Scribe Terms Flashcards
1
Q
Abd
A
Abdomen
2
Q
Abduction
A
Movement away from the midline
3
Q
Accessory muscle use
A
Struggling for breath using muscles in the neck
4
Q
Adduction
A
Movement toward the midline
5
Q
Adenopathy
A
Enlargement of the lymph nodes
6
Q
Adnexa
A
Ovaries and Fallopian tubes
7
Q
AED
A
Automatic external defibrillator
8
Q
Afebrile
A
Without fever
9
Q
A fib
A
Atrial fibrillation
10
Q
Albuterol
A
An inhaled or oral medical to relieve asthma
11
Q
ALOC
A
Altered level of consciousness
12
Q
Ambulatory
A
Can walk
13
Q
Amoxicillin
A
A common antibiotic given to kids
14
Q
AMS
A
Altered mental status
15
Q
Aneurysm
A
An abnormal widening of a blood vessel
16
Q
Angina
A
Chest pain due to a lack of blood flow to heart muscle
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
18
Q
Anion gap
A
A blood test that suggests an unmeasured acid is in the blood
19
Q
Anisocoria
A
Unequal pupil sizes
20
Q
Anterior
A
Front
21
Q
Appendectomy
A
Surgical removal of the appendix
22
Q
Arrhythmia
A
Abnormal heart rhythm
23
Q
Artery
A
Blood vessel carrying blood away from the heart
24
Q
Arthralgia
A
Pain in the joint without swelling or warmth
25
Articulation
Connection between bones
26
ASA
Aspirin
27
Atelectasis
Partial collapse of the small airways in the lungs
28
Atrial fibrillation/fibrillation
A very fast regular arrhythmia of the heart, needs slowing or conversion
29
Augmentin
A common antibiotic for ears, bites, skin
30
Avulsion
A forcible tearing away of a part or structure
31
Axilla
Underarm
32
Azithromycin
A common antibiotic for lung infection
33
BCP
Birth control pill
34
Beta blocker
Group of drugs that slow heart rate and lower bp
35
BIB
Twice per day (refers to Rx)
36
BLE
Bilateral lower extremities
37
Bradycardia
Abnormal slow heart beat
38
Bradypnea
Abnormally slow breathing
39
Brudzinski's sign
Sign of meningitis
40
Bruit
A murmur or sound heard in auscultation indicating narrowing of a vessel
41
BSO
Bilateral salpingo-oophorectomy
42
BTL
Bilateral tubal ligation
43
BUE
Bilateral upper extremities
44
C/O
Complains of
45
C/w
Consistent with
46
CA
Cancer
47
CABG or CABS (cardiac bypass)
Open heart surgery involving arterial bypass using a transplanted vein
48
CAD (coronary artery disease)
Abnormal narrowing of the blood vessels of the heart, predisposing to heart attacks
49
Cardiac catheterization (angiogram)
Passage of a catheter into the heart through an artery usually done to evaluate coronary artery blood flow
50
Cardiomegaly
Enlargement of the heart
51
Carotid bruit
Noise from carotid artery narrowing heard with stethoscope
52
C-dif
Clostridium difficile
53
Cellulitis
Infection of the skin characterized by erythema, warmth, tenderness
54
Cerumen
Earwax
55
Cervical
Pertaining to the neck or to the cervix of the uterus (same word)
56
Cholecystectomy
Surgical removal of the gallbladder
57
Cholelithiasis
Gallstone formation in the gallbladder
58
Cipro
A common antibiotic, especially for lung, urine, kids
59
AAA
Abdominal aortic aneurysm
60
Cirrhosis
Inflammation of a liver resulting in scarring and loss of function
61
Clubbing
Swelling and softening of the nail bed indicating chronic lung problem
62
CMT
Cervical motion tenderness
63
Colectomy
Surgical removal of part or all of the large intestine
64
Colostomy
Surgical procedure that provides an opening between the colon and abdominal wall
65
Conjunctiva
White part of eye and inside lining of eyelid
66
COPD
Lung problem resulting in shortness of breath, usually from smoking (chronic obstructive pulmonary disease or emphysema)
67
Cornea
Transparent coat of the eyeball that covers the iris and pupil
68
Costovetebral angle tenderness (CVA tenderness)
Tenderness posteriorly at the lower rib margins (indicative of kidney infection, kidney stress)
69
CP
Chest pain
70
Creatinine
Blood test measuring kidney function
71
Crepitus
A cracking or grating sound, usually of bones
72
CSF
Cerebrospinal fluid
73
CVA (cerebral vascular accident or stroke)
