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Basic Medical Terms
Terminology for a Medical Scribe
| Term | Definition |
|---|---|
| Abrasion | scrape of the skin due to something abrasive |
| Acute | new, usually of rapid onset and of concern, opposite of chronic |
| Ambulate | to walk from place to place |
| Anterior | located towards the front of the body |
| Artery | blood vessel carrying blood away from the heart |
| Ausculate | listening with a stethoscope |
| Benign | normal, of no danger to health |
| Bony Tenderness | Pain elicited by pressing on a bone, rather than a soft tissue |
| Bradycardia | slow heart-rate (HR less than 60bpm) |
| Cardiomegaly | enlarged heart |
| Cholecystitis | inflammation of the cholecyst (gallbladder) |
| Chronic | long-standing, constant. opposite of acute |
| COPD | Chronic Obstructive Pulmonary Disease; lung disease commonly seen in smokers |
| Coronary artery | the artery that supplies heart tissue with blood |
| Cerebrovascular Accident (CVA) | aka "stroke". lack of blood supply to the brain causing brain damage |
| Diaphoresis | sweating |
| Diffuse | everywhere. opposite of "focal" |
| Distal | farther from the trunk of the body |
| Deep Vein Thrombosis (DVT) | a blood clot in a deep vein, most often an extremity |
| Dyspnea | problems with breathing |
| Dysuria | painful urination |
| Ecchymosis | a bruise |
| Edema | swelling |
| Emesis | vomiting |
| Epistaxis | nose bleed |
| Erythema/Erythematous | redness/red |
| Febrile | Elevated body temperature, fever, indicative infection |
| Focal | localized to one specific area. opposite of diffuse |
| Grossly | obviously. a lot; wholly |
| Hematemesis | very large amounts of blood in the vomit |
| Hematuria | very large amounts of blood in the urine |
| Hemoptysis | coughing up very large amounts of blood |
| Hemorrhage | excessive or profuse bleeding |
| Hepatomegaly | enlarged liver |
| Hypertension | high blood pressure |
| Hypotension | low blood pressure |
| Hypoxia | low oxygen saturation of the body, not enough oxygen in the blood |
| Incontinence | accidentally passig urine (urinary incontinence) or stool (bowel incontinence) |
| Infarct | area of dark tissue after a lack of blood supply |
| Inferior | lower on the body, farther from the head |
| Ischemia | lack of blood supply |
| Laceration | splitting of the skin due to trauma (a cut due to something sharp) |
| Lateral | farther from the midline (a line that can be traced from the nose to belly-botton) |
| Medial | nearer to the midline |
| Melena | black tarry stool |
| Myocardial Infarction (MI) | death of cardiac muscle due to ischemia |
| Myalgia | muscular pain, "muscle aches" |
| Oriented x3 | oriented to person, place, or time |
| Pallor | pale skin |
| Palpate | using a hand to press on an area, e/g. palpating the abdomen |
| Palpitations | feeling a heart-racing, pounding, or fluttering sensation in the chest |
| Point tenderness | When pressing on an area with one finger generates pain |
| Posterior/Dorsal | rear or backside of the body |
| Proximal | nearer to the trunk of the body |
| Pruritic | itchy |
| Pulmonary Embolism (PE) | blocking of a pulmonary artery due to a blood clot |
| Purulent | pus-like |
| Rales | crackles; wet crackling noise in lungs |
| Rhinorrhea | clear nasal discharge, "runny nose" |
| Rhonchi | rattling noise of mucous in the lungs |
| Sepsis | dangerous infection of the blood |
| Soft Tissue Tenderness | tenderness of a soft tissue; muscle, skin, fat. Opposite of bony tenderness |
| STEMI | ST elevation MI, real-time ongoing death of heart tissue due to ischemia |
| Superior | higher on the body, nearer to the head |
| Supine | body position lying face |
| Syncope | "passing out", loss of consciousness or fainting |
| Tachycardia | fast heart rate (HR greater than 100bpm) |
| Tenderness | Physician's assessment if an area is painful (tender) or not (non-tender) |
| Transient Ischemia Attack (TIA) | minor stroke; where neurological function is regained quickly with time |
| Vein | blood vessel carrying blood towards the heart |
| Vertigo | condition of dizziness, "room spinning" |
| Wheezing | high pitched sound heard in the lungs with asthmatics or lung disease |
Created by:
amandatucker10
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