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Training Class 1
Scribe America medical terminology and abbreviations
179
Medical
Professional
01/26/2015
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Term
abrasion
 Definition
scrape of the skin due to something abrasive
Term
acute
 Definition
new, usually rapid onset and of concern, opposite of chronic
Term
ambulate
 Definition
to walk from place to place
Term
anterior
 Definition
located towards the front of the body
Term
artery
 Definition
blood vessel carrying blood away from the heart
Term
auscultate
 Definition
listening with a stethoscope
Term
benign
 Definition
normal, of no danger to health
Term
bony tenderness
 Definition
pain elicited by pressing on a bone, rather than soft tissue
Term
bradycardia
 Definition
slow heart-rate (HR less than 60 bpm)
Term
cardiomegaly
 Definition
enlarged heart
Term
cholecystitis
 Definition
inflammation of the cholecyst (gallbladder)
Term
chronic
 Definition
long-standing, constant. Opposite of acute
Term
COPD
 Definition
Chronic Obstructive Pulmonary Disease, lung Dz commonly seen in smokers
Term
coronary artery
 Definition
the artery that supplies heart tissue with blood
Term
Cererbrovascular Accident (CVA)
 Definition
"stroke", lack of blood supply to the brain causing brain damage
Term
diaphoresis
 Definition
sweating
Term
diffuse
 Definition
everywhere, opposite of "focal"
Term
distal
 Definition
farther from the trunk of the body
Term
Deep Vein Thrombosis (DVT)
 Definition
a blood clot in a deep vein, most often an extremity
Term
dyspnea
 Definition
problems with breathing
Term
dysuria
 Definition
painful urination
Term
ecchymosis
 Definition
bruise
Term
edema
 Definition
swelling
Term
emesis
 Definition
vomiting
Term
epistaxis
 Definition
nose bleed
Term
erythema/erythematous
 Definition
redness/red
Term
febrile
 Definition
elevated body temperature, fever, indicative of infection
Term
focal
 Definition
localized to one specific area, opposite of diffuse
Term
grossly
 Definition
obviously, a lot, wholly
Term
hematemesis
 Definition
very large amounts of blood in the vomit
Term
hematuria
 Definition
very large amounts of blood in the urine
Term
hemoptysis
 Definition
coughing up very large amounts of blood
Term
hemorrhage
 Definition
excessive or profuse bleeding
Term
hepatomegaly
 Definition
enlarged liver
Term
hypertension
 Definition
high blood pressure
Term
hypotension
 Definition
low blood pressure
Term
hypoxia
 Definition
low oxygen saturation of the body, not enough oxygen in the blood
Term
incontinence
 Definition
accidentally passing urine (urinary incontinence) or stool (bowel incontinence)
Term
infarct
 Definition
area of dead tissue after a lack of blood supply
Term
inferior
 Definition
lower on the body, farther from the head
Term
ischemia
 Definition
lack of blood supply
Term
laceration
 Definition
splitting of the skin due to trauma (a cut due to something sharp)
Term
lateral
 Definition
farther from the midline (a line that can be traced from nose to belly-button)
Term
medial
 Definition
nearer to the midline
Term
melena
 Definition
black, tarry stool
Term
oriented x3
 Definition
oriented to person, place, and time
Term
pallor
 Definition
pale skin
Term
palpate
 Definition
using a hand to press on an area, e.g. palpating the abdomen
Term
palpitations
 Definition
feeling a heart-racing, pounding, or fluttering sensation in the chest
Term
point tenderness
 Definition
when pressing on an area with one finger generates pain
Term
posterior/dorsal
 Definition
rear or backside of the body
Term
proximal
 Definition
nearer to the trunk of the body
Term
pruritic
 Definition
itchy
Term
pulmonary embolism (PE)
 Definition
blocking of a pulmonary artery due to a blood clot
Term
purulent
 Definition
pus-like
Term
rales
 Definition
crackles; wet crackling noise in lungs
Term
rhinorrhea
 Definition
clear nasal discharge, "runny nose"
Term
rhonchi
 Definition
rattling noise of mucous in the lungs
Term
sepsis
 Definition
dangerous infection of the blood
Term
soft tissue tenderness
 Definition
tenderness of a soft tissue; muscle, skin, fat. opposite of bony tenderness
Term
STEMI
 Definition
ST elevation MI, real-time ongoing death of heart tissue due to ischemia
Term
superior
 Definition
higher on the body, nearer to the head
Term
supine
 Definition
body position lying face up
Term
syncope
 Definition
"passing out", loss of consciousness or fainting
Term
tachycardia
 Definition
fast heart rate (HR greater than 100 bpm)
Term
tachypnea
 Definition
increased breathing rate
Term
tenderness
 Definition
physician's assessment if an area is painful (tender) or not (non-tender)
Term
Transient Ischemic Attack (TIA)
 Definition
minor stroke; where neurological function is regained quickly with time
Term
vein
 Definition