Death of brain matter from loss of blood supply
74
CW
Chest wall
75
Cyanosis
Blue skin due to a lack of oxygen
76
Cyanotic
Bluish skin color due to a lack of oxygen
77
D&C
Dilation and curettage
78
D5W
An IV solution that has only 5% sugar in it
79
DDD
Degenerative disk disease
80
Debridement
Removal of dead or contaminated tissue from a wound
81
Decubitus
Pressure sore on skin
82
Deep
Farther from the skin
83
Dentition
The condition of the teeth
84
Dermis
True skin, beneath the epidermis
85
Diabetes mellitus
Disease characterized by abnormally high blood sugar
86
Diaphoresis
Excessive or profuse sweating or perspiration
87
Differential diagnosis
A list of possible diagnosis to explain a set of symptoms
88
Dilaudid
A common narcotic used IV
89
Diltiazem
A common medication used to slow heart rate
90
Distal
Farther from the limb root
91
DJD
Degenerative joint disease
92
DKA
Diabetes ketoacidosis
93
Dopamine
Drug to raise blood pressure in shock
94
Dorsiflexion
Upward flexion of the foot
95
Dullness or percussion
Sign of solid fluid or mass under area being "tapped"
96
DVT (deep vein thrombosis)
Clot in the deep veins of the leg or arm
97
Dysmenorrhea
Painful menstruation
98
Dyspareunia
Painful intercourse
99
Dyspepsia
Indigestion
100
Ecchymosis
Bruising
101
EF
Ejection fraction
102
EGD
Upper endoscopy
103
EMS
Emergency medical services
104
Endometriosis
Presence of functioning endometrial tissue outside of the uterus
105
EOMI
Extraocular movements intact
106
Everted
Rolled outward
107
Exophthalmus
Bulging eyes, often from thyroid disease
108
Extension
Straightening out
109
External
Outside
110
Extrasystoles
Extra beats of the heart
111
F/u
Follow up
112
FHR
Fetal heart rate
113
FHT
Fetal heart tones
114
Flexion
Bending or angulation
115
Friction rub
Abnormal heart or lung sound
116
Funduscopic
Exam of back of the eye
117
G_P_A_
Grava (pregnancies), para (live birth), abortions (spontaneous or induced)
118
Gallop
Extra heart sound heard common in CHF
119
GCS
Glasgow Coma Scale
120
GIB
Gastrointestinal bleeding
121
Gravid
Being pregnant
122
GSW
Gun shot wound
123
Guarding
Involuntary tightening of stomach muscles when pushed on - patient cannot control this - due to irritation of lining of abdominal cavity
124
GERD
Gastro esophageal reflux disease
125
HCTZ
Hydrochlorothiazide
126
Hemangioma
Tumor consisting of blood vessels
127
Hematemesis
Vomiting of blood
128
Hematochezia
Bright red blood in the stool
129
Hematoma
Swelling of blood which occurs in an organ or tissue
130
Hematuria
Blood in urine
131
Heme negative
No blood detected by chemical test, usually referring to stool or urine
132
Hemiparesia
Weakness on one half of body
133
Hemiplegia
Paralysis on one half of the body
134
Hemoptysis
Coughing up blood
135
Hemorrhage
Excessive or profuse bleeding
136
Hemothorax
Blood fluid present in the pleural cavity (outside lung but in chest cavity)
137
Hematomegaly
Enlarged liver
138
Hepatosplenomegaly
Enlargement of the liver and spleen
139
HH
Hiatal hernia
140
Hyperlipidemia
Elevation of cholesterol and or triglycerides in the blood
141
Hypertension
Persistently high or arterial blood pressure
142
Hypotension
Persistently low arterial blood pressure
143
Hysterectomy
Surgical removal of the uterus
144
IBS
Irritable bowel syndrome
145
ICH
Intracranial hemorrhage
146
Ileus
Bowel lacks normal contractions, usually shows as air fluid levels on X-rays
147
Induration
Hardened tissue, often from infection
148
Infarct
Cessation of the blood flow causing tissue death
149
Inferior
Lower, farther from head
150
Inguinal
Pertaining to the groin region
151
Internal
Inside
152
Intervertebral disc
Structure lying between the bony vertebral bodies
153
Inverted
Rolled inward
154
Irregularly irregular rhythm
No consistent pattern to the heart rhythm, usually implying arterial fibrillation
155
Ischemia
Temporary and localized lack of blood flow
156
IUP
Intrauterine pregnancy
157
IVC
Inferior vena cava
158
Jaundice
Yellow discoloration of the skin
159
Joint
