Med Scribe Terminology

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138 Terms

1

Anterior

Situated toward the front of the body

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2

Diffuse

Generalized; not localized to any specific location

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3

Distal

Farther from the trunk of the body

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4

Inferior

Lower on the body, farther from the head

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5

Lateral

Farther from the midline

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6

Medial

Nearer to the midline

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7

Posterior

Situated towards the back of the body, opposite of anterior

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8

Proximal

Nearer to the trunk of the body

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9

Superior

Higher on the body, nearer to the head

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10

Abscess

A collection of pus beneath the skin

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11

Appendicitis

Dangerous infection of the appendix

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12

Arthritis

Inflammation of the joints

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13

Atrial fibrillation (A fib)

Irregular and often very rapid heart rhythm (arrhythmia)

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14

Bronchitis

Inflammation/Infection of the bronchi (upper airway)

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15

Cellulitis

Infection of skin cells

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16

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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17

Cholecystitis

Inflammation of the gallbladder

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18

Chronic obstructive pulmonary disease (COPD)

Chronic inflammatory lung disease that causes obstructed airflow to the lungs

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19

Chronic renal failure (CRF)

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

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20

Congestive heart failure (CHF)

Serious condition in which the heart doesn't pump blood as efficiently as it should

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21

Conjunctivitis

Infection of the outer layer of the eye

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22

Coronary artery bypass graft (CABG)

Procedure used to treat coronary artery disease (heart disease)

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23

Coronary artery disease (CAD)

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

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24

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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25

Diverticulitis

Acute inflammation of the diverticula pouches

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26

Ectopic pregnancy

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

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27

Gastroenteritis

General term for inflammation of the GI tract

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28

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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29

Hepatitis

Inflammation of the liver

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30

Hyperglycemia

High blood sugar due to diabetes

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31

Hyperlipidemia (HLD)

High cholesterol

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32

Hypertension (HTN)

High blood pressure (typically >140/90)

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33

Hypoglycemia

Low blood-sugar

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34

Hypotension

Low blood pressure (typically <100/65)

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35

Insulin dependent diabetes mellitus (IDDM)

Diabetes requiring the use of insulin injections

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36

Myocardial infarction (MI)

Heart attack.  Death of cardiac muscle due to prolonged ischemia

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37

Nephrolithiasis / Renal calculi

Kidney stone

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38

Non-insulin dependent diabetes mellitus (NIDDM)

Diabetes not requiring the use of insulin injections

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39

Otitis media (OM)

Infection inner ear (behind the eardrum)

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40

Pancreatitis

Inflammation of the pancreas

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41

Peptic ulcer disease (PUD)

Ulcers developing in the stomach causing pain and emesis

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42

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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43

Pharyngitis

Throat infection

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44

Pneumonia

Infiltrate (infection) inside the lung tissue

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45

Pneumothorax

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

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46

Pulmonary Embolism

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

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47

Pyelonephritis

Infection on the kidneys

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48

Sepsis

Dangerous infection of the blood

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49

Transient ischemic attack (TIA)

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

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50

Upper respiratory infection (URI)

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

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51

Urinary tract infection (UTI)

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

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52

Afebrile

Without fever

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53

Ambulatory

Able to move about, not confined to a bed

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54

Constitutional

The general appearance and nature of a patient

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55

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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56

Extraocular muscles intact (EOMI)

Testing that examines the function of the eye muscle

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57

Pale conjunctiva

Pale inner aspect of the eyelid most often due to anemia

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58

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

Common normal eye exam finding

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59

Scleral icterus

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

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60

Cerumen

Earwax

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61

Dry mucosa

Dry tongue, mouth, and lips, indicating significant dehydration

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62

Epistaxis

Nose bleed

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63

Oropharynx

The back of the mouth, where it meets the throat

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64

Rhinorrhea

Clear nasal discharge. "Runny" nose

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65

Tinnitus

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

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66

Tonsillectomy & Adenoidectomy (T&A)

Tonsils and adenoids removal surgery

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67

Tympanic membrane (TM)

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

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68

Carotid bruit

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

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69

Lymphadenopathy

Enlarged lymph nodes

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70

Supple

Flexible, not-stiff

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71

Thyromegaly

Enlarged thyroid

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72

Jugular vein distention (JVD)

Jugular vein distention, sign of heart dysfunction

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73

Aneurysm

Localized ballooning of a vessel due to a weakened vessel wall

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74

Arrhythmia

Irregular heartbeat

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75

Artery

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

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76

Bradycardia

Slow heart rate (HR<60)

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77

Cardiomegaly

Enlarged heart

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78

Murmur

Abnormal heart sound rated on 1-6 scale

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79

Normal sinus rhythm (NSR)

The rhythm of a healthy heart

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80

Palpitation

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

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81

Regular rate and rhythm (RRR)

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

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82

Stenosis

Narrowing of a body opening or passage

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83

Tachycardia

Fast heart rate (HR>100 bpm)

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84

Vein

Vessel carrying blood towards the heart, soft, compressible

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85

Clear to auscultation (CTA)

No abnormal sounds when listening to the lungs with a stethoscope

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86

Dyspnea

Difficulty/labored breathing, shortness of breath

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87

Hypoxia

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

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88

Pleurisy

General term for pain with breathing

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89

Rales

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

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90

Rhonchi

Sound of mucous rolling around in the bronchioles/bronchi

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91

Shortness of breath (SOB)

Air hunger, difficulty breathing, or breathlessness

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92

Sputum

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

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93

Stridor

Upper airway noise; common sign in croup

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94

Tachypnea

Increased respiratory rate

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95

Wheezing

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

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96

Emesis

Vomiting

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97

Hematemesis

Gross amounts of blood in the vomit

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98

Hepatomegaly

Enlarged liver

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99

Hernia

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

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100

Melena

Black tarry stool indicative of an upper GI bleed

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