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