Chief complaint
Patient's reason for seeking medical attention
Hacking non-productive cough
Persistent dry cough without bringing up phlegm
Body-wracking dry cough
Severe dry cough that causes physical discomfort
Lung cancer symptoms
Signs and symptoms associated with lung cancer
Assessment process
Systematic collection of data about a patient's health
Cerebrovascular accident (CVA)
Stroke caused by interruption of blood supply to the brain
Right hemiparesis
Weakness or paralysis on the right side of the body
Brisk 4+ response
Exaggerated reflex response indicating an upper motor neuron disorder
Abnormal response when palpating the spleen
Finding that deviates from the expected response when examining the spleen
McBurney's point
Specific area in the abdomen associated with appendicitis
Carotid artery bruit
Abnormal sound heard when auscultating the carotid artery
Adventitious lung sounds
Abnormal breath sounds indicating underlying lung pathology
Streptococcus pharyngitis
Infection of the throat caused by Streptococcus bacteria
Peritonsillar abscess
Collection of pus around the tonsils
Cholecystectomy
Surgical removal of the gallbladder
Illegal drugs and alcohol
Substances that are prohibited by law and can cause intoxication or addiction
Rebound tenderness
Pain that occurs when pressure is released after palpation
Venous insufficiency
Condition where veins have difficulty returning blood to the heart
Nutritional status
Evaluation of an individual's overall health in relation to their diet and nutrient intake
Bowel sounds
Sounds produced by the movement of the intestines
Eyelids are matted and crusted
Presence of dried discharge on the eyelids
Flushed and diaphoretic face
, Red and sweaty face
Shortness of breath
Difficulty breathing or feeling breathless
Anterior-posterior (AP) chest diameter
Measurement of the chest from front to back
2+ pitting edema of ankles bilaterally
Swelling of the ankles that leaves a slight indentation when pressed
Cranial nerve exam
Assessment of the nerves responsible for sensory and motor functions of the head and
neck
Pupillary response to light
Constriction or dilation of the pupils in response to changes in light intensity
Peripheral perfusion
Blood flow to the extremities
Musculoskeletal assessment
Evaluation of the muscles, bones, and joints of the body
Range of motion (ROM) of the shoulder
Extent to which the shoulder joint can move in different directions
Post-surgical evaluation
Assessment of a client's condition after a surgical procedure
Level of consciousness
Degree of alertness and awareness of one's surroundings
Sensory nerve function
Ability to perceive and interpret sensory information
Menopausal symptoms
Signs and symptoms experienced by women during menopause
Legally blind
Having a visual acuity of 20/200 or less in the better eye
Chronic cough
Persistent cough lasting for an extended period of time
Barrel chest
Enlarged chest with a rounded shape, often associated with chronic obstructive
pulmonary disease (COPD)
Jugular vein distention (JVD)
Visible bulging of the jugular veins in the neck
Fever
Elevated body temperature above the normal range
Bowel sounds
Sounds produced by the movement of the intestines
Paresthesia
Abnormal sensation, such as burning or tingling, in the hands and legs
Heberden's nodes
Bony nodules that develop at the distal interphalangeal joints in osteoarthritis
Scalp hair texture
Characteristics of the hair strands on the scalp
Back pain