Scribe Terms

  1. Anatomical Position
    Standing erect, arms at the sides, with palms facing forward
  2. Prone
    Denoting the position of the body when lying flat, with face downward
  3. Supine
    Denoting the position of the body when lying flat, with face up
  4. Anterior
    Situated in front of or directed toward the front
  5. Posterior/Dorsal
    Rear or Back
  6. Superior
    Upper, nearer to crown of head
  7. Inferior
    Lower, farther from crown of head
  8. Transverse
    Divides body into upper and lower parts
  9. Midline
    Divides the body into left and right sides
  10. External
  11. Internal
  12. Superficial
    Nearer to the surface
  13. Medial
    Nearer to the midline
  14. Lateral
    Farther from the midline
  15. Proximal
    Nearer to the limb root
  16. Distal
    Farther from the limb root
  17. Flexion
    Bending or angulations
  18. Extension
    To straighten
  19. Supinator
    Turning of the palm of the hand upwards by lateral forearm rotation
  20. Pronator
    Turning of the palm of the hand downward by medial forearm rotation
  21. Afebrile
    Without fever
  22. Aneurysm
    A widening of a blood vessel due to pressure on weakened tissues causing formation of a sac of blood that may become clotted
  23. Angina
    A severe, often constricting pain, usually referring to the chest that occurs when your heart does not get enough blood
  24. Arrhythmia
    Abnormal heart rhythm
  25. Ascites
    Accumulation of serous fluid in the abdominal cavity
  26. Atelectasis
    Partial or total collapse of lung tissue
  27. Bradycardia
    Slow heart rate
  28. Bronchitis
    Inflammation of the bronchi
  29. Bruit
    A murmur or sound heard in auscultation of an artery
  30. Cachectic
    State of ill appearance and malnutrition
  31. Cardiomegaly
    Enlarged heart
  32. Cellulitis
    Inflammation of the skin
  33. Cerumen
    Ear wax
  34. Cervical
    Pertaining to the neck or to the cervix of the uterus
  35. Cholecystectomy
    Surgical removal of the gallbladder
  36. Cholelithiasis
  37. Conjunctiva
    Delicate membrane lining the eyelids and covering the eyeball
  38. Contusion
    A mechanical injury causing hemorrhages beneath unbroken skin; bruise.
  39. Cornea
    Transparent coat of the eyeball covering the iris and pupil, allowing lightinto the eye
  40. Costochondritis
    Inflammation of the costal cartilages.
  41. Crepitus
    A crackling or grating sound, usually of bones
  42. Cyanosis
    Dark blue or purple discoloration of the skin
  43. Debridement
    Removal of foreign matter or dead tissue from a wound
  44. Diaphoresis
  45. Diarrhea
    Frequent discharge of fluid fecal matter
  46. Diverticulitis
    Inflammation of the diverticulum, especially the small pockets in the wall of the colon
  47. Dysmenorrhea
    Painful menstruation
  48. Dyspepsia
    Upset stomach or “Indigestion” characterized by epigastric pain, burning and nausea
  49. Dysphagia
    Difficulty swallowing
  50. Dysphasia
    Inability to understand language as a result of injury or disease to the brain
  51. Dyspnea
    Difficult breathing, shortness of breath
  52. Dysuria
    Painful urination
  53. Ecchymosis
    Non-elevated bruise
  54. Eczema
    Inflammatory condition of the skin, characterized by itching or burning, tiny papules and vesicles, oozing, crusting, and scaling
  55. Edema
    Swelling of body tissues
  56. Edentulous
    Without teeth
  57. Effusion
    Escape of fluid into a cavity
  58. Embolism
    Obstruction of a blood vessel by a clot of blood or foreign substance
  59. Emesis
  60. Epistaxis
    Nose bleed
  61. Erythema
    Redness of the skin
  62. Etiology
    Cause of disease and mode of operation
  63. Exacerbation
  64. Exudate
    A fluid with a high content of protein and cellular debris that has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation.
