Scribe Terms Flashcards

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1
Q

Abd

A

Abdomen

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2
Q

Abduction

A

Movement away from the midline

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3
Q

Accessory muscle use

A

Struggling for breath using muscles in the neck

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4
Q

Adduction

A

Movement toward the midline

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5
Q

Adenopathy

A

Enlargement of the lymph nodes

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6
Q

Adnexa

A

Ovaries and Fallopian tubes

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7
Q

AED

A

Automatic external defibrillator

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8
Q

Afebrile

A

Without fever

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9
Q

A fib

A

Atrial fibrillation

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10
Q

Albuterol

A

An inhaled or oral medical to relieve asthma

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11
Q

ALOC

A

Altered level of consciousness

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12
Q

Ambulatory

A

Can walk

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13
Q

Amoxicillin

A

A common antibiotic given to kids

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14
Q

AMS

A

Altered mental status

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15
Q

Aneurysm

A

An abnormal widening of a blood vessel

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16
Q

Angina

A

Chest pain due to a lack of blood flow to heart muscle

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17
Q

Angioplasty

A

Opening of an artery (usually in heart) with a wire dilator, usually followed by a stent placement to keep it open

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18
Q

Anion gap

A

A blood test that suggests an unmeasured acid is in the blood

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19
Q

Anisocoria

A

Unequal pupil sizes

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20
Q

Anterior

A

Front

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21
Q

Appendectomy

A

Surgical removal of the appendix

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22
Q

Arrhythmia

A

Abnormal heart rhythm

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23
Q

Artery

A

Blood vessel carrying blood away from the heart

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24
Q

Arthralgia

A

Pain in the joint without swelling or warmth

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25
Q

Articulation

A

Connection between bones

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26
Q

ASA

A

Aspirin

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27
Q

Atelectasis

A

Partial collapse of the small airways in the lungs

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28
Q

Atrial fibrillation/fibrillation

A

A very fast regular arrhythmia of the heart, needs slowing or conversion

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29
Q

Augmentin

A

A common antibiotic for ears, bites, skin

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30
Q

Avulsion

A

A forcible tearing away of a part or structure

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31
Q

Axilla

A

Underarm

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32
Q

Azithromycin

A

A common antibiotic for lung infection

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33
Q

BCP

A

Birth control pill

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34
Q

Beta blocker

A

Group of drugs that slow heart rate and lower bp

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35
Q

BIB

A

Twice per day (refers to Rx)

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36
Q

BLE

A

Bilateral lower extremities

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37
Q

Bradycardia

A

Abnormal slow heart beat

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38
Q

Bradypnea

A

Abnormally slow breathing

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39
Q

Brudzinski’s sign

A

Sign of meningitis

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40
Q

Bruit

A

A murmur or sound heard in auscultation indicating narrowing of a vessel

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41
Q

BSO

A

Bilateral salpingo-oophorectomy

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42
Q

BTL

A

Bilateral tubal ligation

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43
Q

BUE

A

Bilateral upper extremities

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44
Q

C/O

A

Complains of

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45
Q

C/w

A

Consistent with

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46
Q

CA

A

Cancer

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47
Q

CABG or CABS (cardiac bypass)

A

Open heart surgery involving arterial bypass using a transplanted vein

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48
Q

CAD (coronary artery disease)

A

Abnormal narrowing of the blood vessels of the heart, predisposing to heart attacks

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49
Q

Cardiac catheterization (angiogram)

A

Passage of a catheter into the heart through an artery usually done to evaluate coronary artery blood flow

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50
Q

Cardiomegaly

A

Enlargement of the heart

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51
Q

Carotid bruit

A

Noise from carotid artery narrowing heard with stethoscope

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52
Q

C-dif

A

Clostridium difficile

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53
Q

Cellulitis

A

Infection of the skin characterized by erythema, warmth, tenderness

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54
Q

Cerumen

A

Earwax

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55
Q

Cervical

A

Pertaining to the neck or to the cervix of the uterus (same word)

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56
Q

Cholecystectomy

A

Surgical removal of the gallbladder

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57
Q

Cholelithiasis

A

Gallstone formation in the gallbladder

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58
Q

Cipro

A

A common antibiotic, especially for lung, urine, kids

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59
Q

AAA

A

Abdominal aortic aneurysm

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60
Q

Cirrhosis

A

Inflammation of a liver resulting in scarring and loss of function

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61
Q

Clubbing

A

Swelling and softening of the nail bed indicating chronic lung problem

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62
Q

CMT

A

Cervical motion tenderness

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63
Q

Colectomy

A

Surgical removal of part or all of the large intestine

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64
Q

Colostomy

A

Surgical procedure that provides an opening between the colon and abdominal wall

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65
Q

Conjunctiva

A

White part of eye and inside lining of eyelid

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66
Q

COPD

A

Lung problem resulting in shortness of breath, usually from smoking (chronic obstructive pulmonary disease or emphysema)

