Scribe America Medical Terms

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, the "soft-spot"

Inferior

Lower on the body, farther from the head

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 the abdomen

Left Upper Extremity (LUE)

left arm

Left Upper Quadrant (LUQ)

Left Upper Quadrant of the abdomen

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

Right leg

Right Lower Quadrant (RLQ)

Right Lower Quadrant of the abdomen

Right Upper Extremity (RUE)

right arm

Right Upper Quadrant (RUQ)

Right Upper Quadrant of the abdomen

Superficial

Nearer to the surface (example: superficial abrasion)

Superior

Higher on the body, nearer to the head

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

Fluctauting

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, skin, etc)

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, etc.

Sx

symptoms

Tx

treatment

UTD

up to date (example vaccination utd)

WNL

Within Normal Limits (normal, not of concern)

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

Cellutitis

Infection of skin cells

Cerebrovascular accident (CVA)

Stroke. Blood supply to the brain is restricted or absent due to hemorrhage or

Cholecytisis

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 surgery (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, typically in the leg

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

Gastoenteritis

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)

Hypoglycemia

Low blood-sugar

Hypotension

Low blood pressure (typically

Insulin dependent diabetes mellitus (IDDM)

Diabetes requiring the use of insulin injections

Lymohangitis

Inflammation of a lymphatic vessel; appears as red streaking

Multiple Sclerosis

Autoimmune disease affecting the brain and spinal cord

Myocardial Infarction (MI)

Death of cardiac muscle due to prolonged ischemia (Heart attack)

Nephrolithiasis / Renal calculi

kidney stone

Non-insulin dependent diabetes mellitus (NIDDM)

Diabetes not requiring the use of insulin injections

Otitis externa

Infection of the outer ear (ear canal)

Otitis media (OM)

Infection inner ear (behind the eardrum)

Pancreatitis

Inflammation of the pancreas

Pelvic inflammatory disease (PID)

Inflammation of a woman's reproductive organs

Peptic ulcer disease (PUD)

Ulcers developing in the stomach causing pain and emesis

Pericarditis

Inflammation of the pericardium

Peripheral vascular disease (PVD)

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

Pharyngitis

Throat infection

Pneumonia

Infiltrate (infection) inside the lung tissue

Pneumothorax

Presence of air or gas in the pleural space; collapsed lung

Psoriasis

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