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Training Class 4
Scribe America terminology, abbreviations, physical exam findings and assoc. dz
71
Medical
Professional
02/04/2015

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Cards

Term
typical physical exam
Definition
assessing pt's external appearance and mental status, auscultating the pt's heart and lungs, palpating the abdomen, examining the pt's legs
Term
IRIR
Definition
irregularly irregular heart rhythm, AFib
Term
R/G
Definition
rebound/guarding
Term
AT/NC
Definition
atraumatic/normocephalic
Term
(conditions) frail/obese
Definition
poor nutrition
Term
(conditions) scleral iceterus
Definition
liver failure
Term
(conditions) hyphema
Definition
trauma causing blood to pool in anterior chamber of eye
Term
(conditions) papilledema
Definition
optic disc swelling caused by intracranial pressure
Term
(conditions) TM erythema, bulging, dullness
Definition
ear infection
Term
(conditions) rhinorrhea
Definition
URI
Term
(conditions) epistaxis
Definition
trauma
Term
(conditions) boggy turbinates
Definition
allergic rhinitis
Term
(conditions) septal hematoma
Definition
trauma
Term
DMM
Definition
dry mucous membranes
Term
(conditions) DMM
Definition
Sjögren's syndrome (autoimmune)
Term
(conditions) pharyngeal erythema
Definition
tonsillopharyngitis
Term
(conditions) tonsillar exudate
Definition
tonsillitis
Term
edentulous
Definition
lacking teeth
Term
(conditions) dental caries
Definition
bacterial infection
Term
PTA
Definition
peritonsillar abscess
Term
(conditions) PTA
Definition
tonsillitis complication
Term
(conditions) nuchal rigidity
Definition
meningitis
Term
(conditions) JVD
Definition
congestive heart failure (CHF)
Term
(conditions) carotid bruit
Definition
carotid artery stenosis
Term
(conditions) cervical lymphadenopathy
Definition
local infection
Term
(conditions) thyromegaly
Definition
hyperthyroidism
Term
RRR
Definition
regular rate and rhythm (of heart)
Term
Normal range of HR
Definition
60-100 bpm
Term
extrasystoles
Definition
extra heart beats
Term
pulse locations
Definition
carotid, radial, femoral, dorsal pedis (DP), posterior tibialis (PT)
Term
DP
Definition
dorsal pedis
Term
PT
Definition
posterior tibialis
Term
(conditions) rebound tenderness, rigidity
Definition
peritonitis
Term
(conditions) hepatomegaly
Definition
hepatitis
Term
(conditions) splenomegaly
Definition
mononucleosis
Term
(conditions) + Murphy's sign
Definition
cholecystitis
Term
(conditions) + McBurney's point tenderness, + Psoa's sign, + obturator's sign, + Rovsing's sign
Definition
appendicitis
Term
Psoa's sign
Definition
passively extending the thigh of a patient lying on his side with knees extended
Term
Obturator's sign
Definition
90° flex of knee and hip with inward rotation of ankle
Term
Rovsing's sign
Definition
palpation of LLQ of abd
Term
(conditions) heme positive (guaiac positive)
Definition
GI bleed
Term
CMT
Definition
cervical motion tenderness
Term
(conditions) adnexal tenderness
Definition
ectopic pregnancy
Term
(conditions) CMT
Definition
pelvic inflammatory disease (PID)
Term
PID
Definition
pelvic inflammatory disease
Term
(conditions) epididymal tenderness
Definition
epididymitis
Term
(conditions) urethral discharge
Definition
STI
Term
inguinal hernia
Definition
protrusion of abdominal-cavity contents through the inguinal canal
Term
EOMI
Definition
extra ocular movements intact
Term
(conditions) bony tenderness
Definition
fx
Term
(conditions) soft tissue tenderness
Definition
contusion
Term
(conditions) calf tenderness
Definition
DVT
Term
full ROM
Definition
full range of motion
Term
CSMT
Definition
circulation, sensory, motor, tendon
Term
(conditions) bilateral pitting pedal edema
Definition
CHF
Term
(conditions) palpable cords/Homan's sign
Definition
DVT
Term
(conditions) CVA tenderness
Definition
pyelonephritis, renal calculi
Term
(conditions) paraspinal tenderness
Definition
muscular injury
Term
(conditions) vertebral point tenderness
Definition
spinal injury
Term
(conditions) jaundice
Definition
liver failure
Term
(conditions) diaphoretic
Definition
febrile
Term
(conditions) cyanotic
Definition
hypoxia
Term
(conditions) pallor
Definition
anemia
Term
(conditions) urticaria
Definition
allergic reaction
Term
(conditions) cellulitis
Definition
skin infection
Term
(conditions) fluctuance
Definition
abscess
Term
(conditions) lymphangitis
Definition
spreading infection
Term
AOx4
Definition
alert and oriented to self, place, situation and time
Term
DTR
Definition
deep tendon reflex
Term
Babinski's reflex
Definition
stimulation of the sole of the foot from the heel to the toes causing upward movement of big toe
Term
Romberg sign
Definition
pt closes eyes with arms at sides and feet together and physician examines balance
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