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ScibeAmerica
ScribeAmerica Terminology
| Term | Definition |
|---|---|
| Anterior | Front of the body |
| Posterior | Back of the body |
| Proximal | Closer to center of body |
| Distal | Farther from center |
| Lateral | Towards sides of the body |
| Medial | Towards middle of the body |
| Diffuse | Generalized |
| Inferior | Lower on body |
| Superior | Closer to head |
| Abscess | Collection of pus beneath surface |
| Appendicitis | Inflammation of appendix |
| Arthritis | Inflammation of joint |
| A fib | Arrhythmia |
| Bronchitis | Inflammation of Bronchi |
| Cellulitis | Inflammation of skin cells |
| Cerebrovascular accident (CVA) | Stroke |
| Cholecystitis | Inflammation of gallbladder |
| Chronic obstructive pulmonary disease (COPD) | Inflammatory lung disease that causes obstruction |
| Congestive heart failure (CHF) | heart does not pump blood effectively |
| Conjunctivitis | inflammation of outer layer of eye |
| Coronary artery bypass graft (CABG) | Procedure used to treat coronary artery disease |
| Coronary artery disease (CAD) | Buildup of plaque in arteries that supply blood to heart |
| Deep Vein Thrombosis (DVT) | Blood clot that forms in a vein deep inside the body |
| Diverticulosis | Acute inflammation of diverticula pouches in colon |
| Ectopic pregnancy | Egg developing outside uterus |
| Gastroenteritis | Inflammation of GI tract |
| Gastroesophageal reflux disease (GERD) | Stomach acid and food back up from stomach to esophagus |
| Hepatitis | Inflammation of liver |
| Hyperglycemia | High blood sugar |
| Hyperlipidemia (HLD) | High cholesterol |
| Hypertension (HTN) | High blood pressure |
| Hypoglycemia | Low blood sugar |
| Hypotension | Low blood pressure |
| Insulin dependent diabetes mellitus (IDDM) | diabetes requiring the use of insulin injections |
| Myocardial Infarction | heart attack |
| Nephrolithiasis | kidney stone |
| Non-Insulin dependent diabetes mellitus (IDDM) | diabetes not requiring the use of insulin injections |
| Otitis media (OM) | infection inner ear (behind eardrum) |
| Pancreatitis | inflammation of pancreas |
| Peptic Ulcer Disease (PUD) | stomach ulcers |
| Peripheral Vascular Disease (PVD) | blood circulation disorder that causes the blood vessels to narrow |
| Pharyngitis | throat infection |
| Pneumonia | infection in the lung tissue |
| Pneumothorax | presence of gas in pleural space, collapsed lung |
| Pulmonary embolism | blockage of the pulmonary artery or one of its branches due to a translocated clot |
| Pyelonephritis | infection on the kidneys |
| Sepsis | dangerous infection of the blood |
| Transient Ischemic Attack (TIA) | Mini-stroke |
| Urinary Tract Infection (UTI) | Infection in any part of the urinary system |
| Afebrile | Without fever |
| Ambulatory | able to move |
| Constitutional | general appearance and nature of the patient |
| Distress | inability to tolerate pain (Often written no acute distress (NAD) if not present) |
| Extraocular muscles intact (EOMI) | Examines the function of the eye muscles |
| Pale conjunctiva | Pale inner aspect of the eyelid likely due to anemia |
| PERRL | Pupils are equal, round, and reactive to light (normal) |
| Scleral icterus | Yellowing of sclera (whites of the eyes) due jaundice |
| Cerumen | Earwax |
| Dry mucosa | Dry tongue, mouth and lips (dehydration) |
| Epistaxis | nose bleed |
| Oropharynx | Back of the mouth |
| Tinnitus | 'Ringing in the ears' |
| Tonsillectomy & Adenoidectomy (T&A) | Tonsils and adenoids removal |
| Tympanic Membrane (TM) | Tympanic Membrane (clear membrane inside the ear) |
