ScibeU

Anatomical Position

To stand erect with arms at the sides and palms of the hands turned forward

Anterior Situated

in front of or directed toward the front

C-spine

Cervical spine (C1-C7)

Diffuse Generalized

not localized to any specific location

Distal

Farther from the trunk of the body

Epigastric Upper

central region of the abdomen

Fontanel

Anatomical feature of an infant’s skull

Inferior

Lower on the body

L-spine

Lumbar spine (L1-L5)

Lateral

Farther from the midline

Left Lower Extremity

(LLE)

Left Lower Quadrant

(LLQ)

Left Upper Extremity

(LUE)

Left Upper Quadrant

(LUQ)

Medial

Nearer to the midline

Palmar or Volar

Palm side of hand or body

Plantar

Sole of foot

Posterior or Dorsal Rear or back

Prone Body

position lying face down with forearms and hands turned palm side down

Proximal

Nearer to the trunk of the body

Right Lower Extremity

(RLE)

Right Lower Quadrant

(RLQ)

Right Upper Extremity

(RUE)

Right Upper Quadrant

(RUQ)

Superficial

Nearer to the surface (example: superficial abrasion)

Superior

Higher on the body

Supine

Body position lying face up

Suprapubic

Lower central region on the abdomen

T-spine

Thoracic spine (T1-T12)

Acute

New onset likely concerning. Opposite of chronic

Acute on chronic

New exacerbation of a chronic condition

Chronic

Long-standing constant. Opposite of acute

Fluctuating

Symptoms that are always present but changing in severity never fully resolving

Intermittent

Symptoms that completely resolve at times but continue to return repeatedly

Paroxysmal

Occasional sporadic transient

Resolved

Gone no longer existing

Transient

Resolving spontaneously after onset

Family History (FHx)

A part of the medical chart that lists diseases and health conditions in your family that may put the patient at an increased risk of also having

Health Insurance Portability and Accountability Act (HIPAA)

Federal law that provides national standards to protect sensitive patient health

information from being disclosed without the patient's consent or knowledge

History of present illness (HPI)

A part of the medical chart describing the development of the illness

pt

Patient

r/o

Rule Out (e.g. X-ray of the wrist to r/o fracture)

Review of system (ROS)

A part of the medical chart that is a checklist of the symptoms the patient has or does not have. The symptoms are grouped by body system (cardiovascular

s/p

Status Post (after) example: Headache s/p fall

Social History (SHx)

A part of the chart addresses substance use occupation diet exercise living situation marital status

Sx

Symptoms

Tx

Treatment

UTD

Up to Date (example vaccination utd)

WNL

Within Normal Limits (normal

Abscess

A collection of pus beneath the skin

Appendicitis

Dangerous infection of the appendix

Arthritis

Inflammation of the joints

Atrial fibrillation (A fib)

Irregular and often very rapid heart rhythm (arrhythmia)

Bell’s Palsy

A localized facial nerve dysfunction that causes facial droop and numbness

Bronchitis

Inflammation/Infection of the bronchi (upper airway)

Cancer (CA)

Cancer Carcinoma

Cellulitis

Infection of skin cells

Cerebrovascular accident (CVA)

Stroke. Blood supply to the brain is restricted or absent due to hemorrhage or occlusion of a vessel resulting in neurological damage and dysfunction

Cholecystitis

Inflammation of the gallbladder

Cholelithiasis

Production of gallstones

Chronic obstructive pulmonary disease (COPD)

Chronic inflammatory lung disease that causes obstructed airflow from the lungs

Chronic renal failure (CRF)

Decrease in the kidneys' ability to filter waste and fluid from the blood

Cirrhosis

Inflammation of an organ by degenerative changes especially of the liver

Congestive heart failure (CHF)

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

Conjunctivitis Infection

of the outer layer of the eye

Coronary artery bypass graft (CABG)

Procedure used to treat coronary artery disease

Coronary artery disease (CAD)

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

Costochondritis

Inflammation of the rib cartilage

Croup

Viral infection of the upper airway with a barking cough and often stridor

Deep venous thrombosis (DVT)

blood clot forms in a vein located deep inside your body

Dermatitis

Inflammation of the skin

Diverticulitis

Acute inflammation of the diverticula pouches

Ectopic pregnancy

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

Endometriosis

Presence of functioning endometrial tissue outside of the uterus

Gastroenteritis

General term for inflammation of the GI tract

Gastroesophageal reflux

disease (GERD)

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

Gout

Type of arthritis diagnosed by ordering a uric acid level

Hepatitis

Inflammation of the liver

Hyperglycemia

High blood sugar due to diabetes

Hyperlipidemia (HLD)

High cholesterol

Hypertension (HTN)

High blood pressure (typically >140/90)