  65. Febrile
    Having fever
  66. Gastroenteritis
    Inflammation of the gastrointestinal tract, involving both the stomach and the small intestine
  67. Hematemesis
    Vomiting blood
  68. Hematochezia
    Passage of bloody stool
  69. Hematoma
    A swelling of blood from ruptured blood vessels
  70. Hematuria
    Blood in the urine
  71. Hemoptysis
    Spitting of blood; bloodstained sputum
  72. Hemorrhage
    Excessive or profuse bleeding
  73. Hemothorax
    Blood fluid present in the pleural cavity
  74. Hepatosplenomegaly
    Enlarged liver and spleen
  75. Hyperkalemia
    High potassium
  76. Hypertension
    High blood pressure
  77. Hyponatremia
    Low sodium
  78. Ileus
    Bowel obstruction
  79. Infarct
    Necrotic area of tissue due to cessation of the blood supply
  80. Infiltrate
    To penetrate the interstices of a tissue or substance
  81. Inguinal
    Groin region
  82. Ischemia
    Temporary, localized restriction of blood supply
  83. Lacrimal
    To do with tears
  84. Lingual
    To do with tongue
  85. Loculations
    The presence of numerous small spaces or cavities
  86. Lymphadenopathy
    A chronic enlargement of the lymph nodes
  87. Malaise
    Generalized discomfort or weakness
  88. Melena
    Black tarry stool
  89. Meningitis
    Inflammation of the meninges
  90. Mottled
    Marked by spots or blotches of different colors or shades
  91. Normocephalic
    Normal shape of the head
  92. Neuralgia
    Nerve pain
  93. Nystagmus
    Involuntary rapid eye movements
  94. Occiput
    Back of the head
  95. Olecranon
    Head or point of the elbow
  96. Paresthesia
    Abnormal tactile sensation (creeping, burning, tingling, or numbness)
  97. Petechia
    Tiny red spot occurring on the skin caused by a small amount of escaping blood
  98. Pharyngitis
    Inflammation of the mucous membrane and underlying parts of the pharnyx
  99. Photophobia
    Intolerance to light
  100. Pleurisy
    Painful inflammation of the pleura
  101. Pneumothorax
    Presence of air or gas in the pleural
  102. Post-ictal
    Following a seizure; post seizure symptoms
  103. Psoriasis
    Chronic, non-contagious disease characterized by inflamed lesions covered with silvery-white scabs of dead skin
  104. Purulent
    Consisting of matter or pus; resembling pus
  105. Rale
    Abnormal respiratory sound heard on auscultation
  106. Rhinorrhea
    Thin, watery discharge from the nose
  107. Rhonchi
    A whistling or snoring sound heard on auscultation of the chest when air channels are partially obstructed; the plural of rhonchus
  108. Sciatic
    Pertaining to the ischium or hip
  109. Seizure
    An attack or sudden onset of symptoms; an epileptic attack
  110. Sepsis
    Presence of pathological microorganisms or their toxins in the blood
  111. Sputum
    Spittle, any mixed matter with saliva that is expectorated through the mouth
  112. Stenosis
    Narrowing of a body opening or passage
  113. Stridor
    Harsh or high-pitched respiratory sound, caused by an obstruction of the air passages
  114. Syncope
    Loss of consciousness; to faint
  115. Tachycardia
    Abnormal rapid heart beat
  116. Tachypnea
    Extremely rapid respiration
  117. Thoracostomy
    Procedure to install a chest tube
  118. Tinea
    Any of many different superficial fungal infections of the skin
  119. Tinnitus
    A ringing in the ears
  120. Torsion
    The twisting of a bodily organ on its own axis (e.g. ovary/fallopian tubes, testicle/vas deferens, etc.)
  121. Turgor
    Condition of being distended or swollen; normal fullness
  122. Urticaria
    Hives or wheals which are either redder or paler than the surrounding area and are often attended by itching
  123. Vertigo
    Condition of dizziness, specifically a room spinning sensation
  124. Wheeze
    Difficult breathing with a whistling sound resulting from narrowing of the lumen of the respiratory passageways
  125. AFib
    Atrial Fibrillation
  126. AAA
    Abdominal aortic aneurysm
  127. AB
  128. abd
    Abdomen, Abdominal
  129. ABG
    Arterial Blood Gas
  130. abx
  131. AMA
    Against Medical Advice
  132. AMI
    Acute Myocardial Infarction
  133. AMS
    Altered mental status
  134. approx
  135. appt
  136. appy
  137. ASA
    Actylsalicylic Acid (aspirin)
  138. Auto/Ped
    automobile v. pedestrian
