericarditis.
G
Genogram
Visual depiction of a family history identifying family members’ health status; a family tree.
Genu Valgum
Knock –knees.
Genu Varum
Bowlegs.
Glaucoma
Group of eye diseases characterized by increased intraocular pressure that leads to pressure on the optic
nerve and can result in blindness.
Glossitis
Inflammation of the tongue.
Goniometer
Instrument used to measure the angle of joint range of motion.
Goodell’s Sign
Probable sign of pregnancy; palpated at 8 weeks; softening of the cervix.
Graphesthesia
Ability to recognize numbers, letters, or symbols traced or written on the skin.
Gravidity
Total number of a woman’s pregnancies.
Grunting
Loud abnormal expiratory sound heard over larger airways resulting from retention of air in the lungs.
Guillain-Barré Syndrome
Acute autoimmune inflammatory destruction of the myelin sheath leading to rapid, progressive, symmetrical
loss of motor function with no sensory loss; usually triggered by a viral infection.
Gynecomastia
Enlarged breast tissue in a male.
H
Hallucination
False perception having no relation to reality; can be auditory, visual, or tactile.
Hallux Valgus
Displacement of the great toe toward the other toes.
Harlequin Sign
Positional color changes seen in infants; dependent side red, nondependent side pale.
Heave
Abnormal, diffuse, lifting precordial impulse.
Hegar’s Sign
Probable sign of pregnancy; appears at 6 weeks; softening of the lower uterine segment.
Hemangioma Simplex
Strawberry marks; collection of dilated blood vessels.
Hematoma
Vascular lesion; a collection of blood in a confined space.
Hemianopsia
Blindness of half the visual field.
Hemimelia
Absence of distal part of an extremity.
Hemiparesis
Weakness on one side of the body.
Hemiplegia
Paralysis on one side of the body.
Hemotympanum
Dark blue tympanic membrane caused by bleeding in the middle ear.
Hepatitis
Inflamed liver.
Hepatomegaly
Enlargement of the liver.
Herbeden’s Nodules
Bony enlargements or nodules on the distal interphalangeal joints.
Hernia
Protrusion of an organ through the wall of a cavity that usually contains it.
Herniated Disc
Prolapse of the nucleus pulposus of a ruptured intravertebral disc into the spinal canal.
Herpes
Vesicular eruptions caused by a virus. Herpes simplex type 1 or 2; commonly called cold sores or fever
blisters. Genital Herpes with herpes simplex type 2; Herpes zoster, shingles.
Hesselbach’s Triangle
Slitlike opening in the groin bounded by the Poupart ligament, the edge of the rectus muscle, andthe deep
epigastric artery; the external inguinal ring.
Hiatal Hernia
Protrusion of the stomach upward into the mediastinal cavity through the esophageal hiatus of the diaphragm.
Hirsutism
Abnormal, excessive hair growth in unusual places, especially in women.
Homen’s Sign
Test for DVT; positive sign if patient complains of calf pain upon dorsiflexion of the foot.
Homeothermic
Ability to stabilize body temperature within a small range.
Homonymous Hemianopsia
Half a visual field cut in the same side on both eyes.
Hordeolum
Sty; inflammation of the sebaceous glands of the eyelid.
Horner’s Syndrome
Contraction of the pupil, partial ptosis of the lid, enopthalmos, and sometimes, loss of sweating on one side
of the face owing to paralysis of the cervical sympathetic nerve trunk.
Hydrocele
Accumulation of serous fluid in a saclike cavity; the tunica vaginalis testis.
Hydrocephalus
Increased accumulation of cerebrospinal fluid within the ventricles of the brain.
Hyperalgesia
Excessive sensitivity to pain.
Hyperresonance
Percussion sound that is very low pitched, very loud, and very long in duration; heard over overinflated lungs.
Hyperthermia
Body temperature elevation above normal.
Hypertonia
Increased tone, tightly flexed arms, and stiffly extended legs with quivering.
Hypertrophy
Increase in size.
Hyperventilation
Increase in the depth of respirations.
Hyphema
Blood in the anterior chamber, in front of the iris.
Hypoalgesia
Decreased sensitivity to pain.
Hypogeusia
Decreased or blunted sense of taste.
Hyponosmia
Decrease in the sense of smell.
Hypopyon
Pus in the anterior chamber of the eye in front of the iris behind the cornea; seen with corneal ulcer.
Hypospadia
Abnormal congenital opening of the urinary meatus on the ventral, undersurface, of the penis in males, in the
vagina in females.
