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Medical Scribe

Med Term and Abbreviations

TermDefinition
Abrasion Scrape of the skin
Ambulation Able to walk
Antipyretics Meds to reduce fever
Afebrile without fever
Atelectasis collapsed lung
Antiemetics Meds to stop vomiting
Apnea not breathing
Avulsion pulling away
Bradycardia slow heart rate
Cerumen ear wax
claudication limping
contusion bruise
Cyanosis bluing of the skin
Debridement removal of dead/damaged/infected tissue
Diaphoresis sweating
Dyspnea difficulty breathing
Dysuria burning while urinating
Ecchymosis bruising
Emesis vomit
Epitaxis nosebleed
Gait walking
Erythema redness of skin
Febrile with fever
Gravid pregnant
hematemesis blood in vomit
hematochezia blood in stool
hematoma bruise
hematuria blood in urine
hemoptysis coughing up blood
incontinence involuntary bowel or bladder
laceration cut of the skin
melena Dark sticky stool
Orthopneic difficulty breathing while lying flat
pallor pale skin
palpable able to be touched or felt
photophobia sensitivity to light
pleurisy inflammation of the pleura
Polyuria increased urine output
Polydipsia increased thirst
pruritus itching of skin
puncture hole/wound made by puncturing
purulent containing pus/discharge
Rhinorrhea runny nose
Syncope passing out
Tachycardia fast heart rate
Tinnitus ringing in ears
transient temporary condition
Vertigo dizziness
abd abdomen
abx antibiotics
AKA above knee amputation
ALOC Altered level of conscious
AMS altered mental status
appy appendectomy
ASA aspirin
BKA below knee amputation
BLE Bilateral lower extremities
BM bowel movement
BP blood pressure
BTL bilateral tubal ligation
BUE bilateral upper extremities
c/o complains of
CA cancer
CABG coronary artery bypass graft
cc chief complaint
CHI closed head injury
COPD chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CSF cerebral spinal fluid
CT computed tomography
CVA cerebral vascular accident
CVAT costobertebral angle tenderness
CXR chest xray
DDx Differential Diagnosis
DI Diabetes insipidus
DM diabetes mellitus
DNR Do not resuscitate
DOE dyspnea on exertion
DTR Deep tendon reflex
Dx Diagnosis
EKG Electrocardiogram
ENT Ear nose throat
EOMI extraoccular movements intact
EtOH Alcohol
f/u follow up
Fb foreign body
FROM Full range of motion
Fx fracture
GCS glascow coma scale
GERD gastroesophageal reflux disease
GI gastrointestinal
GSW gun shot wound
GU genitourinary
h/o history of
HA headache
HR heart rate
HTN Hypertension
hx history
I&D incision and drainage
IM intramuscular
IUP intrauterine pregnancy
IV intravenous
LLE left lower extremity
LLQ left lower quadrant
LMP last menstrual period
LOC loss of consciousness
LP lumbar puncture
LUE left upper extremity
LUQ left upper quadrant
MI myocardial infarction
MVA motor vehicle accident
NAD no acute distress
NKA no known allergy
nl normal
NPO nothing by mouth
NSTEMI No ST segment elevation myocardial infarction
NSR normal sinus rhythm
NTG nitroglycerin
PCN penicillin
PCP primary care provider
PERRL pupils equal, round and reactive to light
PMD primary medical doctor
PNA pneumonia
PO by mouth
PTA prior to arrival
PTX pneumothorax
r/o rule out
RLE right lower extremity
RUE right upper extremity
RUQ right upper quadrant
rx prescription
s/p status post
SNF skilled nursing facility
SOB shortness of breath
STEMI ST segment elevation myocardial infarction
STS soft tissue swelling
sx symptoms
TBI traumatic brain injury
TIA Transient ischemic attack
TM tympanic membrane
tx treatment
UA urinalysis
URI upper respiratory infection
UTI urinary tract infection
VSS vital signs stable
Created by: 1658367313
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