Medical Scribe Comprehensive Practice Exam Master Study Guide

Comprehensive vocabulary flashcards covering medical terminology, clinical workflow, history documentation, and physical exam findings for medical scribe training.

Hyperlipidemia

The core medical term for high cholesterol used in scribe foundational training.

Adenoidectomy

The surgical removal of the adenoids.

CABG

Abbreviation for Coronary Artery Bypass Graft, representing heart bypass or open heart surgery.

A&P

Stands for Assessment and Plan, referring to the section of the SOAP note for diagnoses and treatment steps.

Diagnostic visits

Visits addressing new, symptomatic, or unexplained complaints where the definitive cause is uncertain, requiring a differential diagnosis list.

Differential Diagnosis (DDx)

A list of potential diagnoses outlined by a physician when a definitive diagnosis has not yet been determined.

Family History (FHx)

Medical history information restricted to blood relatives only (e.g., Mother); excludes non-genetic relations like step-parents.

True Allergy

An immunoglobulin-mediated allergic hypersensitivity reaction presenting as hives, rash, dyspnea, or anaphylaxis.

Adverse Side Effect

Non-allergic reactions to medication, such as nausea, which are documented separately from true allergies.

Myocardial Infarction

The primary diagnosis of concern for a patient with CAD, hypertension, and smoking history presenting with acute chest pain.

CAD Management

Lifestyle modifications including quitting smoking, exercising, and managing stress.

Pancreatitis

A condition that can be caused by extremely high triglycerides associated with untreated Hyperlipidemia.

CVA

Cerebrovascular Accident or stroke; a potential consequence of plaque buildup from untreated Hyperlipidemia.

Hypertension Medications

Therapeutic agents including ACE Inhibitors (e.g., Lisinopril), Ca Channel Blockers (e.g., Norvasc/amlodipine), and Diuretics (e.g., HCTZ).

Onset

The specific timeframe describing exactly when a patient's complaint started.

Review of Systems (ROS)

The section of the medical chart where unrelated, secondary, or non-chief complaints are documented.

Associated Symptoms

Acute complaints that directly match or accompany the context of the primary illness.

Hemoptysis

The medical term for coughing up blood, categorized under the Respiratory system.

McBurney's Point Tenderness

A physical exam finding in the Right Lower Quadrant (RLQ) that raises concern for appendicitis.

Murphy's Sign

A physical exam test used to check for cholecystitis (gallbladder) in the RUQ.

Bradycardia

An abnormally slow heart rate defined as being below $60\,bpm$.

Pale conjunctiva

An abnormal physical exam finding associated with Anemia.

Scleral Icterus

An abnormal physical exam finding associated with Liver failure.

Dry mucous membranes

A physical exam sign of dehydration that contradicts a finding of "well hydrated."

Jugular venous distention (JVD)

An abnormal physical exam finding associated with Congestive Heart Failure (CHF).

Irregularly irregular rhythm

An abnormal physical exam finding associated with Atrial fibrillation.

Inspiratory wheeze

An abnormal physical exam finding associated with Asthma.

Auscultation

The act of listening to internal body sounds with a stethoscope.

Cachectic

A physical appearance described as being very thin or emaciated.

Palpation

The medical act of pressing on an area of the body during a physical exam.

Medial

A directional term meaning closer to the midline of the body.

Diffuse

A term used to describe a finding that is widespread or covers a large area.

Distress

The physician's appreciation or clinical assessment of the patient's level of discomfort.

Plan (Last Line)

The final component of the clinical plan, typically stating "Follow up at your clinic."

Assessment Components

The section of the chart containing the patient's age and sex, diagnosis, physical exam highlights, and diagnostic test results.

HIPAA

The Health Insurance Portability and Accountability Act, designed to maintain patient privacy and confidentiality.