Hypothermia
Body temperature below normal.
Hypotonia
Decreased tone; floppy, limp extremities.
Hypoxia
Oxygen deficiency.
I
Icthyosis
Dry, scaly skin, resembling fish skin.
Iliopsoas Test
Abdominal pain as the patient attempts to raise right thigh against resistance; sign of appendicitis.
Illusions
Misperception of a real external stimuli; common with dementia of Alzheimer’s and schizophrenia.
Imperforated Anus
No anal opening
Impetigo
Inflammatory skin disease with pustules that rupture, then develop crusts.
Inotropes
Influencing the force of muscular contractility.
J
Jaundice
Yellow discoloration of the skin, sclera, and mucous membranes that can result from impaired bile excretion.
K
Kaposi Sarcoma
Vascular malignancy that often first appears on the skin and mucous membranes. Currently, the most common
AIDS-related tumor.
Kehr’s Sign
Referred pain to the left shoulder; sign of splenic rupture. Keloids Hypertropied scar tissue.
Keratoconjunctivitis
Inflammation of the cornea and the conjunctiva.
Kernig’s Sign
Reflex contraction and pain in hamstrings when flexed leg is extended; sign of meningitis.
Kinesthesia
Ability to perceive extent, direction, or weight of movement.
Koran
Sacred book of Islam regulating faith and practices; written by Mohammed.
Korotkoff Sounds
Sounds heard when auscultating the blood pressure.
Kussmaul Breathing
Rapid and deep breathing associated with diabetic acidosis.
Kwashiorkor
Protein deficiency caused by inadequate dietary protein, malabsorption, cancer, or AIDS.
Kyphosis
Accentuated thoracic curve of the spine; hunch back.
L
Lachman’s Test
Test for stability of the collateral cruciate ligaments.
Lacto-Ovovegetarian
Vegetarian diet that includes eggs and dairy products.
Lactovegetarian
Vegetarian diet that includes dairy products.
Lanugo Hair
Fine, downy hair on face, shoulders, and back of newborns.
Lasegue Test
Sstraight-leg test; test for herniated disc; positive if patient has pain with straight-leg rise.
Lentigines
Hyperpigmented macular lesions; liver spots.
Leopold’s Maneuvers
Four steps used to palpate the uterus to determine the position and presentation of the fetus.
Leukonychia
White spots or streaks on the nail.
Leukoplakia
White spots or patches on the mucous membranes or tongue; considered a precancerous lesion.
Lichenification
Cutaneous thickening and hardening from continued irritation.
Lift
Abnormal lifting precordial impulse.
Linea Alba
White line of connective tissue in the middle of the abdomen from the sternum to the pubis.
Linea Nigra
Darkening of the linea alba due to increased pigmentation during pregnancy.
Lipoprotein
Conjugated proteins composed of simple proteins and lipids.
Loose Association
Loose connection between thoughts that are unrelated.
Lordosis
Accentuated lumbar curve of the spine.
Lymphadenopathy
Disease of the lymph nodes.
Lymphedema
Abnormal accumulation of lymphatic fluid in the interstitial space.
M
Macular Degeneration
Degeneration of the macular area of the retina, the area of most acute vision.
Macule
Primary lesions; area of color change less than 1 cm in size.
Macrosomic
Infant large for gestational age.
Mammary Souffle
Murmur that occurs during pregnancy resulting from increased blood flow through the mammary artery.
Mania
Type of bipolar disorder in which the predominant mood is elevated, expansive, or irritable. Motor activity is
frenzied and excessive.
Marasmus
Protein-calorie malnutrition; a severe protein and calorie deficiency leading to tissue breakdown to supply
energy needs; caused by dietary deficiency, severe infections, burns, eating disorders, chronic liver disease,
cancer, and AIDS.
Mastalgia
Breast pain.
Mastitis
Inflammation of the breast.
McBurney’s Sign
Tenderness and rigidity at McBurney’s point (above anterosuperior spine of the ileum, on a line between
the ilium and umbilicus); sign of appendicitis.
McMurray’s Test
Test for torn meniscus of the knee.
Melanoma
Malignant, darkly pigmented mole or tumor of the skin.
Menarche
Age at the onset of menstruation.
Ménière’s Disease
Chronic progressive disease of the inner ear that leads to permanent hearing loss.
Meningitis
Inflammation of the meninges of the brain and spinal cord; may be viral or bacterial.