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67
Q

Cornea

A

Transparent coat of the eyeball that covers the iris and pupil

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68
Q

Costovetebral angle tenderness (CVA tenderness)

A

Tenderness posteriorly at the lower rib margins (indicative of kidney infection, kidney stress)

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69
Q

CP

A

Chest pain

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70
Q

Creatinine

A

Blood test measuring kidney function

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71
Q

Crepitus

A

A cracking or grating sound, usually of bones

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72
Q

CSF

A

Cerebrospinal fluid

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73
Q

CVA (cerebral vascular accident or stroke)

A

Death of brain matter from loss of blood supply

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74
Q

CW

A

Chest wall

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75
Q

Cyanosis

A

Blue skin due to a lack of oxygen

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76
Q

Cyanotic

A

Bluish skin color due to a lack of oxygen

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77
Q

D&C

A

Dilation and curettage

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78
Q

D5W

A

An IV solution that has only 5% sugar in it

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79
Q

DDD

A

Degenerative disk disease

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80
Q

Debridement

A

Removal of dead or contaminated tissue from a wound

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81
Q

Decubitus

A

Pressure sore on skin

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82
Q

Deep

A

Farther from the skin

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83
Q

Dentition

A

The condition of the teeth

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84
Q

Dermis

A

True skin, beneath the epidermis

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85
Q

Diabetes mellitus

A

Disease characterized by abnormally high blood sugar

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86
Q

Diaphoresis

A

Excessive or profuse sweating or perspiration

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87
Q

Differential diagnosis

A

A list of possible diagnosis to explain a set of symptoms

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88
Q

Dilaudid

A

A common narcotic used IV

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89
Q

Diltiazem

A

A common medication used to slow heart rate

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90
Q

Distal

A

Farther from the limb root

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91
Q

DJD

A

Degenerative joint disease

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92
Q

DKA

A

Diabetes ketoacidosis

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93
Q

Dopamine

A

Drug to raise blood pressure in shock

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94
Q

Dorsiflexion

A

Upward flexion of the foot

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95
Q

Dullness or percussion

A

Sign of solid fluid or mass under area being “tapped”

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96
Q

DVT (deep vein thrombosis)

A

Clot in the deep veins of the leg or arm

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97
Q

Dysmenorrhea

A

Painful menstruation

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98
Q

Dyspareunia

A

Painful intercourse

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99
Q

Dyspepsia

A

Indigestion

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100
Q

Ecchymosis

A

Bruising

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101
Q

EF

A

Ejection fraction

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102
Q

EGD

A

Upper endoscopy

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103
Q

EMS

A

Emergency medical services

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104
Q

Endometriosis

A

Presence of functioning endometrial tissue outside of the uterus

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105
Q

EOMI

A

Extraocular movements intact

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106
Q

Everted

A

Rolled outward

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107
Q

Exophthalmus

A

Bulging eyes, often from thyroid disease

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108
Q

Extension

A

Straightening out

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109
Q

External

A

Outside

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110
Q

Extrasystoles

A

Extra beats of the heart

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111
Q

F/u

A

Follow up

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112
Q

FHR

A

Fetal heart rate

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113
Q

FHT

A

Fetal heart tones

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114
Q

Flexion

A

Bending or angulation

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115
Q

Friction rub

A

Abnormal heart or lung sound

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116
Q

Funduscopic

A

Exam of back of the eye

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117
Q

G_P_A_

A

Grava (pregnancies), para (live birth), abortions (spontaneous or induced)

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118
Q

Gallop

A

Extra heart sound heard common in CHF

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119
Q

GCS

A

Glasgow Coma Scale

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120
Q

GIB

A

Gastrointestinal bleeding

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121
Q

Gravid

A

Being pregnant

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122
Q

GSW

A

Gun shot wound

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123
Q

Guarding

A

Involuntary tightening of stomach muscles when pushed on - patient cannot control this - due to irritation of lining of abdominal cavity