  139. A&O x3
    Alert & Oriented x3 (person, place, time)
  140. BBS
    Bilateral Breath Sounds
  141. BCP
    Birth Control Pill
  142. bilat
  143. BLE
    Bilateral lower extremities
  144. BM
    Bowel movement
  145. BP
    Blood Pressure
  146. BS
    Bowel sounds, breath sounds
  147. BSG
    Blood Sugar Glucose
  148. BUE
    Bilateral upper extremities
  149. CABG
    Coronary Arterial Bypass Graft
  150. CAD
    Coronary Artery Disease
  151. cath
  152. CBC
    complete blood count
  153. CHF
    congestive heart failure
  154. CHI
    closed head injury
  155. chole
  156. CMT
    cervical motion tenderness
  157. CNS
    central nervous system
  158. c/o
    complains of
  159. CO2
    carbon dioxide
  160. COPD
    chronic obstructive pulmonary disease
  161. CP
    chest pain
  162. CPAP
    continuous positive airway pressure
  163. CPR
    cardiopulmonary resuscitation
  164. C&S
    culture and sensitivity
  165. CSF
    cerebrospinal fluid
  166. CTA
    clear to ascultation, CT angiogram
  167. CV
  168. CVA
    cerebrovascular accident
  169. CVAT
    costovertebral angle tenderness
  170. CXR
    chest xray
  171. C-collar
    cervical collar
  172. C-spine
    cervical spine
  173. C-section
    ceasarean section
  174. d/c
  175. DIP
    distal interphalangeal (joint)
  176. DJD
    degenerative joint disease
  177. DKA
    diabetic ketoacidosis
  178. DM
    diabetes mellitus
  179. DNR
    do not resuscitate
  180. DTR
    deep tendon reflex
  181. DVT
    deep vein thrombosis
  182. Dx, dx
  183. EKG (ECG)
  184. EOMI
    extra ocular movements intact
  185. epi
  186. EtOH
    Ethyl Alcohol (consumption, dependency)
  187. ETT
    endotracheal tube
  188. FB
    foreign bodies
  189. FHT
    fetal heart tone
  190. FROM
    full range of motion
  191. FTN
    finger-to-nose (coordination test)
  192. Fx
  193. F/U
    follow up
  194. GB
  195. GCS
    Glasgow coma scale
  196. GERD
    gastroesophageal reflux disease
  197. GSW
    gunshot wound
  198. HA
  199. Hgb
  200. HCT
  201. h/o
    history of
  202. HR
    heart rate
  203. Hx
  204. Hyst
  205. IBS
    irritable bowel syndrome
  206. ICD
    implantable cardioverter-defibrillator
  207. ICE
    ice, compression, elevation
  208. ICH
    intracranial hemorrhage
  209. ICP
    intracrainal pressure
  210. IM
  211. IUP
    intrauterine pregnancy
  212. IV
  213. IVPB
    Intravenous piggyback
  214. I&D
    incision and drainage
  215. JVD
    jugular vein distension
  216. KUB
    kidneys, ureters, bladder (X-ray)
  217. L
  218. lac
  219. LBBB
    left bundle branch block
  220. LFT
    liver function test
  221. LLQ
    left lower quadrant
  222. LMP
    last menstrual period
  223. LNMP
    last normal menstrual period
  224. LOC
    loss of consciousness
  225. LP
    lumbar puncture
  226. L-spine
    lumbar spine
  227. LUQ
    left upper quadrant
  228. LVH
    left ventricular hypertrophy
  229. MAEW
    moves all extremities well
  230. med, meds
  231. MI
    myocardial infarction
  232. MIP
    metacarpointerphalangeal (joint)
  233. MVC
    motor vehicle collision
  234. NAD
    no acute distress
  235. NCAT
    normocephalic, atraumatic
  236. NG
  237. NH
    nursing home
  238. NKA
    no known allergies
  239. NKDA
    no known drug allergies
  240. nl
  241. NPO
    nothing per os (by mouth)
  242. NRB
    nonrebreather (oxygen mask)
  243. NSR
    normal sinus rhythm
  244. NTG
  245. N/V
    nausea and vomiting
  246. N/V/D
    nausea, vomiting, diarrhea
  247. NVID
    neuovascularly intact distally
  248. NS
    normal saline
  249. O2
  250. obs
  251. OD
  252. Ortho
  253. PA & Lat
    posteroanterior and lateral (x-rays)
  254. palp
  255. PCN
  256. PCP
    primary care physician
  257. PE
    pulmonary embolism
  258. PERRLA
    pupils equal, round and reactive to light and accommodation
  259. PID
    pelvic inflammatory disease
  260. PIP
    proximal interphalageal (joint)
  261. post-op
    post operative
  262. preg
    pregnancy, prengant
  263. PPD
    packs per day (cigarettes)
  264. PRN
    as needed
  265. Pt
  266. PTA
    prior to arrival
  267. PTX
  268. PUD
    peptic ulcer disease
  269. PVC
    premature ventricular contractions
  270. PVD
    peripheral vascular disease
  271. q
    each, every
  272. q.d.