Menorrhagia
Excessive menstrual bleeding.
Migraine
Vascular headache, usually temporal and unilateral.
Milia
White, pinhead-sized, keratin-filled cysts.
Molding
Shaping of the fetal head to accommodate the pelvic inlet during delivery.
Mongolian Spots
Bluish colored spot in the sacral area; may be seen at birth in Asian, American Indians, African American, and
Southern European infants; usually disappears during childhood.
Monotheistic
One who believes in one God.
Morphology
Classification of organisms by form and structure.
Multigravida
Woman that has had more than one pregnancy.
Multiparous
Having borne more than one child.
Munchausen Syndrome by Proxy
Fabrication of symptoms or physical evidence of another’s illness, or deliberately causing another’s illness,
to gain medical attention.
Murmur
Abnormal heart sound caused by turbulent flow.
Murphy Sign
Sign for an inflamed gallbladder if pain at right midclavicular line under costal angle.
N
Nabothian Cysts
Small, round, yellow, benign lesions on the cervix due to obstruction of the cervical glands.
Naegele’s Rule
System used to estimate the date of onset of labor by counting back exactly 90 days from the onset of last
period and adding 7 days to the date.
Nasolabial Fold
Distance from the corner of the nose to the edge of the lip; smile crease.
Neglect Syndrome
Unilateral inattention in which a patient is unaware of the existence of the affected side of the body, as with
right stroke with left-sided paralysis.
Neologisms
Made-up, meaningless, nonsense words.
Neuralgia
Severe, sharp pain occurring along a nerve.
Neuritis
Inflammation of a nerve.
Neuroleptic Malignant Syndrome
Rare but potentially fatal complication of treatment with neuroleptic drugs. Symptoms include severe muscle
rigidity, high fever, tachycardia, fluctuations in blood pressure, diaphoresis, rapid deterioration of mental status
to coma.
Neuropathic Pain
Pain serves no adaptive purpose and therefore is “pathological” pain.
Neuropathy, Peripheral
Characterized by weakness, paresthesia, ataxia, and decreased deep tendon reflexes with decrease in or loss
of sensation.
Nevus
Mole; congenital discoloration of a circumscribed area of the skin owing to pigmentation.
Nevus Flammeus
Port-wine stain; a large reddish-purplish discoloration on the face or neck.
Nightmare
Frightening dream; bad dreams.
Night Terrors
Type of nightmare from which the child awakens screaming.
Nociceptive Pain
Pain that results from exposure to noxious (painful) stimuli.
Nociceptors
Receptors that respond to painful stimuli found in the skin, subcutaneous tissue, joints, walls of arteries, and
most internal organs, with the highest concentration found in the skin and the least in internal organs.
Nocturia
Excessive urination during the night.
Nocturnal Enuresis
Involuntary loss of bladder control while sleeping; bed wetting.
Nonfluent Aphasia
Slow, deliberate speech; few words.
Nulligravida
Woman who has never conceived a child.
Nulliparous
Never having borne a child.
Nursing Diagnosis
Second phase of the nursing process; an actual or potential health problem or response to life process.
Nursing diagnosis can be actual, potential, possible, collaborative, or wellness focused.
Nursing Process
Systematic problem-solving method that has five steps: assessment, nursing diagnoses, planning,
implementation, and evaluation.
Nystagmus
Involuntary, cyclic movement of the eyeball.
O
Obturator Test
Abdominal pain on inward rotation of the hip; sign of appendicitis.
Onycholysis
Loosening or detachment of the nail from the nailbed.
Opening Snap
Abnormal heart sound; opening of the mitral or tricuspid valves is heard, high-pitched, diastolic sound.
Ophthalmoplegia
Paralysis of the extraocular muscles.
Opisthotonic
Arched back.
Opposition
Movement of thumb to finger.
Orchitis
Inflammation of the testes, causing pain, swelling, and warmth of the scrotum.
Osteoporosis
Loss of bone mass density.
Otalgia
Ear pain.
Otitis Externa
Inflammation of the external ear canal.
Otitis Media
Inflammation or infection of the middle ear.
Otorrhea
Inflammation of the ear with purulent drainage.
Ototoxic
Having detrimental effects on the inner ear or the eighth cranial nerve.
P
Palmar Erythema
Pinkish-red, diffuse mottling over the palms of the hands.
Palpation
Physical assessment technique that uses the sense of touch to collect data. There are two types of palpation:
light, indenting the skin less than ½ inch, best for assessing surface characteristics; and deep palpation.
indenting the skin more than ½ inch, best for assessing organs and masses.