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124
Q

GERD

A

Gastro esophageal reflux disease

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125
Q

HCTZ

A

Hydrochlorothiazide

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126
Q

Hemangioma

A

Tumor consisting of blood vessels

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127
Q

Hematemesis

A

Vomiting of blood

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128
Q

Hematochezia

A

Bright red blood in the stool

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129
Q

Hematoma

A

Swelling of blood which occurs in an organ or tissue

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130
Q

Hematuria

A

Blood in urine

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131
Q

Heme negative

A

No blood detected by chemical test, usually referring to stool or urine

132
Q

Hemiparesia

A

Weakness on one half of body

133
Q

Hemiplegia

A

Paralysis on one half of the body

134
Q

Hemoptysis

A

Coughing up blood

135
Q

Hemorrhage

A

Excessive or profuse bleeding

136
Q

Hemothorax

A

Blood fluid present in the pleural cavity (outside lung but in chest cavity)

137
Q

Hematomegaly

A

Enlarged liver

138
Q

Hepatosplenomegaly

A

Enlargement of the liver and spleen

139
Q

HH

A

Hiatal hernia

140
Q

Hyperlipidemia

A

Elevation of cholesterol and or triglycerides in the blood

141
Q

Hypertension

A

Persistently high or arterial blood pressure

142
Q

Hypotension

A

Persistently low arterial blood pressure

143
Q

Hysterectomy

A

Surgical removal of the uterus

144
Q

IBS

A

Irritable bowel syndrome

145
Q

ICH

A

Intracranial hemorrhage

146
Q

Ileus

A

Bowel lacks normal contractions, usually shows as air fluid levels on X-rays

147
Q

Induration

A

Hardened tissue, often from infection

148
Q

Infarct

A

Cessation of the blood flow causing tissue death

149
Q

Inferior

A

Lower, farther from head

150
Q

Inguinal

A

Pertaining to the groin region

151
Q

Internal

A

Inside

152
Q

Intervertebral disc

A

Structure lying between the bony vertebral bodies

153
Q

Inverted

A

Rolled inward

154
Q

Irregularly irregular rhythm

A

No consistent pattern to the heart rhythm, usually implying arterial fibrillation

155
Q

Ischemia

A

Temporary and localized lack of blood flow

156
Q

IUP

A

Intrauterine pregnancy

157
Q

IVC

A

Inferior vena cava

158
Q

Jaundice

A

Yellow discoloration of the skin

159
Q

Joint

A

Articulation or junction between two or more bones or cartilage

160
Q

JVD

A

Jugular vein dissension

161
Q

Keloid

A

Scar formation consisting of dense tissue

162
Q

Kernig’s sign

A

Sign of meningitis

163
Q

Lacrimal

A

Pertaining to tears

164
Q

LAFB

A

Left anterior fascicular block

165
Q

Lateral

A

Farther from the midline

166
Q

LBBB

A

Left bundle branch block

167
Q

Lingual

A

Pertaining to the tongue

168
Q

Lipase

A

Blood test measuring pancreas activity

169
Q

LLE

A

Left lower extremity

170
Q

LLQ

A

Left lower quadrant

171
Q

LNMP

A

Last normal menstrual period

172
Q

LOC

A

Loss of consciousness

173
Q

LUE

A

Left upper extremity

174
Q

LUQ

A

Left upper quadrant

175
Q

LVH

A

Left ventricular hypertrophy

176
Q

Lymphadenopathy

A

Enlargement of lymph nodes

177
Q

Lymphangitis

A

Infection traveling up lymphatic system

178
Q

Macule

A

Small colored spot on the skin

179
Q

Malaise

A

Generalized discomfort or weakness

180
Q

Malleolus

A

Projection on either side of the ankle joint from the lower leg bones

181
Q

Malocclusion

A

Teeth don’t fit together

182
Q

Mandible

A

Jaw bone

183
Q

Mass

A

Any firm abnormality seen or palpated on physical exam

184
Q

Mastectomy

A

Surgical excision of the breast

185
Q

Maxalt

A

A migraine medication

186
Q

Maxilla

A

Cheek, or structures near cheek

187
Q

MCA or MCC

A

Motorcycle accident

188
Q

Medial

A

Nearer to the midline

189
Q

Melena

A

Black tarry stool

190
Q

Meningismus

A

Stiff neck

191
Q

MI

A

Myocardial infarction

192
Q

Morphine

A

A common narcotic used IV

193
Q

MRA

A

Magnetic resonance angiogram

194
Q

MRSA/VRSA

A

Two types of very resistant bacteria

195
Q

Murmur

A

Abnormal heart sound rated on 1 to 6 scales, 6 being the loudest

196
Q

MVA

A

Motor vehicle accident

197
Q

Myalgia

A

Muscular pain

198
Q

Myocardial infarction

A

Heart attack (coronary artery occluded)

