ScribeAmerica Terms

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This packet marks the first step towards an exceptional opportunity that provides one-of-a-kind first-hand experience in the healthcare setting. We aim to provide our employees with a fun and rewarding job where they can gain first hand experience in medicine, observe a variety of patients, become versed in medical terminology and learn clinician decision making. The next pages are a glimpse of the work that lies ahead. Consider this list as both a sample of the rigors of training as well as your first opportunity to demonstrate that you have the ability to succeed as a scribe.

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150 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

Farther from the midline

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Medial

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

Higher on the body, nearer to the head

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Diseases

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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 <100/65)

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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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Constsitutional

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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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Eye

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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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Ear, Nose, and Throat (ENT)

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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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Neck

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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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Cardiovascular (CV)

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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<60

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Cardiomegaly

Enlarged heart

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Murmur

Abnormal heart sound rated on 1-6 scale

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