Scribe

C-spine

cervical spine (C1-C7)

diffuse

generalized; not localized

epigastric

upper central region of abdomen

fontanel

anatomical feature of infant’s skull, “soft spot”

L-spine

lumbar spine (L1-L5)

lateral

farther from the midline

left lower extremity (LLE)

left leg

left lower quadrant (LLQ)

left lower quadrant of abdomen

left upper extremity (LUE)

left arm

left upper quadrant (LUQ)

left upper quadrant of abdomen

medial

nearer to midline

palmar/volar

palm side of hand or body

plantar

sole of foot

prone

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

proximal

nearer to trunk of body

right lower extremity (RLE)

right leg

right lower quadrant (RLQ)

right lower quadrant of abdomen

right upper extremity (RUE)

right arm

right upper quadrant (RUQ)

right upper quadrant of abdomen

supine

body position lying face up

suprapubic

lower central region of 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)

part of the medical chart that lists diseases and health conditions in a 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 info from being disclosed w/o patient’s consent or knowledge

history of present illness (HPI)

part of the medical chart describing the development of illness

pt

patient

r/o

rule out

review of systems (ROS)

part of medical chart that is a checklist of the symptoms the patient has or doesn’t have. symptoms are grouped by body system

s/p

status post (after)

social history (SHx)

part of medical chart that addresses substance use, occupation, diet, exercise, living situation, marital status, etc.

Sx

symptoms

Tx

treatment

UTD

up to date

WNL

within normal limits

diagnosis

Dx

abscess

collection of pus beneath skin

appendicitis

dangerous infection of appendix

arthritis

inflammation of joints

atrial fibrillation (a fib)

irregular and often very rapid heart rhythm, irregularly irregular rhythm

bell’s palsy

localized facial nerve dysfunction that causes facial droop and numbness

bronchitis

inflammation/infection of bronchi (upper airway)

cancer (CA)

cancer, carcinoma

cellulitis

infection of skin cells

cerebrovascular accident (CVA)

stroke. blood supply to brain restricted or absent due to hemorrhage or occlusion of a vessel resulting in neurological damage and dysfunction, aphasia is sign

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 kidneys’ ability to filter waste and fluid from blood

cirrhosis

inflammation of an organ by degenerative changes, especially of liver

congestive heart failure (CHF)

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

conjuctivitis

infection of outer layer of eye

coronary artery bypass graft (CABG)

procedure used to treat coronary artery disease

coronary artery disease (CAD)

buildup of plaque in arteries that supply oxygen-rich blood to heart

costochondritis

inflammation of rib cage

croup

viral infection of upper airway with barking cough and often stridor

deep vein thrombosis (DVT)

blood clot forms in vein located deep inside body, typically in leg, calf tenderness is sign

dermatitis

inflammation of skin

diverticulitis

acute inflammation of diverticula pouches

ectopic pregnancy

egg developing outside uterus, extremely dangerous due to risk of rupture

endometriosis

presence of functioning endometrial tissue outside uterus

gastroenteritis

general term for inflammation of GI tract

gastroesophageal reflux disease (GERD)

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

gout

type of arthritis; diagnosed by ordering a uric acid level

hepatitis

inflammation of liver

hyperglycemia

high blood sugar due to diabetes

hyperlipidemia (HLD)

high cholesterol

hypertension (HTN)

high blood pressure (> 140/90)

hypoglycemia

low blood sugar

hypotension

low blood pressure (< 100/65)

insulin dependent diabetes mellitus (IDDM)

diabetes requiring use of insulin injections

lymphangitis

inflammation of lymphatic vessels; appears as red streaking

multiple sclerosis

autoimmune disease affecting brain and spinal cord

myocardial infarction (MI)

death of cardiac muscle due to prolonged ischemia (heart attack)

nephrolithiasis / renal calculi

kidney stones, CVA tenderness is sign

non-insulin dependent diabetes mellitus (NIDDM)

diabetes not requiring use of insulin injections

otitis externa

infection of outer ear (ear canal)

otitis media (OM)

infection of inner ear (behind eardrum)

pancreatitis

inflammation of pancreas, dx by elevated lipase and amylase levels

pelvic inflammatory disease (PID)

inflammation of woman’s reproductive organs

peptic ulcer disease (PUD)

ulcers developing in stomach causing pain and emesis

pericarditis

inflammation of pericardium

peripheral vascular disease (PVD)

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

pharyngitis

throat infection

pneumonia

infiltrate (infection) inside lung tissue

pneumothorax

presence of air or gas in pleural space; collapsed lung

psoriasis

autoimmune skin disease. dry, scaly, red, itchy patches of skin

pulmonary embolism

blockage of pulmonary artery or one of its branches due to translocated clot

pyelonphritis

infection on kidneys, CVA tenderness is sign

sciatica

compression of sciatic nerve causing back pain with radiation to posterior leg

sepsis

dangerous infection of blood

sinusitis

infection/inflammation of sinuses

tinea

fungal rash