  273. q.h.
    every hour
  274. q.h.s.
    at bedtime, every night
  275. R
  276. RA
    room air
  277. RA
    rheumatoid arthritis
  278. RBBB
    right bundle branch block
  279. RBC
    red blood cell
  280. resp
    respiration, respiratory
  281. RICE
    rest, ice, compression, elevation
  282. RLQ
    right lower quadrant
  283. R/O
    rule out
  284. ROM
    range of motion
  285. RR
    respiratory rate
  286. RRR
    regular rate and rhythm
  287. RUQ
    right upper quadrant (of abdomen)
  288. Rx
  289. SBO
    small bowel obstruction
  290. scope
    arthroscopy, endoscopy
  291. script
  292. SEM
    systolic ejection murmur
  293. SI
    sacroiliac (joint)
  294. SLR
    straight-leg raise
  295. SOB
    shortness of breath
  296. sono
  297. s/p
    status post
  298. SP
  299. SR
    sinus rhythm
  300. STAT, stat
    at once, immediately
  301. STD
    sexually transmitted disease
  302. strep
  303. SVT
    supraventricular tachycardia
  304. Sx
  305. tachy
  306. TIA
    transient ischemic attack
  307. TM
    tympanic membrane
  308. T-spine
    thoracic spine
  309. TTP
    tender to palpation
  310. Tx
  311. UA
  312. UDS
    urine drug screen
  313. URI
    upper respiratory infection
  314. US
  315. UTD
    up to date
  316. UTI
    urinary tract infection
  317. V-fib
    ventricular fibrillation
  318. VS
    vital signs
  319. VSS
    vital signs stable
  320. V-Tach
    ventricular tachycardia
  321. WBC
    white blood count
  322. W/D
    warm and dry
  323. WDWN
    well-developed, well-nourished
  324. WNL
    within normal limits
  325. YTD
    year to date
  326. 7 routes of drug administration
    • 1. IV
    • 2. SubQ
    • 3. PO
    • 4. transdermal
    • 5. IM
    • 6. SubL
    • 7. PR
  327. SubQ
  328. PO
    by mouth (per os)
  329. transdermal
    upon skin
  330. SubL
  331. PR
    per rectum
  332. respiratory updrafts and treatment (4)
    • ventolin updraft
    • DuoNeb Updraft (Albuterol with Atrovent)
    • Xopenex Updraft
    • Solumedrol
  333. Allergic reactions (5 drugs)
    • epinephrine
    • benadryl
    • solumedrol
    • prednisone
    • decadron
  334. 13 cardiac drugs
    • NTG 0.4 (1/150) SL q5 minutes x 3
    • NTG drip
    • NTG Paste
    • Morphine
    • ASA 325 mg PO
    • Heparin drip - anticoagulant
    • Adenosine - antiarrhythmic
    • Dopamine drip - vasopressor
    • Cardizem – antianginal, antiarrhythmic, htn
    • Atenolol – antianginal, htn
    • Lasix – diuretic
    • Clonidine – htn
    • Atropine – antiarrhythmic
  335. antiplatelet drugs (1)
    plavix (generic = clopidogrel)
  336. thrombolytic agent
    TPA per protocol
  337. Antibiotics
    • Ancef
    • Rocephin
    • Bicillin
    • Levaquin
    • Cipro
    • Amoxil
    • Bactrim
    • Unasyn
    • Mefoxin
    • Clindamycin
    • Flagyl
  338. Antiemetic
    • Phenergan
    • Zofran
    • Compazine
    • Reglan
  339. Antispasmotic
  340. antacid
    • Pepcid – H2 antagonist
    • Protonix – Proton Pump Inhibitor (PPI)
    • Tagamet – H2 antagonist
    • GI Cocktail
  341. anti-diarrheal
  342. Pain control (opiate)
    • Morphine
    • Dilaudid
    • Vicodin/Lortab
  343. Pain Control - NSAID
    • Toradol
    • Ibuprofen
  344. Migraine relief
  345. Anxiolytic
    • Valium
    • Ativan
    • Xanax
    • Vistaril
  346. Coumadin
    Coumadin is a blood thinner that is commonly used in the treatment of cardiacconditions and in patients that have had strokes or DVT’s; a PT/PTT is ordered to determinetherapeutic levels of this drug
  347. Digoxin/lanoxin
    The brand name for digitalis, this drug is an extract of the purplefoxglove, and used by many cardiac patients. It is a powerful cardiac stimulant as well as adiuretic. A Digoxin level measures the amount of the drug in a patient’s blood stream.
  348. Dilantin
    Dilantin is an antiepileptic drug, useful in the treatment of epilepsy and otherseizure disorders. Its primary site of action is the motor cortex where spread of seizure activity isinhibited. The appropriate lab for this drug is a Dilantin level.