blood vessel carrying blood towards the heart
Term
vertigo
 Definition
condition of dizziness, "room spinning"
Term
wheezing
 Definition
high pitched sound heard in the lungs with asthmatics or lung disease
Term
AAA
 Definition
abdominal aortic aneurysm
Term
A Fib
 Definition
atrial fibrillation
Term
Abx
 Definition
antibiotics
Term
AMA
 Definition
against medical advice
Term
AMS
 Definition
altered mental status
Term
ASA
 Definition
acetylsalicylic acid (aspirin)
Term
BID
 Definition
twice daily
Term
Bilat LE
 Definition
bilateral lower extremities
Term
BM
 Definition
bowel movement
Term
BP
 Definition
blood pressure
Term
CA
 Definition
cancer, carcinoma
Term
CABG
 Definition
coronary artery bypass graft, "open heart surgery"
Term
CAD
 Definition
coronary artery disease, "heart disease"
Term
CT or CAT
 Definition
computerized assisted tomography
Term
CHF
 Definition
congestive heart failure
Term
COPD
 Definition
chronic obstructive pulmonary disease
Term
CP
 Definition
chest pain
Term
CPR
 Definition
cardiopulmonary resuscitation
Term
C-section
 Definition
Caesarean section
Term
C-spine
 Definition
cervical spine
Term
CSF
 Definition
cerebrospinal fluid
Term
CVA
 Definition
cerebrovascular accident or costovertebral angle
Term
CXR
 Definition
chest X-ray
Term
c/o
 Definition
complains of
Term
DKA
 Definition
diabetic ketoacidosis
Term
DM
 Definition
diabetes mellitus
Term
DNR
 Definition
do not resuscitate
Term
DOE
 Definition
dyspnea on exertion
Term
DVT
 Definition
deep venous thrombosis
Term
Dx
 Definition
diagnosis
Term
Dz
 Definition
disease
Term
EKG/ECG
 Definition
electrocardiogram
Term
EtOH
 Definition
alcohol
Term
FHx
 Definition
family history
Term
Fx
 Definition
fracture
Term
GI
 Definition
gastrointestinal
Term
G/P/Ab
 Definition
Gravida/Para/Abortion
Term
GSW
 Definition
gun shot wound
Term
GU
 Definition
genitourinary
Term
HA
 Definition
headache
Term
HEENT
 Definition
head, eyes, ears, nose, throat
Term
HPI
 Definition
history of present illness
Term
HTN
 Definition
hypertension
Term
Hx
 Definition
history
Term
H&H
 Definition
hemoglobin and hematocrit
Term
H&P
 Definition
history of present illness and physical exam
Term
I&D
 Definition
incision and drainage
Term
IDDM
 Definition
insulin dependent diabetes mellitus
Term
IUP
 Definition
intrauterine pregnancy
Term
IVDA
 Definition
IV drug abuse
Term
JVD
 Definition
jugular vein distension
Term
LLE
 Definition
left lower extremity
Term
LLQ
 Definition
left lower quadrant
Term
LNMP
 Definition
last normal menstrual period
Term
LOC
 Definition
loss of consciousness
Term
LP
 Definition
lumbar puncture
Term
L-spine
 Definition
lumbar spine
Term
LUE
 Definition
left upper extremity
Term
LUQ
 Definition
left upper quadrant
Term
MCA
 Definition
motorcycle accident
Term
MI
 Definition
myocardial infarction
Term
MVA/MVC
 Definition
motor vehicle accident/collision
Term
N/A
 Definition
not applicable
Term
NAD
 Definition
no acute distress, no acute disease
Term
NIDDM
 Definition
non-insulin dependent diabetes mellitus
Term
NKDA
 Definition
no known drug allergies
Term
Nml or nl
 Definition
normal
Term
NSAID
 Definition
non steroidal anti-inflammatory drug
Term
NSR
 Definition
normal sinus rhythm
Term
NTG
 Definition
nitroglycerin
Term
N/V/D
 Definition
nausea/vomiting/diarrhea
Term
O2 Sat
 Definition
oxygen saturation (aka SaO2)
Term
OD
 Definition
overdose
Term
PCP
 Definition
primary care physician (aka PMD)
Term
PE
 Definition
pulmonary embolism or physical exam
Term
PERRL
 Definition
pupils are equal, round, and reactive to light
Term
PO
 Definition
Per Os (by mouth)
Term
prn
 Definition
as need
Term
pt
 Definition
patient
Term
PTA
 Definition
prior to arrival
Term
PUD
 Definition
peptic ulcer disease
Term
qd
 Definition
every day
Term
qh
 Definition
every hour
Term
qhs
 Definition
at every bedtime
Term
q2h
 Definition
every 2 hours
Term
QID
 Definition
four times a day
Term
RLE
 Definition
right lower extremity
Term
RLQ
 Definition
right lower quadrant
Term
ROM
 Definition
range of motion
Term
ROS
 Definition
review of system
Term
RUE
 Definition
right upper extremity
Term
RUQ
 Definition
right upper quadrant
Term
Rx
 Definition
prescription
Term
r/o
 Definition
rule out
Term
SOB
 Definition
shortness of breath
Term
s/p
 Definition
status post (after)
Term
Sx
 Definition
symptoms
Term
TIA
 Definition
Transient Ischemic Attack
Term
TID
 Definition
three times a day
Term
TM
 Definition
tympanic membrane
Term
T-spine
 Definition
thoracic spine
Term
Tx
 Definition
treatment
Term
UA
 Definition
urinalysis
Term
URI
 Definition
upper respiratory infection
Term
US
 Definition
ultrasound
Term
UTD
 Definition
up to date
Term
UTI
 Definition
urinary tract infection
Term
WNL
 Definition
within normal limits
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