| Carotid Bruit | Whooshing blood flow heard with auscultation |
| Lymphadenopathy | Enlarged lymph nodes |
| Supple | Flexible, not-stiff |
| Thyromegaly | Enlarged thyroid |
| Jugular Vein Distention (JVD) | sign of heart disfunction |
| Aneurysm | Ballooning of a vessel due to weakened vessel wall |
| Artery | blood vessels carrying blood away from the heart |
| Arrhythmia | Irregular Heartbeat |
| Bradycardia | Slow heart rate |
| Cardiomegaly | Enlarged heart |
| Murmur | Abnormal heart sound rated on 1-6 scale |
| Normal sinus rhythm (NSR) | Rhythm of a healthy heart |
| Palpitation | to beat irregularly or forcefully |
| Regular rate and rhythm (RRR) | Normal heart sounds with a regular rate |
| Stenosis | Narrowing of a body opening or passage |
| Tachycardia | Fast heart beat |
| Vein | Vessel carry blood towards the heart |
| Acute | new, onset |
| Chronic | Long-standing, constant |
| Benign | Normal, of no danger |
| -ectomy | surgical removal |
| -itis | inflammation |
| -scopy | viewing with a scope |
| Aphasic | inability to create words or understand spoken language |
| Epilepsy | Seizure disorder |
| Hemiparesis | Weakness of one half of the body |
| Hemiplegia | Paralysis of one half of the body |
| Loss of Consciousness (LOC) | passing out |
| Meningitis | infection of the meninges (outer lining of brain and spinal cord) |
| DTRs | Deep tendon reflexes |
| Oriented x3 | Oriented to person, place and time |
| Syncope | passing out |
| Vertigo | Room-spinning dizziness |
| Abrasion | Scrape of the skin |
| Cyanosis | Blue color of the skin |
| Diaphoresis | Sweating |
| Ecchymosis | Bruising |
| Edema | Swelling |
| Erythema | Redness |
| Fluctuance | Palpable fluid beneath the skin (pus/abscess) |
| Laceration | Splitting of the skin due to trauma |
| Maculopapular rash | Rash that is red and raised |
| Pallor | Pale skin due to anemia |
| Purulence | Pus-like |
| Urticarial rash (Wheals) | patchy red, raised rash, consistent with allergic reaction |
| Clear to Auscultation (CTA) | No abnormal sounds when listening to the lungs with a stethoscope |
| Dyspnea | Difficult breathing |
| Hypoxia | Low oxygen saturation of the body |
| Pleuisy | Pain while breathing |
| Rales | Crackles (wet crackling heard in lungs) |
| Rhonchi | Sound of mucous rolling around in bronchi |
| Shortness of breath (SOB) | Breathlessness |
| Sputum | Any matter mixed with saliva that is passed through the mouth |
| Stridor | Upper airway noise (croup) |
| Bradypnea | Slow breathing |
| Tachypnea | Fast breathing |
| Wheezing | High pitched sound heard in the lungs with asthmatics/lung disease |
| Emesis | Vomiting |
| Hematemesis | Blood in vomit |
| Hepatomegaly | Enlarged liver |
| Hernia | Protrusion of part of an internal organ or tissue bulges through a weak area of muscle |
| Melena | Black tarry stool indicative of an upper GI bleed |
| N/V/D | Nausea, Vomiting, Diarrhea |
| Peritoneal signs | signs indicative of acute abdominal inflammation |
| C-section | Cesarean Section |
| CVA tenderness | Costovertebral angle tenderness (tenderness over kidney) |
| Dysuria | Painful urination |
| Foley catheter | Tube inserted through urethra to drain urine |
| G/P/Ab | Gravida (# of times pregnant) Para (# of live children born) Ab (# of failed pregnancies) |
| Hematuria | Blood in urine |
| Intrauterine pregnancy (IUP) | When a fertilized egg implants and starts to develop within the uterus |
| Last normal menstrual period (LNMP) | The first day of one's period |
| Anatomical Position | Stand erect with arms at the sides and palms supine |
| C-spine | Cervical spine (C1 - C7) |