Palpebral Conjunctiva
Conjunctiva that covers the eyelids.
Palpebral Fissure
Distance between the upper and the lower eyelids; the opening of the eyes.
Pancreatitis
Inflamed pancreas.
Pantheistic
Polytheistic; one who believes in many gods.
Papilledema
Edema and inflammation of the optic nerve at the entrance of the eyeball, the optic disc, often caused by
increased intracranial pressure.
Papules
Primary lesion; raised macules.
Paralytic Ileus
Paralysis of the intestines.
Paranoia
Extreme suspiciousness.
Paraphimosis
Strangulation of the glans penis due to retraction of a narrowed or inflamed foreskin.
Paraphrasia
Loss of ability to use words correctly and coherently; words are jumbled or misused.
Paraplegia
Paralysis on lower half of the body.
Paresthesia
Sensation of numbness or tingling; heightened sensitivity.
Parity
Number of pregnancies carried to viability, regardless of outcomes.
Parkinson’s Disease
Chronic nervous system disease characterized by a fine, slowly spreading tremor, muscular weakness and
rigidity, and shuffling gait.
Paronychia
Acute or chronic infection of or around the nail.
Parotitis
Inflammation of the parotid glands; the mumps.
Patellar Tap
Test for fluid in the patellar space.
Pathological Jaundice
Jaundice that occurs within the first 24 hours after birth; caused by destruction of the newborn’s red blood cells
by the mother’s antibodies.
Pectus Carinatum
Pigeon breast shape of chest.
Pectus Excavatum
Funnel shape of chest.
Pediculosis
Genus of parasitic insects; lice.
Pedunculated
Possessing a stalk or stem.
Perceptive Hearing Loss
Sound transmission through bone is affected; caused by a problem with the inner ear.
Percussion
Physical assessment technique that involves striking or tapping a body surface to determine the density
of underlying tissue, identify areas of tenderness, or test reflexes. Types include direct (immediate), directly
tapping on body surface, and indirect (mediate), tapping a hand placed over a body surface or using an
instrument to elicit a response.
Pericarditis
Inflammation of the pericardium.
Peridontitis
Inflammation or degeneration of the periosteum, bone and adjacent gingivae.
Peristalsis
Is the wavelike movement of the intestinal tract caused by contraction and relaxation of the circular muscles
that moves the contents forward through the tract.
Peritonitis
Inflammation of the peritoneum, the serous membrane lining of the abdominal cavity.
Perseveration
Involuntary, excessive repetition of a single response to different questions.
Pes Planus
Flat feet.
Petechiae
Macule; hemorrhagic spot that results from capillary fragility.
Phalen Test
Test for carpal tunnel syndrome; positive if patient complains of numbness of fingers with flexion at the wrist.
Phimosis
Stenosis of the preputial orifice so that the foreskin cannot return over the penis.
Phobia
Irrational fear.
Phocomelia
Hands and feet attached close to the chest.
Physiological Jaundice
Nonpathological jaundice that occurs in newborns after 24 hours of birth; usually appears 48 to 72 hours after
birth, lasts for a few days, and resolves with no treatment.
Pica
Unusual cravings to ingest material that is not food.
Pinguecula
Yellow triangular thickening of the bulbar conjunctiva on the inner and outer margins of the cornea.
Piskacek’s Sign
Probable sign of pregnancy; palpated at 4 to 6 weeks; asymmetry of the uterus with soft prominence on
implantation side.
Pityriasis Rosea
Acute inflammatory skin condition, cause unknown; herald patch precedes fawn-colored, scaly rash on trunk.
Placenta Abruptio
Premature detachment of a normally positioned placenta after the 20th week of gestation.
Placenta Previa
Placenta that is implanted in the lower uterine segment.
Plaque
Primary lesion; palpable, raised, and superficial; greater than 1 cm in size.
Pleural Effusion
Collection of fluid in the pleural space.
Pleuritis
Inflammation of the pleura.
Pneumonia
Inflammation of the alveoli, interstitial tissue, and bronchioles of the lung due to bacteria, virus, other
pathogens, or irritation from chemicals or other agents.
Pneumothorax
Collection of air or gas in the pleural cavity.
Pseudofollicultis
Inflammation of beard follicles when tightly coiled hairs become ingrown.
Psoriasis
Chronic skin disorder characterized by erythematous papules that coalesce to form plaques; silvery-white
in color.
