Med Scribe Terminology

Anterior

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Situated toward the front of the body

Diffuse

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Generalized; not localized to any specific location

Distal

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Farther from the trunk of the body

Inferior

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Lower on the body, farther from the head

Lateral

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Farther from the midline

Medial

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Nearer to the midline

Posterior

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Situated towards the back of the body, opposite of anterior

Proximal

Nearer to the trunk of the body

Superior

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Higher on the body, nearer to the head

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)

Bronchitis

Inflammation/Infection of the bronchi (upper airway)

Cellulitis

Infection of skin cells

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

Cholecystitis

Inflammation of the gallbladder

Chronic obstructive pulmonary disease (COPD)

Chronic inflammatory lung disease that causes obstructed airflow to the lungs

Chronic renal failure (CRF)

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

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 (heart disease)

Coronary artery disease (CAD)

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

Deep venous thrombosis (DVT)

A blood clot that  forms in a vein located deep inside your body, typically in the leg

Diverticulitis

Acute inflammation of the diverticula pouches

Ectopic pregnancy

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

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

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

Myocardial infarction (MI)

Heart attack.  Death of cardiac muscle due to prolonged ischemia

Nephrolithiasis / Renal calculi

Kidney stone

Non-insulin dependent diabetes mellitus (NIDDM)

Diabetes not requiring the use of insulin injections

Otitis media (OM)

Infection inner ear (behind the eardrum)

Pancreatitis

Inflammation of the pancreas

Peptic ulcer disease (PUD)

Ulcers developing in the stomach causing pain and emesis

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

Pulmonary Embolism

Blockage of the pulmonary artery or one of its branches due to a translocated clot

Pyelonephritis

Infection on the kidneys

Sepsis

Dangerous infection of the blood

Transient ischemic attack (TIA)

Transient “mini-stroke”, neurological function is regained completely with time

Upper respiratory infection (URI)

Contagious infection of the upper respiratory tract (sinuses, throat, lungs or airways)

Urinary tract infection (UTI)

Infection in any part of the urinary system — kidneys, ureters, bladder and urethra

Afebrile

Without fever

Ambulatory

Able to move about, not confined to a bed

Constitutional

The general appearance and nature of a patient

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.

Extraocular muscles intact (EOMI)

Testing that examines the function of the eye muscle

Pale conjunctiva

Pale inner aspect of the eyelid most often due to anemia

Pupils are Equal, Round, and Reactive, to Light (PERRL)

Common normal eye exam finding

Scleral icterus

Yellowing of the sclera (whites of the eye) due to jaundice

Cerumen

Earwax

Dry mucosa

Dry tongue, mouth, and lips, indicating significant dehydration

Epistaxis

Nose bleed

Oropharynx

The back of the mouth, where it meets the throat

Rhinorrhea

Clear nasal discharge. "Runny" nose

Tinnitus

“Ringing in the ears”, the perception of ringing even with no external stimuli

Tonsillectomy & Adenoidectomy (T&A)

Tonsils and adenoids removal surgery

Tympanic membrane (TM)

Tympanic membrane, the clear membrane inside the ear; (ear drum)

Carotid bruit

Whooshing blood flow heard with auscultation (carotid narrowing or plaque)

Lymphadenopathy

Enlarged lymph nodes

Supple

Flexible, not-stiff

Thyromegaly

Enlarged thyroid

Jugular vein distention (JVD)

Jugular vein distention, sign of heart dysfunction

Aneurysm

Localized ballooning of a vessel due to a weakened vessel wall

Arrhythmia

Irregular heartbeat

Artery

Blood vessel carrying blood away from the heart, muscular, contractile

Bradycardia

Slow heart rate (HR

Cardiomegaly

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Enlarged heart

Murmur

Abnormal heart sound rated on 1-6 scale

Normal sinus rhythm (NSR)

The rhythm of a healthy heart

Palpitation

To beat rapidly, irregularly, or forcibly (usually relating to the heart)

Regular rate and rhythm (RRR)

Normal heart sounds with a regular rate (60-100 bpm)

Stenosis

Narrowing of a body opening or passage

Tachycardia

Fast heart rate (HR>100 bpm)

Vein

Vessel carrying blood towards the heart, soft, compressible

Clear to auscultation (CTA)

No abnormal sounds when listening to the lungs with a stethoscope

Dyspnea

Difficulty/labored breathing, shortness of breath

Hypoxia

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Low oxygen saturation of the body, not enough oxygen in the blood

Pleurisy

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General term for pain with breathing

Rales

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Crackles; Wet crackling heard in the lungs, typically due to pneumonia or CHF

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

Sputum

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Any mixed matter with the saliva that is passed through the mouth

Stridor

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Upper airway noise; common sign in croup

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**Tachypnea**

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Increased respiratory rate

Wheezing

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High pitched sound heard in the lungs with asthmatics or lung disease

Emesis

Vomiting

Hematemesis

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Gross amounts of blood in the vomit

Hepatomegaly

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Enlarged liver

Hernia

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Protrusion of part of an internal organ or tissue bulges through a weak area of muscle

Melena

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Black tarry stool indicative of an upper GI bleed