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Scribe Training > Initial Exam > Flashcards

Initial Exam Flashcards

1
Q

Abrasion

A

scrape of the skin due to something abrasive

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2
Q

Acute

A

new, usually of rapid onset and of concern, opposite of chronic

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3
Q

Anterior

A

located towards the front of the body

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4
Q

Benign

A

Normal, of no danger to health

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5
Q

Bradycardia

A

Slow HR (less than 60 bpm)

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6
Q

Cardiomegaly

A

Enlarged heart

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7
Q

Cholecystitis

A

Inflammation of the cholecyst (gallbladder)

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8
Q

Chronic

A

Long standing, constant, opposite of acute

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9
Q

COPD

A

Chronic Obstructive Pulmonary Disease, lung disease commonly seen in smokers

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10
Q

Coronary artery

A

the artery that supplies heart tissue with blood

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11
Q

Cerebrovascular Accident (CVA)

A

aka Stroke. Lack of blood supply to the brain causing brain damage

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12
Q

Diaphoresis

A

Sweating

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13
Q

Distal

A

farther from the trunk of the body

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14
Q

Deep Vein Thrombosis (DVT)

A

a blood clot in a deep vein, most often an extremity

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15
Q

Dyspnea

A

problems with breathing

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16
Q

Dysuria

A

painful urination

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17
Q

Ecchymosis

A

a bruise

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18
Q

Edema

A

swelling

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19
Q

Emesis

A

Vomiting

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20
Q

Epistaxis

A

Nose bleed

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21
Q

Erythema/ erythematous

A

Redness/ red

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22
Q

Grossly

A

obviously, a lot, wholly

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23
Q

Hematemesis

A

very large amounts of blood in the vomit

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24
Q

Hematuria

A

very large amounts of blood in the urine

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25
Q

Hemoptysis

A

coughing up very large amounts of blood

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26
Q

Hemorrhage

A

excessive or profuse bleeding

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27
Q

Hepatomegaly

A

enlarged liver

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28
Q

Hypertension

A

high BP

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29
Q

Hypotension

A

low BP

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30
Q

Hypoxia

A

low oxygen saturation of the body, not enough oxygen in the blood

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31
Q

Infarct

A

area of dead tissue after a lack of blood supply

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32
Q

Inferior

A

lower on the body, farther from the head

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33
Q

Ischemia

A

lack of blood supply

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34
Q

Laceration

A

splitting of the skin due to a trauma (a cut due to something sharp)

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35
Q

Lateral

A

farther from the midline (a line that can be traced from nose to belly button)

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36
Q

Medial

A

nearer to the midline

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37
Q

Melena

A

black tarry stool

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38
Q

Myocardial Infarction (MI)

A

death of cardiac muscle to ischemia

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39
Q

Myalgia

A

muscular pain, “muscle aches”

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40
Q

Oriented x3

A

Oriented to person, place, and time

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41
Q

Pallor

A

Pale skin

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42
Q

Pulmonary embolism (PE)

A

blocking of a pulmonary artery due to a blood clot

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43
Q

Posterior/Dorsal

A

Rear or backside of the body

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44
Q

Proximal

A

Nearer to the trunk of the body

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45
Q

Purulent

A

Pus-like

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46
Q

Rales

A

Crackles; wet crackling noise in lungs

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47
Q

Rhinorrhea

A

Clear nasal discharge, “runny nose”

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48
Q

Rhonchi

A

rattling noise of mucus in the lungs

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49
Q

Sepsis

A

dangerous infection of the blood

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50
Q

STEMI

A

ST elevation MI; real time ongoing death of heart tissue due to ischemia

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51
Q

Superior

A

higher on the body, nearer to the head

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52
Q

Supine

A

body position lying face up

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53
Q

Syncope

A

“Passing out”, loss of consciousness or fainting

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54
Q

Tachycardia

A

Fast HR (greater than 100 bpm)

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55
Q

Tachypnea

A

Increased breathing rate

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56
Q

Transient Ischemic Attack (TIA)

A

Minor stoke; where neurological function is regained quickly with time

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57
Q

Vertigo

A

Condition of dizziness, room spinning

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58
Q

Wheezing

A

High pitched sound heard in the lungs with asthmatics or lung disease

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59
Q

↓

A

Down, below, less, decrease, lower

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60
Q

↑

A

up, above, more, increase, higher

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61
Q

>

A

Greater than

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62
Q
A

Less than

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63
Q

~

A

Approximately

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64
Q

∆

A

change

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65
Q

ā

A

before

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66
Q

AAA

A

Abdominal Aortic Aneurysm

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67
Q

A Fib

A

Atrial Fibrillation

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68
Q

Abd

A

Abdomen, abdominal

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69
Q

Abx

A

Antibiotics

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70
Q

AMA

A

Against Medical Advice

71
Q

AMS

A

Altered Mental Status

72
Q

ASA

A

Acetylsalicylic Acid (aspirin)

