Med Scribe Terminology

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138 Terms

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Anterior
\
Situated toward the front of the body
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Diffuse
\
Generalized; not localized to any specific location
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Distal
\
Farther from the trunk of the body
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Inferior
\
Lower on the body, farther from the head
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Lateral
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Farther from the midline
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Medial
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Nearer to the midline
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Posterior
\
Situated towards the back of the body, opposite of anterior
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Proximal
Nearer to the trunk of the body
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Superior
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Higher on the body, nearer to the head
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Abscess
A collection of pus beneath the skin
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Appendicitis
Dangerous infection of the appendix
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Arthritis
Inflammation of the joints
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Atrial fibrillation (A fib)
Irregular and often very rapid heart rhythm (arrhythmia)
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Bronchitis
Inflammation/Infection of the bronchi (upper airway)
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Cellulitis
Infection of skin cells
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Cerebrovascular accident (CVA)
A stroke. Blood supply to the brain is restricted or absent due to hemorrhage or blockage of a vessel resulting in brain damage and dysfunction
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Cholecystitis
Inflammation of the gallbladder
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Chronic obstructive pulmonary disease (COPD)
Chronic inflammatory lung disease that causes obstructed airflow to the lungs
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Chronic renal failure (CRF)
Decrease in the kidneys' ability to filter waste and fluid from the blood
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Congestive heart failure (CHF)
Serious condition in which the heart doesn't pump blood as efficiently as it should
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Conjunctivitis
Infection of the outer layer of the eye
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Coronary artery bypass graft (CABG)
Procedure used to treat coronary artery disease (heart disease)
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Coronary artery disease (CAD)
Buildup of plaque in the arteries that supply oxygen-rich blood to your heart
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Deep venous thrombosis (DVT)
A blood clot that  forms in a vein located deep inside your body, typically in the leg
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Diverticulitis
Acute inflammation of the diverticula pouches
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Ectopic pregnancy
Egg developing outside the uterus extremely dangerous due to risk of rupture
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Gastroenteritis
General term for inflammation of the GI tract
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Gastroesophageal reflux disease (GERD)
Digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus
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Hepatitis
Inflammation of the liver
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Hyperglycemia
High blood sugar due to diabetes
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Hyperlipidemia (HLD)
High cholesterol
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Hypertension (HTN)
High blood pressure (typically >140/90)
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Hypoglycemia
Low blood-sugar
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Hypotension
Low blood pressure (typically
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Insulin dependent diabetes mellitus (IDDM)
Diabetes requiring the use of insulin injections
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Myocardial infarction (MI)
Heart attack.  Death of cardiac muscle due to prolonged ischemia
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Nephrolithiasis / Renal calculi
Kidney stone
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Non-insulin dependent diabetes mellitus (NIDDM)
Diabetes not requiring the use of insulin injections
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Otitis media (OM)
Infection inner ear (behind the eardrum)
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Pancreatitis
Inflammation of the pancreas
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Peptic ulcer disease (PUD)
Ulcers developing in the stomach causing pain and emesis
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Peripheral vascular disease (PVD)
Blood circulation disorder that causes the blood vessels (excluding the heart and brain) to narrow, block, or spasm
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Pharyngitis
Throat infection
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Pneumonia
Infiltrate (infection) inside the lung tissue
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Pneumothorax
Presence of air or gas in the pleural space; collapsed lung
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Pulmonary Embolism
Blockage of the pulmonary artery or one of its branches due to a translocated clot
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Pyelonephritis
Infection on the kidneys
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Sepsis
Dangerous infection of the blood
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Transient ischemic attack (TIA)
Transient “mini-stroke”, neurological function is regained completely with time
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Upper respiratory infection (URI)
Contagious infection of the upper respiratory tract (sinuses, throat, lungs or airways)
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Urinary tract infection (UTI)
Infection in any part of the urinary system — kidneys, ureters, bladder and urethra
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Afebrile
Without fever
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Ambulatory
Able to move about, not confined to a bed
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Constitutional
The general appearance and nature of a patient
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Distress
A patient’s inability to tolerate their body-state, due to pain or respiratory failure. No Acute Distress (NAD) is commonly written if a patient looks comfortable.
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Extraocular muscles intact (EOMI)
Testing that examines the function of the eye muscle
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Pale conjunctiva
Pale inner aspect of the eyelid most often due to anemia
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Pupils are Equal, Round, and Reactive, to Light (PERRL)
Common normal eye exam finding
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Scleral icterus
Yellowing of the sclera (whites of the eye) due to jaundice
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Cerumen
Earwax
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Dry mucosa
Dry tongue, mouth, and lips, indicating significant dehydration
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Epistaxis
Nose bleed
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Oropharynx
The back of the mouth, where it meets the throat
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Rhinorrhea
Clear nasal discharge. "Runny" nose
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Tinnitus
“Ringing in the ears”, the perception of ringing even with no external stimuli
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Tonsillectomy & Adenoidectomy (T&A)
Tonsils and adenoids removal surgery
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Tympanic membrane (TM)
Tympanic membrane, the clear membrane inside the ear; (ear drum)
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Carotid bruit
Whooshing blood flow heard with auscultation (carotid narrowing or plaque)
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Lymphadenopathy
Enlarged lymph nodes
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Supple
Flexible, not-stiff
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Thyromegaly
Enlarged thyroid
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Jugular vein distention (JVD)
Jugular vein distention, sign of heart dysfunction
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Aneurysm
Localized ballooning of a vessel due to a weakened vessel wall
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Arrhythmia
Irregular heartbeat
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Artery
Blood vessel carrying blood away from the heart, muscular, contractile
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Bradycardia
Slow heart rate (HR
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Cardiomegaly
\
Enlarged heart
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Murmur
Abnormal heart sound rated on 1-6 scale
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Normal sinus rhythm (NSR)
The rhythm of a healthy heart
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Palpitation
To beat rapidly, irregularly, or forcibly (usually relating to the heart)
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Regular rate and rhythm (RRR)
Normal heart sounds with a regular rate (60-100 bpm)
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Stenosis
Narrowing of a body opening or passage
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Tachycardia
Fast heart rate (HR>100 bpm)
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Vein
Vessel carrying blood towards the heart, soft, compressible
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Clear to auscultation (CTA)
No abnormal sounds when listening to the lungs with a stethoscope
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Dyspnea
Difficulty/labored breathing, shortness of breath
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Hypoxia
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Low oxygen saturation of the body, not enough oxygen in the blood
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Pleurisy
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General term for pain with breathing
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Rales
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Crackles; Wet crackling heard in the lungs, typically due to pneumonia or CHF
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Rhonchi
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Sound of mucous rolling around in the bronchioles/bronchi
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**Shortness of breath (SOB)**
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Air hunger, difficulty breathing, or breathlessness
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Sputum
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Any mixed matter with the saliva that is passed through the mouth
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Stridor
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Upper airway noise; common sign in croup
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**Tachypnea**
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Increased respiratory rate
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Wheezing
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High pitched sound heard in the lungs with asthmatics or lung disease
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Emesis
Vomiting
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Hematemesis
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Gross amounts of blood in the vomit
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Hepatomegaly
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Enlarged liver
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Hernia
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Protrusion of part of an internal organ or tissue bulges through a weak area of muscle
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Melena
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Black tarry stool indicative of an upper GI bleed