| Epigastric | Upper central region of the abdomen |
| Fontanel | Anatomical feature of an infant's skull "soft spot" |
| L-spine | Lumbar Spine (L1-L5) |
| Left Lower Extremity (LLE) | Left Leg |
| Left Lower Quadrant (LLQ) | Left Lower Quadrant of the Abdomen |
| Left Upper Extremity (LUE) | Left Arm |
| Left Upper Quadrant (LUQ) | Left Upper Quadrant of the Abdomen |
| Palmar | Palm side of hand/body |
| Plantar | Sole of the Foot |
| Prone | Body position lying face down with forearms and hands turned palm side down |
| Right Lower Extremity (RLE) | Right Leg |
| Right Lower Quadrant (RLQ) | Right Lower Quadrant of the Abdomen |
| Right Upper Extremity (RUE) | Right Arm |
| Right Upper Quadrant (RUQ) | Right Upper Quadrant of the Abdomen |
| Superficial | Closer to the surface |
| Supine | Body position lying face up |
| Suprapubic | Lower central region on the abdomen |
| T-spine | Thoracic spine (T1-T12) |
| Acute on chronic | New exacerbation of a chronic condition |
| Fluctuating | Symptoms that are always present but changing in severity |
| Intermittent | Symptoms that completely resolve at time, but return |
| Paroxysmal | Occasional, sporadic, transient |
| Resolved | Gone, no longer existing |
| Transient | Resolving spontaneously after onset |
| Family History (FHx) | A part of the medical chart that lists diseases and health conditions in your family that may put the patient at an increased risk of also having |
| Health Insurance Portability and Accountability Act (HIPAA) | Federal law that provides national standards to protect sensitive PHI from being disclosed |
| History of Present Illness (HPI) | A part of the medical chart describing the development of the illness |
| pt | Patient |
| r/o | Rule out |
| Review of system (ROS) | A part of the medical chart that is a checklist of the symptoms the patient has or does not have. Grouped by body system |
| s/p | Status Post (after) |
| Social History (SHx) | Addresses substance use, occupation, diet, exercise, living situation, marital status |
| Sx | Symptoms |
| Tx | Treatment |
| UTD | Up to Date |
| WNL | Within Normal Limits |
| Bell's Palsy | Localized facial nerve dysfunction that causes facial droop and numbness |
| Cancer (CA) | Cancer, carcinoma |
| Cholelithiasis | Production of gallstone |
| Chronic Renal Failure (CRF) | Decrease in the kidney's ability to filter waste and fluid from the blood |
| Chief complaint | Main reason for patient's visit |
| EMR | Electronic Medical Record |
| Subjective | Feeling |
| Objective | Factual finding from provider |
| Pain | Patient's feelings of discomfort |
| Tenderness | Doctor's findings of reproducible pain |
| Cirrhosis | Inflammation of an organ by degenerative changes, especially of the liver |
| Costochondritis | Inflammation of the rib cartilage |
| Croup | Viral infection of the upper airway with a barking cough and often stridor |
| Dermatitis | Inflammation of the skin |
| Endometriosis | Presence of functioning endometrial tissue outside the uterus |
| Gout | Type of arthritis, diagnosed by ordering a uric acid level |
| Lymphangitis | Inflammation of a lymphatic vessel, appears as red streaking |
| Multiple Sclerosis | Autoimmune disease affecting the brain and spinal cord |
| Otitis Externa | Infection of the outer ear (ear canal) |
| Pelvic Inflammatory Disease (PID) | Inflammation of a woman's reproductive organs |
| Pericarditis | Inflammation of the pericardium |
| Psoriasis | Autoimmune skin disease (dry, scaly, red itchy patches of skin) |
| Sciatica | Compression of sciatic nerve causing back pain with radiation to posterior leg |
