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Medical Scribe > Intro To Scribing > Flashcards

Intro To Scribing Flashcards

1
Q

Afebrile

A

Without fever

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2
Q

Abscess

A

Collection of pus beneath the skin

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3
Q

Appendicitis

A

Dangerous infection of the appendix

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4
Q

Arthritis

A

Inflammation of the joint’s

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5
Q

Atrial Fibrillation (A Fib)

A

Irregular and often very rapid heart rhythm (arrythmia)

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6
Q

Bronchitis

A

Inflammation/Infection of the bronchi (upper airway)

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7
Q

Cellulitis

A

Infection for the cells

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8
Q

Cerebrovascular Accident (CVA)

A

A stroke.
Blood supply to the brain is restricted or absent due to hemorrhage or black age of a vessel resulting in brain damage and dysfunction

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9
Q

Cholecystitis

A

Inflammation of the gallbladder

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10
Q

Chronic Obstructive Pulmonary Disease (COPD)

A

Chronic inflammatory lung disease that causes obstructed airflow to the lungs

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11
Q

Chronic Renal Failure (CRF)

A

Decrease in the kidney’s ability to filter waste and fluid from blood

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12
Q

Congestive Heart Failure (CHF)

A

Serious condition in which the heart doesn’t pump blood as efficiently as it should

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13
Q

Conjunctivitis

A

Infection of the outer layer of the eye

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14
Q

Coronary Artery Bypass Graft (CABG)

A

Procedure used to treat coronary artery disease (heart disease)

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15
Q

Coronary Artery Disease (CAD)

A

Build up of plaque in the arteries that supply oxygen-rich blood to your heart

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16
Q

Deep Venous Thrombosis (DVT)

A

A blood clot that forms in a vein located deep inside your body, typically in your leg

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17
Q

Diverticulitis

A

Acute inflammation of the diverticula pouches

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18
Q

Ectopic pregnancy

A

Egg developing outside the uterus
Extremely dangerous due to risk of rupture

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19
Q

Gastroenteritis

A

General term for inflammation of the GI tract

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20
Q

Gastroesophageal Reflux Disease (GERD)

A

Digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus

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21
Q

Hepatitis

A

Inflammation of the liver

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22
Q

Hyperglycemia

A

High blood sugar due to diabetes

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23
Q

Hyperlipidemia (HLD)

A

High cholestorol

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24
Q

Hypertension (HTN)

A

High blood pressure (typically >140/90)

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25
Q

Hypoglycemia

A

Low blood sugar

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26
Q

Hypotension

A

Low blood pressure (typically <100/65)

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27
Q

Insulin Dependent Diabetes Mellitus (IDDM)

A

Diabetes requiring use of insulin injections

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28
Q

Myocardial Infarction (MI)

A

Heart attack.
Death of cardiac muscle due to prolonged ischemia

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29
Q

Renal Calculi

A

Kidney stone

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30
Q

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

A

Diabetes NOT requiring use of insulin injections

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31
Q

Otitis Media (OM)

A

Infection of the inner ear (behind the eardrum)

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32
Q

Pancreatitis

A

Inflammation of the pancreas

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33
Q

Peptic Ulcer Disease (PUD)

A

Ulcers developing in the stomach causing pain and emesis

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34
Q

Peripheral Vascular Disease (PVD)

A

Blood circulation disorder that causes the blood vessels (excluding heart and brain) to narrow, block, or spasm

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35
Q

Pharyngitis

A

Throat infection

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36
Q

Pneumonia

A

Infiltrate (infection) inside the lung tissue

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37
Q

Pneumothorax

A

Presence of air or gas in the pleural space; collapsed lung

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38
Q

Pulmonary Embolism

A

Blockage of the pulmonary artery or one of its branches due to a translocated clot

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39
Q

Pyelonephritis

A

Infection of the kidneys

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40
Q

Sepsis

A

Dangerous infection of the blood

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41
Q

Transient Ischemic Attack (TIA)

A

“Mini stroke”
Neurological function is regained completely with time

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42
Q

Upper Respiratory Infection (URI)

A

Contagious infection of the upper respiratory tract (sinuses, throat, lungs, or airways)

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43
Q

Urinary Tract Infection (UTI)

A

Infection of any part of the urinary system- kidneys, ureter, bladder, and urethra

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44
Q

Anterior

A

Situated toward front of the body

Opposite of posterior

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45
Q

Posterior

A

Situated toward back of the body

Opposite of anterior

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46
Q

Diffuse

A

Generalized

Not localized to any specific location

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47
Q

Distal

A

Further from the trunk of the body

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48
Q

Inferior

A

Lower on body, further from head

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49
Q

Lateral

A

Further from the midline

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50
Q

Medial

A

Nearer to the midline

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51
Q

Proximal

A

Nearer trunk of the body

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52
Q

Superior

A

Higher on the body, nearer to the head

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53
Q

Ambulatory

A

Able to move about

Not confined to a bed

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54
Q

Constitutional

A

General appearance and nature of the patient

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55
Q

Distress

A

Patients inability to tolerate their body-state, due to pain or respiratory failure

No Acute Distress (NAD) is common to write for a comfortable patient

56
Q

Extraocular Muscles Intact (EOMI)

A

Testing that examines the function of the eye muscle

57
Q

Pale Conjunctiva

A

Pale inner aspect for the eyelid most often due to anemia

58
Q

Pupils are Equal, Round, and Reactive, to Light (PERRL)

A

Common normal eye exam finding

59
Q

Scleral Icterus

A

Yellowing the sclera (whites of the eyes) due to jaundice

60
Q

Cerumen

61
Q

Dry mucosa

A

Dry tongue, mouth, and lips.