Psychosis
Psychiatric disorder characterized by disorganization of personality, disturbance in reality testing, and
impairment of interpersonal functioning and relationship to the external world.
Pterygium
Triangular thickening of the bulbar conjunctiva from the inner canthus to the border of the cornea.
Ptosis
Drooping of an organ or body part.
Ptyalism
Excessive salivation.
Pulsus Alternans
Weak pulse alternating with a strong one.
Pulsus Bigeminus
Irregular pulse rhythm with premature beats alternating with sinus beats.
Pulsus Bisferiens
Pulse with a strong upstroke, downstroke, and second upstroke.
Pulsus Paradoxus
Pulse amplitude decreases with inspiration.
Purpura
Hemorrhage into the skin, mucous membranes, internal organs, or other tissue, usually red to dark purple
in color.
Pustule
Primary lesion; pus-filled papule.
Pyrosis
Heartburn.
Q
Quadriplegia
Paralysis of all four extremities.
Quickening
Perception of fetal movement.
R
Rales
Also known as crackles.
Romberg Test/Sign
Test of inner ear vestibular function and cerebellar function. Positive if the person loses balance when feet are
together and eyes are closed.
Rosacea
Chronic skin disease of the face; occurring in middle- and older-aged persons. Characterized by erythema,
papules, pustules, telangiectasis, and hyperplasia.
Rovsing’s Sign
Positive test for appendicitis; patient complains of pain as examiner presses left lower quadrant.
S
S1
first heart sound; created by the closing of the mitral and tricuspid valves.
S2
second heart sound; created by the closing of the aortic and pulmonic valves.
S3
third heart sound; low-pitched; heard best with the bell; early diastolic sound. May be normal in children and
young adults, but is a sign of CHF in patients over 30 years.
S4
Fourth heart sound; low-pitched; heard best with the bell; late diastolic sound. May be normal in children and
young adults, but is a sign of a stressed heart in patients over 30 years.
Scale
Secondary lesion; shedding; dead skin cells.
Scientific Method
Systematic, critical-thinking approach to problem solving. The steps of the scientific method include problem
identification, data collection, hypothesis formulation, planning, implementing, and evaluating plan.
Sclera Icterus
Jaundice; yellow discoloration of the sclera.
Scoliosis
Lateral “s” curve of the spine.
Seborrheic Keratosis
Benign skin lesion of immature epithelial cells; common in the elderly.
Secondary Malnutrition
Impaired bioavailability of nutrients to the body owing to deficient breakdown, assimilation, or utilization
of the food.
Senile Ectasias
Red-purple macule or papule lesions (senile or cherry angiomas).
Senile Pruritus
Itching in older adults with degenerative skin changes.
Sensible Water Loss
Measurable water loss, such as urine and gastrointestinal secretions.
Sjögren’s Syndrome
Immunologic disorder characterized by decreased production of tears and saliva.
Sleep Latency
Increased amount of time needed to fall asleep.
Smegma
Sebaceous gland secretions that are thick, white, cheesy, odoriferous; found under the labia minora of the
female or the male prepuce.
Somnambulism
Sleepwalking.
Spermatocele
Nontender, well-defined cyst on the epididymis containing spermatozoa.
Spider Angioma
Type of telangiectasis that looks like spider, with central body and radiating legs.
Spirituality
Belief in something greater than oneself and in a faith that affirms life.
Sprue
Intestinal tract disease characterized by malabsorption, weight loss, abdominal distension, bloating, diarrhea,
and steatorrhea.
Stenosis
Narrowing.
Stereognosis
Ability to identify an object by touch.
Stomatitis
Inflammation of the mouth.
Stork Bites
Flat hemangiomas, reddish in color, at the nape of the neck in newborns.
Strabismus
Axis of eye deviates and cannot fixate; crossed or wall eye; caused by weak extraocular muscles or oculomotor
nerve damage.
Striae
Stretch marks; pinkish-white to gray in color.
Stridor
High-pitched, harsh inspiratory abnormal sound; caused by obstruction of upper airways or spasms of trachea
or larynx.
Stroke Volume
Amount of blood ejected from the heart with each contraction.
Subdural Hematoma
Hematoma located beneath the dura; results from a venous bleed.
Supination
Turning upward; palms up.
Syncope
Transient loss of consciousness resulting from inadequate blood flow to the brain.
Syndactyly
Webbed digits.
T
Tachypnea
Respiratory rates above normal.
Talipes
Clubfoot.