199
Q

Nares

A

Nostrils

200
Q

Neuralgia

A

Sharp pain along the course of a nerve

201
Q

Nitroglycerine

A

Dilates blood vessels, used with heart pain

202
Q

NL

A

Normal

203
Q

Norco

A

An oral narcotic, identical to Vicodin

204
Q

Normal saline

A

An IV fluid that is equimolar to blood

205
Q

NSAID

A

Non-steroidal anti-inflammatory

206
Q

NSR

A

Normal sinus rhythm

207
Q

NSVD

A

Normal spontaneous delivery

208
Q

NTG

A

Nitroglycerine

209
Q

Nystagmus

A

Involuntary rapid eye movement

210
Q

Occiput

A

Back part of the skull

211
Q

Olecranon

A

Bony projection of the ulna forming the point of the elbow

212
Q

Oophorectomy

A

Surgical removal of the ovaries

213
Q

OOT/OOA

A

Out of town/area

214
Q

Organomegaly

A

Enlargement of the abdominal organs, usually spleen, liver or kidneys

215
Q

Os

A

Mouth, orifice

216
Q

OTC

A

Over the counter

217
Q

Pallor

A

Paleness of the skin

218
Q

Palmar or volar

A

Palm side of hand or body

219
Q

Palpable

A

Able to be touched or easily perceived

220
Q

Paresthesia

A

Abnormal tactile sensation often described as burning, tingling, or numbness

221
Q

PAT

A

Paroxysmal atrial tachycardia

222
Q

PE (pulmonary embolus)

A

Clot in the lung, often arising from leg veins or pelvis

223
Q

Pedal edema

A

Water retention in the foot/ankle area

224
Q

Peritonsillar abscess

A

Abscess that forms behind the tonsils

225
Q

Petechia

A

Tiny red spot occurring on the skin caused by a small amount of subcutaneous bleeding from the capillaries

226
Q

Pharynx

A

Back of throat extending up to the nose and down to the vocal cords

227
Q

Photophobia

A

Abnormal intolerance to light

228
Q

Plantar

A

Sole side of foot

229
Q

Plantar flexion

A

Downward flexion of the foot

230
Q

PMD/PCP

A

Primary care doctor

231
Q

PMI displaced laterally

A

Sign of enlarged heart

232
Q

Pneumothorax

A

Abnormal presence of air in the pleural space (chest cavity) and outside of the lung, causing the lung to collapse

233
Q

Posterior or dorsal

A

Back of body

234
Q

PRN

A

As needed (refers to Rx)

235
Q

Prolonged expiration

A

Indicates airway narrowing on expiration, common in asthma

236
Q

Prominent abdominal aortic pulsation

A

Possible abdominal aortic aneurysm

237
Q

Prone

A

Face down

238
Q

Proximal

A

Nearer to the limb root

239
Q

PSVT

A

Paroxysmal supraventricular tachycardia

240
Q

Pt

A

Patient

241
Q

Pulmonary

A

Relating to lung

242
Q

Purulent

A

Consisting of pus

243
Q

PVC

A

Premature ventricular contraction

244
Q

PVD

A

Peripheral vascular disease

245
Q

Q

A

Every (refers to Rx)

246
Q

Q4H

A

Every 4 hours (refers to Rx)

247
Q

QD

A

Everyday (refers to Rx)

248
Q

RA

A

Rheumatoid arthritis

249
Q

Rales

A

Clicking, rattling, or crackling noises heard in the lungs on inhalation, indicating fluid in the alveoli (signs of pneumonia or heart failure)