| Differential Diagnoses (DDx) | List of things that MAY be causing the patient's subjective symptoms |
| Tinea | Fungal Rash |
| Upper Respiratory Infection (URI) | Contagious infection of the upper respiratory tract (sinuses, throat, lungs) |
| Basic Metabolic Panel (BMP) | Blood test that measures eight different substances to evaluate kidney function, fluid and electrolyte balance, blood sugar levels, acid and base balance, and metabolism |
| Chest X-ray (CXR) | Images of heart, lungs, blood vessels, airways, and bones of chest and spine |
| Complete Blood Count | Blood test used to evaluate overall health and detect a wide range of disorders (anemia, infection, and leukemia) |
| Comprehensive Metabolic Panel (CMP) | Blood test that measures 14 different substances (BMP + liver function eval) |
| Computerized Assisted Tomography (CT/CAT) Scan | X-ray procedure provide a 2D cross-sectional scan of the body to find irregularities |
| EKG | A test that records the electrical signal from the heart to check for different heart conditions |
| Hemoglobin and Hematocrit (H&H) | Red blood cell measurements to evaluate anemia |
| Urinalysis (UA) | Urine test to detect a wide range of disorders (UTI, KD, diabetes) |
| Abx | Antibiotics |
| ASA | Acetylsalicylic Acid (aspirin) |
| BID | Twice daily |
| IM | Intramuscular |
| NKDA | No Known Drug Allergies |
| NSAID | Non-steroidal anti-inflammatory drug |
| PO | Per mouth |
| prn | as needed |
| QHS | At every bedtime |
| QID | Four times daily |
| Rx | Prescription |
| TID | Three times a day |
| Cachectic | Extremely Skinny, bony, malnourished |
| Lethargic | Septic, very sick |
| Febrile | Fever |
| Malaise | Generalized discomfort or weakness |
| Non-toxic | Stable with no deterioration risk |
| Somnolent | Appearing drowsy |
| Unkempt | Poor Self hygiene |
| Well developed | Normal State of mental and body development |
| Cornea | Transparent frontal aspect of the eye, covering iris and pupil |
| Fundoscopic Exam | Use of opthalmoscope to look through pupil and examine the interior surface of the posterior eye |
| Nystagmus | Involuntary 'shaking' eye movements |
| Ophthalmalgia | Pain in the eye |
| Conjunctiva | Thin outer lining of the eye and eyelid |
| Periorbital Ecchymosis | Bruising around the eye (trauma) |
| Photophobia | Light Sensitivity |
| Subconjunctival Hemorrhage | Blood in white part of the eye |
| Gingiva | Gums |
| Nare | Nostril |
| Otalgia | Ear Ache |
| Pharyngeal erythema | Redness of the pharynx (throat infection) |
| Rhinorrhea | Clear nasal discharge (runny nose) |
| TM erythema | redness of the TM |
| Tonsillar exudate | Pus on the tonsils (infection) |
| Meningismus | Stiff neck (sign of meningitis) |
| Coronary Artery | Artery that supplies the heart with blood |
| Dorsalis pedis pulse | pulse that is palpable on the dorsum (top) of the foot) |
| Pulse Exam | Carotid, brachial, radial, femoral, politeal, dorsalis pedis (DP) or posterior tibia (PT) |
| Thrombus | Blood clot or blockage |
| Serosanguinous | Consisting of serum and blood |
| Dyspnea on exertion (DOE) | Feeling short of breath during very light exercise (walking) |
| Hemoptysis | Coughing up gross amounts of blood |
| Dyspepsia | Indigestion |
| Dysphagia | Difficulty swallowing |
| Hematochezia | Bright red blood in stool |
| McBurney's Point | RLQ point tenderness indicitive of appendicitis |
| Murphy's sign | Pain with palpation of the RUQ during a deep breath (Cholecystitis) |
| Organomegaly | Enlarged organ |
| Peritoneal signs (Rebound, guarding, or rigidity) | Signs indicative of acute abdominal inflammation (peritonitis) |