Articulation or junction between two or more bones or cartilage
160
JVD
Jugular vein dissension
161
Keloid
Scar formation consisting of dense tissue
162
Kernig's sign
Sign of meningitis
163
Lacrimal
Pertaining to tears
164
LAFB
Left anterior fascicular block
165
Lateral
Farther from the midline
166
LBBB
Left bundle branch block
167
Lingual
Pertaining to the tongue
168
Lipase
Blood test measuring pancreas activity
169
LLE
Left lower extremity
170
LLQ
Left lower quadrant
171
LNMP
Last normal menstrual period
172
LOC
Loss of consciousness
173
LUE
Left upper extremity
174
LUQ
Left upper quadrant
175
LVH
Left ventricular hypertrophy
176
Lymphadenopathy
Enlargement of lymph nodes
177
Lymphangitis
Infection traveling up lymphatic system
178
Macule
Small colored spot on the skin
179
Malaise
Generalized discomfort or weakness
180
Malleolus
Projection on either side of the ankle joint from the lower leg bones
181
Malocclusion
Teeth don't fit together
182
Mandible
Jaw bone
183
Mass
Any firm abnormality seen or palpated on physical exam
184
Mastectomy
Surgical excision of the breast
185
Maxalt
A migraine medication
186
Maxilla
Cheek, or structures near cheek
187
MCA or MCC
Motorcycle accident
188
Medial
Nearer to the midline
189
Melena
Black tarry stool
190
Meningismus
Stiff neck
191
MI
Myocardial infarction
192
Morphine
A common narcotic used IV
193
MRA
Magnetic resonance angiogram
194
MRSA/VRSA
Two types of very resistant bacteria
195
Murmur
Abnormal heart sound rated on 1 to 6 scales, 6 being the loudest
196
MVA
Motor vehicle accident
197
Myalgia
Muscular pain
198
Myocardial infarction
Heart attack (coronary artery occluded)
199
Nares
Nostrils
200
Neuralgia
Sharp pain along the course of a nerve
201
Nitroglycerine
Dilates blood vessels, used with heart pain
202
NL
Normal
203
Norco
An oral narcotic, identical to Vicodin
204
Normal saline
An IV fluid that is equimolar to blood
205
NSAID
Non-steroidal anti-inflammatory
206
NSR
Normal sinus rhythm
207
NSVD
Normal spontaneous delivery
208
NTG
Nitroglycerine
209
Nystagmus
Involuntary rapid eye movement
210
Occiput
Back part of the skull
211
Olecranon
Bony projection of the ulna forming the point of the elbow
212
Oophorectomy
Surgical removal of the ovaries
213
OOT/OOA
Out of town/area
214
Organomegaly
Enlargement of the abdominal organs, usually spleen, liver or kidneys
215
Os
Mouth, orifice
216
OTC
Over the counter
217
Pallor
Paleness of the skin
218
Palmar or volar
Palm side of hand or body
219
Palpable
Able to be touched or easily perceived
220
Paresthesia
Abnormal tactile sensation often described as burning, tingling, or numbness
221
PAT
Paroxysmal atrial tachycardia
222
PE (pulmonary embolus)
Clot in the lung, often arising from leg veins or pelvis
223
Pedal edema
Water retention in the foot/ankle area
224
Peritonsillar abscess
Abscess that forms behind the tonsils
225
Petechia
Tiny red spot occurring on the skin caused by a small amount of subcutaneous bleeding from the capillaries
226
Pharynx
Back of throat extending up to the nose and down to the vocal cords
227
Photophobia
Abnormal intolerance to light
228
Plantar
Sole side of foot
229
Plantar flexion
Downward flexion of the foot
230
PMD/PCP
Primary care doctor
231
PMI displaced laterally
Sign of enlarged heart
232
Pneumothorax
Abnormal presence of air in the pleural space (chest cavity) and outside of the lung, causing the lung to collapse
233
Posterior or dorsal
Back of body
234
PRN
As needed (refers to Rx)
235
Prolonged expiration
Indicates airway narrowing on expiration, common in asthma
236
Prominent abdominal aortic pulsation
Possible abdominal aortic aneurysm
237
Prone
Face down
238
Proximal
Nearer to the limb root
239
PSVT
Paroxysmal supraventricular tachycardia
240
Pt
Patient
241
Pulmonary
Relating to lung
242
Purulent
Consisting of pus
243
PVC
Premature ventricular contraction
244
PVD
Peripheral vascular disease
245
Q
Every (refers to Rx)
246
Q4H
Every 4 hours (refers to Rx)
247
QD
Everyday (refers to Rx)
248
