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Scribe America > 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 rapid onset and of concern

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3
Q

benign

A

normal, of no danger to health

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4
Q

bradycardia

A

slow heart rate

< 60 bpm

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5
Q

cardiomegaly

A

enlarged heart

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6
Q

cholecystitis

A

inflammation of the cholescyst (gallbladder)

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7
Q

chronic

A

long-standing, constant

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8
Q

COPD

A

chronic obstructive pulmonary disease

lung commonly seen in smokers

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9
Q

coronary artery

A

artery that supplies heart tissue with blood

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10
Q

cerebrovascular accident (CVA)

A

lack of blood supply to the brain causing damage

stroke

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11
Q

diaphoresis

A

sweating

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12
Q

deep vein thrombosis (DVT)

A

blood clot in a deep vein, most often an extremity

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13
Q

dyspnea

A

problems with breathing

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14
Q

dysuria

A

painful urination

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15
Q

ecchymosis

A

bruise

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16
Q

edema

A

swelling

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17
Q

emesis

A

vomiting

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18
Q

epistaxis

A

nose bleed

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19
Q

erythema/erythematous

A

redness/red

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20
Q

grossly

A

obviously, a lot, wholly

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21
Q

hematemesis

A

large amounts of blood in vomit

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22
Q

hematuria

A

large amounts of blood in urine

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23
Q

hemoptysis

A

coughing up large amounts of blood

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24
Q

hemorrhage

A

excessive or profuse bleeding

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25
Q

hepatomegaly

A

enlarged liver

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26
Q

hypertension

A

high blood pressure

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27
Q

hypotension

A

lower blood pressure

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28
Q

hypoxia

A

low oxygen saturation of the body

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29
Q

infarct

A

area of dead tissue after a lack of blood supply

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30
Q

ischemia

A

lack of blood supply

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31
Q

laceration

A

splitting of the skin due to trauma

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32
Q

melena

A

black, tarry stool

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33
Q

myocardial infarction (MI)

A

death of cardiac muscle due to ischemia

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34
Q

myalgia

A

muscle pain/aches

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35
Q

oriented x3

A

oriented to person, place, and time

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36
Q

pallor

A

pale skin

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37
Q

pulmonary embolism (PE)

A

blocked pulmonary artery due to blood clot

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38
Q

purulent

A

pus-like

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39
Q

rales

A

crackles, wet crackling noise in lungs

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40
Q

rhinorrhea

A

clear nasal discharge

runny nose

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41
Q

rhonchi

A

rattling noise of lung mucous

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42
Q

sepsis

A

dangerous infection of the blood

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43
Q

STEMI

A

ST elevation MI

real-time ongoing death of heart tissue due to ischemia

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44
Q

syncope

A

loss of consciousness

passing out

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45
Q

tachycardia

A

fast heart rate

> 100 bpm

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46
Q

tachypnea

A

increased breathing rate

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47
Q

transient ischemic attack (TIA)