| Splenomegaly | Enlarged Spleen |
| Adnexal Tenderness | Tenderness of the ovaries during the pelvic ecam indicitive of ovarian cyst |
| Cervical os | Opening of the cervix |
| Dysmenorrhea | Painful menstruation |
| Frequency | Urinating often |
| Gravid | State of being pregnant |
| OB/GYN | Obstetrics and gynecology |
| Spotting | Passing very small amounts of blood from vagina |
| Urgency | Abrupt onset of urge to urinate |
| Arthralgias | Joint pain |
| Atropic | Showing signs of tissue degredation/breakdown |
| Bony tenderness | Tenderness of bone indicitive of a fracture |
| Deformity | Visual abnormality of a bone or anatomical structure |
| Dislocation | Disconnected joint |
| Fracture (Fx) | Broken bone |
| Kyphosis | Hunchback |
| Malleolus | Bony prominence on each side of the ankle |
| Myalgia | Muscular Pain |
| Paraspinal Tenderness | Tenderness of muscle besides the spine |
| Range of Motion (ROM) | Capability of a joint to go through its complete spectrum |
| Vetebral point-tenderness | Tenderness directly over the spine |
| Avulsion | Forcible pulling away of a part or structure |
| Eczematous rash | Dry skin consistent with eczema |
| Fascia | Fibrous membrane of connective tissue supporting and separating muscles and bodily organs |
| Hematoma | Raised area with underlying blood with occurs in tissue from ruptured blood vessel |
| Incision and Drainage (I&D) | Procedure used to drain and abscess to relieve pain and speed healing |
| Induration | Hardened area of tissue |
| Keloid | Hypertrophic scar |
| Subungual | Beneath the nail |
| Mottled | Patchy skin color due to poor blood circulation |
| Tenting | Slow return of the skin to its normal position after being pinched (dehydration or aging) |
| Papular | Raised bumps |
| Petechial Rash | Red or purple discoloration on the skin that do not blanch (lighten) or applying pressure (meningitis) |
| Pitting edema | Edema that retains an imprint when touched |
| Pruitic | Itchy |
| Tugor | Skin elasticity (Poor tugor is tenting) |
| Ulcerations | Blisters or open-sores |
| Vesicular Rash | Vesicles (Fluid filled blisters - herpes) |
| Ataxia | Loos of coordination |
| Cephalgia | Headache |
| Facial Asymmetry | Drooping of the face (neurological condition) |
| Moves all Extremities (MAE x4) | Normal motor function of arms and legs |
| Paresthesia | Abnormal tactile sensation often described as tingling/numbness |
| Postictal | State of somnolence and decreased responsiveness after seizure |
| Affect | Expressed/observed emotional and social responses |
| Auditory Hallucinations | Hearing voices, music, or sounds that aren't real |
| Depressed | Appearing sad/unhappy |
| Flat Affect | Lack of normal interaction, monotone, unemotional |
| Homicidal Ideation | Thoughts of killing another person |
| Suicidal Ideation | Thoughts of killing onself |
| Tangential Thoughts | Thought processess that do not follow normal/logical progessions |
| Visual Hallucinations | Seeing objects, people or things that do not exist |
| Auscultation | Listening with the stethoscope |
| Baseline | Normal state of being for each specific patient |
| Catheter | Tube inserted into vessels or body cavities to permit injection or withdrawl of fluids to keep a passage open |
| Grossly | A lot |
| Hemorrhage | Excessive Bleeding |
| Infarct | Area of dead tissue after lack of blood supply |
| Ischemia | Lack of blood supply to a specific area |
| Palpation | Examine by touch |
| Focal Neurological Deficit | Damage localized in a specic area of the brain |
Created by:
emilyleff
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