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Medical Scribe > Basic/Common Scribe Vocab > Flashcards

Basic/Common Scribe Vocab Flashcards

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USMLE® Step 1 flashcards
1
Q

Chief complain

A

Main reason for the patient’s ED visit

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2
Q

EMR/EHR

A

Electronic Health Record

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3
Q

Subjective

A

Feeling

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4
Q

Objective

A

Factual finding from the provider

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5
Q

Pain

A

Patient’s feeling of discomfort

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6
Q

Tenderness

A

Doctor’s finding of reproducible pain

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7
Q

Acute

A

New onset, likely concerning

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8
Q

Chronic

A

Long0standing, not of direct concern

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9
Q

HR

A

Heart Rate (bpm)

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10
Q

BP

A

Blood Pressure (mmHg)

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11
Q

RR

A

Respiratory Rate

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12
Q

T

A

Temperature (C or F)

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13
Q

SaO2

A

Oxygen Saturation(%)

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14
Q

CC

A

Chief Complain

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15
Q

HPI

A

History of Present Illness

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16
Q

ROS

A

Review of Systems

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17
Q

PE

A

Physical Exam

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18
Q

DDx

A

Differential Diagnoses

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19
Q

Differential Diagnoses

A

Physician generated list of possible things causing patient’s subjective symptoms

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20
Q

MDM

A

Medical Decision Making

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21
Q

Disposition

A

Next steps or final step in medical care

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22
Q

HPI

A

History of Present Illness

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23
Q

Dx

A

Diagnosis

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24
Q

Hypertension (HTN)

A

High blood pressure

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25
Q

Hyperlipidemia (HLD)

A

High cholestorol

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26
Q

Diabetes Mellitus (DM)

A

Diabetes

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27
Q

“Only pills for my diabetes”

A

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

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28
Q

“Insulin shots for my diabetes”

A

Insulin Dependent Diabetes Mellitus (IDDM)

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29
Q

Coronary Artery Disease (CAD)

A

Heart disease

30
Q

Myocardial Infarction (MI) and CAD

A

Heart attack

31
Q

Congestive Heart Failure (CHF)

A

Heart failure

32
Q

Arrythmia

A

Irregular heartbeat

33
Q

Asthma

A

Asthma

34
Q

Chronic Obstructive Pulmonary Disease (COPD)

A

Emphysema or Chronic Bronchitis

35
Q

Pulmonary Embolism (PE)

A

Blood clot in lung

36
Q

Pneumonia (PNA)

A

Pneumonia

37
Q

Gastroesophageal Reflux Disease (GERD)

A

Reflux

38
Q

Gastric Ulcer or Peptic Ulcer Disease (PUD)

A

Ulcers

39
Q

Hepatitis

A

Hepatitis

40
Q

Irritable Bowel Syndrome (IBS)

A

Irritable bowel

41
Q

Urinary Tract Infection (UTI)

A

Bladder infection

42
Q

Pyelonephritis

A

Kidney infection

43
Q

Renal Calculi

A

Kidney stones

44
Q

Chronic Kidney Disease (CKD) on dialysis

A

“On dialysis”

45
Q

Benign Prostatic Hyperplasia (BPH)

A

Enlarged prostate

46
Q

G:P:A:

A

Gravida- total # of pregnancies
Para- total pregnancies with viable births
Abortus- total miscarriages or elected abortions

47
Q

Cereal Vascular Accident (CVA)

A

Stroke

48
Q

Ischemic CVA

A

Blockage in the brain

49
Q

Hemorrhagic CVA

A

Brain bleed

50
Q

Transient Ischemic Attack (TIA)

A

“Mini stroke”

51
Q

Deep vein Thrombosis (DVT)

A

Blood clot in the leg

52
Q

Aortic Aneurysm

A

Bulge in the aorta

53
Q

Peripheral Vascular Disease (PVD)

A

Bad blood flow in the legs

54
Q

PSHx

A

Past Surgical Histories

55
Q

Tonsillectomy

A

Tonsils removed

56
Q

Adenoidectomy

A

Adenoids removed

57
Q

Pressure Equalizer (P.E.) Tubes

A

Ear tubes

58
Q

Angioplasty

A

Balloon in the heart

59
Q

Coronary Stents

A

Stents in my heart

60
Q

Coronary artery Bypass Graft (CABG)

A

Heart bypass

61
Q

Mastectomy

A

Breast removal

62
Q

Partial lobectomy

A

Part of lung removed

63
Q

Appendectomy

A

Removed appedix

64
Q

Cholecystectomy

A

Removed gallbladder

65
Q

Partial colectomy

A

Part of colon removed

66
Q

Splenectomy

A

Removed spleen

67
Q

Nephrectomy

A

Removed kidney

68
Q

Hysterectomy

A

Removed uterus

69
Q

Oophorectomy

A

Removed ovary

70
Q

Salpingo-oophorectomy

A

Ovary and ovarian tube removed

71
Q

Prostatectomy

A

Removed prostate

72
Q

PPD

A

Pack per day

Medical Scribe (2 decks)

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