A

minor stroke

neurological function is regained quickly with time

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48
Q

vertigo

A

dizziness/room spinning

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49
Q

wheezing

A

high pitched sound heard in lungs

in asthmatics or lung disease

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50
Q

ā

A

before

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51
Q

AAA

A

abdominal aortic aneurysm

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52
Q

A Fib

A

atrial fibrillation

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53
Q

Abd

A

abdomen

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54
Q

Abx

A

antibiotics

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55
Q

AMA

A

against medical advice

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56
Q

AMS

A

altered mental state

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57
Q

ASA

A

acetylsalicylic acid/asprin

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58
Q

BID

A

twice daily

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59
Q

Bilat LE

A

bilateral lower extremities

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60
Q

BM

A

bowel movement

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61
Q

BP

A

blood pressure

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62
Q

c̅

A

with

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63
Q

CA

A

carcinoma/cancer

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64
Q

CABG

A

coronary artery bypass graft / open heart surgery

65
Q

CAD

A

coronary artery disease / heart disease

66
Q

CT or CAT

A

computerized assisted tomography

67
Q

CHF

A

congestive heart failure

68
Q

COPD

A

chronic obstructive pulmonary disease

69
Q

CP

A

chest pain

70
Q

CPR

A

cardiopulmonary resuscitation

71
Q

C-section

A

caesarean section

72
Q

CSF

A

cerebrospinal fluid

73
Q

CVA

A

cerebrovascular accident

costovertebral angle

74
Q

CXR

A

chest X-ray

75
Q

c/o

A

complains of

76
Q

C-Spine

A

cervical spine / neck

77
Q

DKA

A

diabetic ketoscidosis

78
Q

DM

A

diabetes mellitus

79
Q

DNR

A

do not resuscitate

80
Q

DOE

A

dyspnea on exertion

81
Q

DVT

A

deep vein thrombosis

82
Q

Dx

83
Q

Dz

84
Q

EKG/ECG

A

electrocardiogram

85
Q

EtOH

86
Q

FHx

A

family history

87
Q

Fx

88
Q

GI

A

gastrointestinal

89
Q

G/P/Ab

A

gravida/para/abortion

90
Q

GSW

A

gun shot wound

91
Q

GU

A

genitouninary

92
Q

HA

93
Q

HEENT

A

head, eyes, ears, nose, throat

94
Q

HPI

A

history of present illness

95
Q

HTN

A

hypertension

96
Q

Hx

97
Q

H&H

A

hemoglobin and hematocrit

98
Q

H&P

A

history of present illness and physical exam

99
Q

I&D

A

incision and drainage

100
Q

IDDM

A

insulin dependent diabetes mellitus

101
Q

IUP

A

intrauterine pregnancy

102
Q

IVDA

A

IV drug abuse

103
Q

JVD

A

jugular vein distension

104
Q

LLE

A

left lower extemity

105
Q

LLQ

A

left lower quadrant

106
Q

LNMP

A

last normal menstrual period

107
Q

LOC

A

loss of consciousness

108
Q

LP

A

lumbar puncture

109
Q

LUE

A

left lower extremity

110
Q

LUQ

A

left upper quadrant

111
Q

MCA

A

motorcycle accident

112
Q

MI

A

myocardial infarction

113
Q

MVA/MVC

A

motorvehicle accident/collision

114
Q

N/A

A

not applicable

115
Q

NAD

A

no acute distress, no acute disease

116
Q

NIDDM

A

non insulin dependent diabetes mellitus

117
Q

NKDA

A

no known drug allergies

118
Q

Nml / nl

119
Q

NSAID

A

non steroidal anti-inflammatory drugs

120
Q

NSR

A

normal sinus rhythm

121
Q

NTG

A

nitroglycerin

122
Q

N/V/D

A

nausea / vomiting / diarrhea

123
Q

O2 Sat

A

oxygen saturation

124
Q

OD

125
Q

p̄

A

post, after

126
Q

PCP

A

primary care physician

127
Q

PE

A

physical exam or pulmonary embolism

128
Q

PERRL

A

pupils are equal, round, and reactive to light

129
Q

PO

A

Per Os (by mouth)

130
Q

prn

131
Q

pt

132
Q

PTA

A

prior to arrival

133
Q

qd

134
Q

qh

A

every hour

135
Q

qhs

A

at every bedtime

136
Q

q2h

A

every 2 hours

137
Q

QID

A

four times a day

138
Q

RLE

A

lower right extremity

139
Q

RLQ

A

lower right quadrant

140
Q

ROM

A

range of motion

141
Q

ROS

A

review of systems

142
Q

RUE

A

right upper extremity

143
Q

RUQ

A

right upper quadrant

144
Q

Rx

A

prescription

145
Q

r/o

146
Q

s̅

147
Q

SOB

A

shortness of breath

148
Q

s/p

A

status post (after)

149
Q

Sx

150
Q

TIA

A

transient ischemic attack

151
Q

TID

A

three times a day

152
Q

TM

A

tympanic membrane

153
Q

Tx

154
Q

US

A

urinalysis

155
Q

URI

A

upper respiratory infection

156
Q

US

A

ultrasound

157
Q

UTD

A

up to date

158
Q

UTI

A

urinary tract infection

159
Q

WNL

A

within normal limits

Scribe America (1 decks)

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