73
Q

BID

A

twice daily

74
Q

Bilat LE

A

Bilateral lower extremities

75
Q

BM

A

bowel movement

76
Q

BP

A

blood pressure

77
Q

c (with dash on top)

A

with

78
Q

CA

A

cancer, carcinoma

79
Q

CABG

A

coronary artery bypass graft, open heart surgery

80
Q

CAD

A

coronary artery disease, heart disease

81
Q

CT or CAT

A

computerized assisted tomography

82
Q

CHF

A

congestive heart failure

83
Q

CP

A

chest pain

84
Q

CPR

A

cardiopulmonary resuscitation

85
Q

C-section

A

Caesarean section

86
Q

CSF

A

Cerebrospinal fluid

87
Q

CVA

A

cerebrovascular accident or costo-vertebral angel

88
Q

CXR

A

chest xray

89
Q

c/o

A

complaints of

90
Q

C-Spine

A

Cervical Spine (neck)

91
Q

DKA

A

Diabetic Ketoacidosis

92
Q

DM

A

diabetes mellitus

93
Q

DNR

A

do not resuscitate

94
Q

DOE

A

dyspnea on exertion

95
Q

DVT

A

Deep venous thrombosis

96
Q

Dx

A

diagnosis

97
Q

Dz

A

disease

98
Q

EKG/ECG

A

electrocardiogram

99
Q

EtOH

A

alcohol

100
Q

FHx

A

family history

101
Q

Fx

A

fracture

102
Q

GI

A

gastrointestinal

103
Q

G/P/Ab

A

gravida/para/abortion

104
Q

GSW

A

gun shot wound

105
Q

GU

A

genitourinary

106
Q

HA

A

headache

107
Q

HEENT

A

head, eyes, ears, nose, throat

108
Q

HPI

A

history of present illness

109
Q

HTN

A

hypertension

110
Q

Hx

A

history

111
Q

H&H

A

hemoglobin and hematocrit

112
Q

H&P

A

history of present illness and physical exam

113
Q

I&D

A

incision and drainage

114
Q

IDDM

A

insulin dependent diabetes mellitus

115
Q

IUP

A

intrauterine pregnancy

116
Q

IVDA

A

IV drug abuse

117
Q

JVD

A

jugular vein distension

118
Q

LLE

A

left lower extremity

119
Q

LLQ

A

left lower quadrant

120
Q

LNMP

A

last normal menstrual period

121
Q

LOC

A

loss of consciousness

122
Q

LP

A

lumbar puncture

123
Q

LUE

A

left upper extremity

124
Q

LUQ

A

left upper quandrant

125
Q

MCA

A

motorcycle accident

126
Q

MI

A

myocardial infarction

127
Q

MVA/MVC

A

motor vehicle accident/collision

128
Q

N/A

A

not applicable

129
Q

NAD

A

no acute distress/ no acute disease

130
Q

NIDDM

A

non-insulin dependent diabetes mellitus

131
Q

NKDA

A

no known drug allergies

132
Q

Nml or nl

A

Normal

133
Q

NSAID

A

Non-steroidal anti inflammatory drug

134
Q

NSR

A

normal sinus rhythm

135
Q

NTG

A

nitroglycerin

136
Q

N/V/D

A

nausea/vomiting/diarrhea

137
Q

O2 Sat

A

Oxygen Saturation (aka SaO2)

138
Q

OD

A

overdose

139
Q

p (with dash on top)

A

post, after

140
Q

PCP

A

primary care physician

141
Q

PE

A

pulmonary embolism or physical exam

142
Q

PERRL

A

pupils are equal, round, and reactive to light

143
Q

PO

A

per Os (by mouth)

144
Q

prn

A

as needed

145
Q

pt

A

patient

146
Q

PTA

A

prior to arrival

147
Q

qd

A

every day

148
Q

qh

A

every hour

149
Q

qhs

A

at every bedtime

150
Q

q2h

A

every 2 hours

151
Q

QID

A

four times a day

152
Q

RLE

A

right lower extremity

153
Q

RLQ

A

right lower quadrant

154
Q

ROM

A

range of motion

155
Q

ROS

A

review of system

156
Q

RUE

A

right upper extremity

157
Q

RUQ

A

right upper quadrant

158
Q

Rx

A

prescription

159
Q

r/o

A

rule out

160
Q

s (with line on top)

A

without

161
Q

SOB

A

shortness of breath

162
Q

s/p

A

status post (after)

163
Q

Sx

A

symptoms

164
Q

TIA

A

transient ischemic attack

165
Q

TID

A

three times a day

166
Q

TM

A

tympanic membrane

167
Q

Tx

A

treatment

168
Q

UA

A

urinalysis

169
Q

URI

A

upper respiratory infection

170
Q

US

A

ultrasound

171
Q

UTD

A

up to date

172
Q

UTI

A

urinary tract infection

173
Q

WNL

A

within normal limits

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