Tangential Thinking
Digresses from topic to topic, never getting to the point.
Tardive Dyskinesia
Bizarre facial and tongue movements, a stiff neck, and difficulty swallowing; an adverse effect of long-term
antipsychotic medication use.
Telangiectasis
Vascular lesion of dilated blood vessels frequently seen on face.
Telogen
Resting phase of hair growth.
Tendinitis
Inflammation of the tendon.
Testicular Torsion
Twisting of the testes; a surgical emergency.
Tetany
Intermittent tonic spasms caused by a calcium or magnesium deficiency.
Thomas Test
Test for hip flexure contraction.
Thrill
Palpable vibrations created by turbulent blood flow.
Thrombophlebitis
Inflammation of a vein in conjunction with the formation of a blood clot.
Thrombosis
Formation, development, or existence of a blood clot in the vascular system.
Thrust
Palpable precordial rocking movement.
Tic
Involuntary muscle spasm, usually involving the face, mouth, eyes, head, neck, or shoulders.
Tic Douloureux
Degeneration or pressure on the trigeminal nerve, causing neuralgia.
Tinea
Fungal infection of the skin. Versicolor, causing yellow or fawn-colored patches; pedis, involving the feet; cruis,
involving the male genitalia; corporis, involving the body; capitis, involving the head.
Tineal Test
Test for carpal tunnel syndrome; positive if patient has numbness and tingling of fingers when wrist
is percussed.
Torah
First five books of the Bible; written on scrolls.
Torus Mandibularis
Exostosis, a benign bony growth, that develops on the lingual aspect of the body of the mandible.
Torus Palatinus
Exostosis, a benign bony growth, that develops on the hard palate.
Toxoplasmosis
Infectious disease caused by protozoan.
Tremor
Involuntary movement of body parts.
Trendelenburg Test
Test for dislocated hip and gluteal medius muscle strength.
Triceps Skin Fatfold Measurements
Measurement of skin fold and subcutaneous tissue of the dominant arm to estimate body fat.
Tumor
Primary encapsulated lesion that extends into the dermis; filled with fluid or solid material; greater than 2 cm in size.
Turgor
Elasticity, or resilience, of the skin.
Tympany
Percussion sound that is medium-pitched, medium intensity and duration, with a distinct musical quality; heard
over the stomach or intestines with gastric air.
U
Ulcer
Secondary lesion; loss of tissue to or through the dermis.
Uremic Frost
Excretion of urea through the skin owing to renal insufficiency or failure.
Urticaria
Hive; temporary primary lesion.
V
Vaginitis
Inflammation of the vagina.
Varicocele
Varicose veins of the spermatic cord; “bag of worms.”
Varicose Veins
Irregular, tortuous veins with incompetent valves; usually affecting the lower extremities.
Vegan
Vegetarian diet that avoids all animal products.
Vegetarian
Diet that consists primarily of plant foods.
Vena Caval Syndrome
Supine hypotension due to compression of the vena cava and aorta by abdominal contents when a pregnant
women is supine; causes 30 mm Hg drop in blood pressure with reflex tachycardia.
Venous Hum
Low-pitched vascular sound; continuous sound due to increased or turbulent venous flow.
Venous Lake
Bluish-black papular vascular lesion.
Venous Stasis Ulcer
Poor-healing ulcer, usually located on the ankle, due to poor venous return.
Vernix Caseosa
White, cheesy substance of sebum and desquamated epithelium seen in the folds of full-term babies.
Vesicle
Primary lesion; fluid-filled papule less than 1 cm in size.
Vesicular Breath Sound
Normal breath sound with a long inspiratory phase and a short expiratory phase; low-pitched, soft intensity;
heard in most of the lung fields.
Vitiligo
Patchy loss of pigmentation; seen as white patches on the skin.
W
Wellness Nursing Diagnosis
Identifies areas that promote or enhance a client’s level of wellness.
Wheal
Primary lesion; temporary raised area.
Wheezes
High-pitched, musical abnormal breath sound caused by a narrowing of an airway, as heard with asthma.
Whispered Pectoriloquy
Abnormal voice sound; clearer transmission of whispered voice sounds over the affected area.
Word Salad
Combination of words that have no meaning.
XYZ
Xanthomas/Xanthelasma
Flat or raised yellow plaques, usually around the eyes; usually resulting from lipid deposits.
Xerosis
Excessive dryness of the skin, mucous membranes, or conjunctiva.
Xerostomia
Dry mouth.