RA
Rheumatoid arthritis
249
Rales
Clicking, rattling, or crackling noises heard in the lungs on inhalation, indicating fluid in the alveoli (signs of pneumonia or heart failure)
250
RBBB
Right bunch branch block
251
Rebound
Pain when releasing hand from abdominal palpation or from other movement
252
Retractions
Sucking in between ribs or sternum, during inspiration - usually children
253
Rhinorrhea
Thin, watery discharge from the nose
254
Rhonchi
A course sound in the lungs that indicates the presence of thick fluid
255
Rhonchi
Abnormal respiratory sound heard on auscultation
256
RLE
Right lower extremity
257
RLQ
Right lower quadrant
258
Rocephin
A common IV antibiotic
259
ROM
Range of motion
260
Romberg's sign
Falling to one side, standing with eyes closed
261
RUE
Right upper extremity
262
RUQ
Right upper quadrant
263
RVR
Rapid ventricular response
264
S/P
Status post
265
SAB
Spotaneous abortion
266
SAH
Spontaneous hemorrhage
267
Sclera
The layer under the white part of the eye
268
SDH
Subdural hemorrhage
269
Sepsis
Presence of pathological microorganisms or their tons in the blood
270
Shaft
Long, slender portion of a long bone
271
SNF
Skilled nursing facility
272
SOB
Shortness of breath
273
Splenectomy
Surgical removal of the spleen
274
Splenomegaly
Enlarged spleen
275
Splinting
Not moving because of pain
276
Sputum
Spittle, any mixed matter with saliva that is expectorated through the mouth
277
Status epilepticus
Continuous seizure activity
278
Stellate
Star-shaped
279
Stenosis
Narrowing of a body opening or passage
280
Stridor
High pitched sound heart on inspiration that is indicative or airway obstruction
281
Superficial
Nearer to the surface
282
Superior
Upper, nearer to head
283
Supine
Face up
284
Supraventricular
Arising from the atria of the heart
285
SVT
Supraventricular tachycardia
286
Syncope
Loss of consciousness
287
T&A
Tonsillectomy and adenoidectomy
288
TAB
Therapeutic abortion
289
Tachycardia
Abnormal rapid heart beat
290
Tachycardia
Fast heart rate
291
Tachypnea
Extreme rapid respiration
292
TAH
Total abdominal hysterectomy
293
TC
Traffic collision
294
TGA
Transient global amnesia
295
TGN
Trigeminal neuralgia
296
Thoracotomy
Surgical opening of the chest cavity
297
Thyroid
Gland in front of the windpipe that makes thyroid hormones
298
Thyromegaly
Enlarged thyroid
299
TIA
Transient ischemic attack; "minor stroke", neurological function is regained with time
300
Tinea
Superficial fungal infection of the skin
301
Tinnitus
Ringing in the ear
302
Tonsillectomy
Surgical excision of the tonsils
303
Torsion
The twisting of a bodily organ on its own axis (usually pertaining to an ovary or testicle)
304
TPA
Tissue plasminogen activator, drug that immediately dissolves clot
305
Troponin
Test done to indicate recent heart attack
306
TTP
Tenderness to palpation
307
Turgor
Condition of being distended or swollen
308
TURP
Transurethral resection of prostate; procedure to remove prostatic tissue preformed using an endoscope passed through the urethra
309
URI
Upper respiratory infection
310
Urinary retention
Large bladder due to obstruction
311
Urticaria
Hives or wheals, either redder or paler than the surrounding area and see often itchy
312
Vancomycin
A common IV antibiotic given for skin infection
313
Vein
Vessel carrying deoxygenated blood back to the heart
314
Vertebral point tenderness
Tenderness directed over the spine
315
Vertigo
A spinning sensation caused by an inner ear problem
316
Vestibulitis
Inflammation of balance mechanism in the inner ear causing dizziness
317
Vicodin
An oral narcotic, identical to Norco
318
VSS
Vital signs stable
319
W/
With
320
W/o
Without
321
W/u
Work up
322
WBC
White blood cells including leukocytes, monocytes, and others
323
Wheal
Round, localized area of edema on the skin attended by severe itching
324
Wheezing
High pitched whistling sound of air moving through narrowed airways
325
Xopenex
An inhaled medication to relieve asthma
326
Zofran
A common anti-nausea medication