250
Q

RBBB

A

Right bunch branch block

251
Q

Rebound

A

Pain when releasing hand from abdominal palpation or from other movement

252
Q

Retractions

A

Sucking in between ribs or sternum, during inspiration - usually children

253
Q

Rhinorrhea

A

Thin, watery discharge from the nose

254
Q

Rhonchi

A

A course sound in the lungs that indicates the presence of thick fluid

255
Q

Rhonchi

A

Abnormal respiratory sound heard on auscultation

256
Q

RLE

A

Right lower extremity

257
Q

RLQ

A

Right lower quadrant

258
Q

Rocephin

A

A common IV antibiotic

259
Q

ROM

A

Range of motion

260
Q

Romberg’s sign

A

Falling to one side, standing with eyes closed

261
Q

RUE

A

Right upper extremity

262
Q

RUQ

A

Right upper quadrant

263
Q

RVR

A

Rapid ventricular response

264
Q

S/P

A

Status post

265
Q

SAB

A

Spotaneous abortion

266
Q

SAH

A

Spontaneous hemorrhage

267
Q

Sclera

A

The layer under the white part of the eye

268
Q

SDH

A

Subdural hemorrhage

269
Q

Sepsis

A

Presence of pathological microorganisms or their tons in the blood

270
Q

Shaft

A

Long, slender portion of a long bone

271
Q

SNF

A

Skilled nursing facility

272
Q

SOB

A

Shortness of breath

273
Q

Splenectomy

A

Surgical removal of the spleen

274
Q

Splenomegaly

A

Enlarged spleen

275
Q

Splinting

A

Not moving because of pain

276
Q

Sputum

A

Spittle, any mixed matter with saliva that is expectorated through the mouth

277
Q

Status epilepticus

A

Continuous seizure activity

278
Q

Stellate

A

Star-shaped

279
Q

Stenosis

A

Narrowing of a body opening or passage

280
Q

Stridor

A

High pitched sound heart on inspiration that is indicative or airway obstruction

281
Q

Superficial

A

Nearer to the surface

282
Q

Superior

A

Upper, nearer to head

283
Q

Supine

A

Face up

284
Q

Supraventricular

A

Arising from the atria of the heart

285
Q

SVT

A

Supraventricular tachycardia

286
Q

Syncope

A

Loss of consciousness

287
Q

T&A

A

Tonsillectomy and adenoidectomy

288
Q

TAB

A

Therapeutic abortion

289
Q

Tachycardia

A

Abnormal rapid heart beat

290
Q

Tachycardia

A

Fast heart rate

291
Q

Tachypnea

A

Extreme rapid respiration

292
Q

TAH

A

Total abdominal hysterectomy

293
Q

TC

A

Traffic collision

294
Q

TGA

A

Transient global amnesia

295
Q

TGN

A

Trigeminal neuralgia

296
Q

Thoracotomy

A

Surgical opening of the chest cavity

297
Q

Thyroid

A

Gland in front of the windpipe that makes thyroid hormones

298
Q

Thyromegaly

A

Enlarged thyroid

299
Q

TIA

A

Transient ischemic attack; “minor stroke”, neurological function is regained with time

300
Q

Tinea

A

Superficial fungal infection of the skin

301
Q

Tinnitus

A

Ringing in the ear

302
Q

Tonsillectomy

A

Surgical excision of the tonsils

303
Q

Torsion

A

The twisting of a bodily organ on its own axis (usually pertaining to an ovary or testicle)

304
Q

TPA

A

Tissue plasminogen activator, drug that immediately dissolves clot

305
Q

Troponin

A

Test done to indicate recent heart attack

306
Q

TTP

A

Tenderness to palpation

307
Q

Turgor

A

Condition of being distended or swollen

308
Q

TURP

A

Transurethral resection of prostate; procedure to remove prostatic tissue preformed using an endoscope passed through the urethra

309
Q

URI

A

Upper respiratory infection

310
Q

Urinary retention

A

Large bladder due to obstruction

311
Q

Urticaria

A

Hives or wheals, either redder or paler than the surrounding area and see often itchy

312
Q

Vancomycin

A

A common IV antibiotic given for skin infection

313
Q

Vein

A

Vessel carrying deoxygenated blood back to the heart

314
Q

Vertebral point tenderness

A

Tenderness directed over the spine

315
Q

Vertigo

A

A spinning sensation caused by an inner ear problem

316
Q

Vestibulitis

A

Inflammation of balance mechanism in the inner ear causing dizziness

317
Q

Vicodin

A

An oral narcotic, identical to Norco

318
Q

VSS

A

Vital signs stable

319
Q

W/

A

With

320
Q

W/o

A

Without

321
Q

W/u

A

Work up

322
Q

WBC

A

White blood cells including leukocytes, monocytes, and others

323
Q

Wheal

A

Round, localized area of edema on the skin attended by severe itching

324
Q

Wheezing

A

High pitched whistling sound of air moving through narrowed airways

325
Q

Xopenex

A

An inhaled medication to relieve asthma

326
Q

Zofran

A

A common anti-nausea medication