Indicating significant dehydration

62
Q

Epistaxis

A

Nose bleed

63
Q

Oropharynx

A

Back of mouth, where it meets throat

64
Q

Rhinorrhea

A

Clear nasal discharge

“Runny nose”

65
Q

Tinnitus

A

Perception of ringing even with no external stimuli

“Ringing in ears”

66
Q

Tonsillectomy and Adenoidectomy (T&A)

A

Tonsils and adenoids removal surgery

67
Q

Tympanic Membrane (TM)

A

Clear membrane inside the ear (ear drum)

68
Q

Carotid Bruit

A

Whooshing blood flow heard with auscultation (carotid narrowing or plaque)

69
Q

Lymphadenopathy

A

Enlarged lymph nodes

70
Q

Supple

A

Flexible, not stiff

71
Q

Thyromegaly

A

Enlarged thyroid

72
Q

Benign

A

Normal, no longer danger to health

73
Q

Chronic

A

Long standing, constant

Opposite of acute

74
Q

Acute

A

New onset, likely concerning

Opposite of chronic

75
Q

Vertigo

A

Room-spinning dizziness

76
Q

Syncope

A

Loss of consciousness or fainting

“Passing out”

77
Q

Oriented x3

A

Oriented to person, place, and time

78
Q

DTRs

A

Deep tendon reflexes

79
Q

Meningitis

A

Infection of the meninges (outer lining of brain chord and spinal chord)

80
Q

Loss of consciousness (LOC)

A

Passing out

81
Q

Hemiplegia

A

Paralysis of one half the body

82
Q

Hemiparesis

A

Weakness of one half of the body

83
Q

Epilepsy

A

Seizure disorder

84
Q

Aphasic

A

Absence of ability to neurologically generate or understand language.

Either inability to create words or inability to understand spoken words

85
Q

Wheals

A

Patchy, red, raised rash. Consistent with allergic reactions

86
Q

Purulence

87
Q

Purulent

88
Q

Pallor

A

Pale skin typically due to anemia

89
Q

Maculopapular Rash

A

Rash both raised and red

90
Q

Laceration

A

Splitting of skin due to trauma

91
Q

Fluctuance

A

Palpable fluid beneath skin indicative of infection/pus/abscess

92
Q

Erythema

93
Q

Erythematous

94
Q

Edema

95
Q

Ecchymosis

96
Q

Diaphoresis

97
Q

Cyanosis

A

Blue color of skin due to lack of oxygen

98
Q

Abrasion

A

Scrape of skin due to something abrasive

99
Q

Last normal menstrual period (LNMP)

A

First day of ones period

100
Q

Intrauterine Pregnancy (IUP)

A

When a fertilized egg implants and starts to develop within the uterus

101
Q

Hematuria

A

Blood in the urine

102
Q

G/P/Ab

A

Gravida- # of times pregnant
Para- # of live children born
Abortion- # of failed pregnancies

103
Q

Foley Catheter

A

Tube inserted through the urethra to drain urine, often left in place

104
Q

Dysuria

A

Painful urination

105
Q

CVA tenderness

A

Costovertebral Angle tenderness; tenderness over kidneys

106
Q

C-section

A

Cesarean section

107
Q

Peritoneal signs (Rebound, guarding, or rigidity)

A

Signs indicative of acute abdominal inflammation (peritonitis)

108
Q

N/V/D

A

Nausea/Vomiting/Diarrhea

109
Q

Melena

A

Black tarry stool inductive of upper GI bleed

110
Q

Hernia

A

Protrusion of part of an internal organ or tissue bulges through weak area of muscle

111
Q

Hepatomegaly

A

Enlarged liver

112
Q

Hematemesis

A

Gross amounts of blood in vomit

113
Q

Emesis

114
Q

Wheezing

A

High pitched sound heard in lungs with asthmatics or lung disease

115
Q

Tachypnea

A

Increased respiratory rate

116
Q

Stridor

A

Upper airway noise

Common sign in croup

117
Q

Sputum

A

Any mixed matter with saliva that is passed through the mouth

118
Q

Shortness of breath (SOB)

A

Air hunger, difficulty breathing, or breathlessness

119
Q

Rhonchi

A

Sounds of mucous rolling around in bronchioles/bronchi

120
Q

Rales

A

Crackles

Wet crackling heard in the lungs, typically due to pneumonia of CHF

121
Q

Pleurisy

A

General term for pain with breathing

122
Q

Hypoxia

A

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

123
Q

Dyspnea

A

Difficulty/labored breathing, shortness of breath

124
Q

Clear to auscultation (CTA)

A

No abnormal sounds when listening to the lungs with a stethoscope

125
Q

Vein

A

Vessel carrying blood towards the heart, soft, compressible

126
Q

Tachycardia

A

Fast heart rate ( >100 bpm)

127
Q

Stenosis

A

Narrowing of a body opening or passage

128
Q

Regular rate and rhythm (RRR)

A

Normal heart sounds with a regular rate (60-100 bpm)

129
Q

Palpitation

A

To beat rapidly, irregularly, or forcibly

130
Q

Normal Sinus Rhythm (NSR)

A

Rhythm of healthy heart

131
Q

Murmur

A

Abnormal heart sound rated on 1-6 scale

132
Q

Cardiomegaly

A

Enlarged heart

133
Q

Bradycardia

A

Slow heart rate (HR<60)

134
Q

Artery

A

Blood vessel carrying blood away from the heart, muscular, contractile

135
Q

Arrhythmia

A

Irregular heartbeat

136
Q

Aneurysm

A

Localized ballooning of a vessel due to weakened vessel wall

137
Q

Jugular vein distention (JVD)

A

Sign of heart dysfunction

Medical Scribe (2 decks)

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