  349. Tegretol
    Tegretol is an anticonvulsant and specific analgesic effective in the treatment ofpsychomotor and grand mal seizures, as well as trigeminal neuralgia. The appropriate lab forthis drug is a Tegretol level. A CBC is also indicated due to the contraindications of thismedicine, which include aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia.
  350. Phenobarbital
    Phenobarbital is a barbiturate that is commonly used as a hypnotic andsedative. It can be included in various medicines, and is commonly used in the treatment ofseizure disorders. Because of its nature, it can be addictive. The appropriate lab for this drug isa Phenobarbital level
  351. depakote
    Depakote is another common anti-seizure drug that can also be used to stabilizemanic depressive disorder and as a migraine prophylaxis. The appropriate lab for this drug is aDepakote level.
    Theophylline is a drug commonly used by asthmatics andthose with emphysema (COPD). It is a bronchodilator that directly relaxes the smooth musclesof the bronchial airways and pulmonary blood vessels (coronary vasodilator). Because of thismechanism of action, this drug also produces actions such as cardiac stimulation, diuretic action,cerebral stimulation, and skeletal muscle stimulation. The appropriate test for this drug is a Theophylline level.
  353. acetaminophen
    Acetaminophen or Tylenol is one of the key ingredients in manyprescription and non-prescription pain medications. If a patient has been taking multiple painmeds or has intentionally overdosed on them, an Acetaminophen level should be ordered
  354. SOAP
    • subjective information
    • objective information
    • assessment
    • plan
  355. subjective information
    chief complaint, HPI, ROS (review of systems), PMHx (past medical history), SHx (social history), FMHx (family history)
  356. Objective information
    • Physical examination (PEx)
    • Medical Decision Making (MDM) -- differential diagnosis (DDx), orders, lab results, procedures/consultations
  357. Assessment
    This is the physician’s impression of the patient’s condition after evaluating the information in both the Subjective and Objective sections.

    The Assessment includes:a. Diagnosis (Dx) identifies the physician’s evaluation of the patient.
  358. Plan
    • admission
    • discharge instructions
  359. 8 significant areas of the HPI
    • 1. location
    • 2. quality
    • 3. severity
    • 4. duration
    • 5. timing
    • 6. context
    • 7. modifying factors
    • 8. associated signs and symptoms
  360. Body systems
    • constitutional
    • eyes
    • ENT
    • neck
    • respiratory/chest
    • CVS
    • abdomen/GI
    • MS
    • GU (genitourinary)
    • neurologic
    • skin
    • psychiatric
  361. Constitutional
    General appearance of patient: unkempt, alert, distressed
  362. eyes
    • • Inspection of conjunctiva and lids
    • • Exam of pupil and irises
    • • Ophthalmoscopic exam of optic discs
  363. ENT (ears nose mouth throat)
    • • External inspection of ears and nose
    • • Exam of external auditory canals & tympanic membranes
    • • Assessment of hearing
    • • Inspection of nasal mucosa, septum & turbinates
    • • Exam of oropharynx: oral mucosa, salivary glands, hard and soft palates,tongue, tonsils, posterior pharynx
  364. Neck
    Exam of neck / thyroid
  365. Respiratory/chest
    • • Assessment of respiratory effort
    • • Percussion and Palpation of chest
    • • Auscultation of Lungs
  366. CVS
    • • Auscultation of heart noting abnormal sounds and murmurs
    • • Exam of: Carotid/femoral arteries; Pedal pulses; Abnormal Aorta; Extremities for edema
  367. abdomen/GI
    • • Exam of abdomen noting masses or tenderness
    • • Exam of liver and spleen
    • • Exam for presence of hernia
    • • Exam of anus, perineum, and rectum for rectal masses, presence ofhemorrhoids, sphincter tone
    • • Obtain stool sample for occult blood test
  368. Muskuloskeletal
    • • Exam of gait and or station
    • • Exam of joints, bones, and muscles of: Head and Neck; Spine, ribs, andpelvis; Both upper and/or lower extremities
    • • Inspection and/or palpation noting any misalignment, asymmetry, masses,tenderness, effusions
    • • Assessment of ROM with note of pain, crepitance or contracture
    • • Assessment of stability with note of: dislocation, subluxation/laxity
  369. Genitourinary
    • • Male: Exam of scrotal contents,¬†Exam of penis, Digital rectal exam of prostate gland
    • • Female: Pelvic Exam, Exam of external genitalia, Cervix, Urethra, Uterus, Bladder, Adnexa
  370. Neurologic
    • • Test cranial nerves with notation of deficits
    • • Exam of deep tendon reflexes
    • • Exam of Sensation
  371. skin
    • • Inspection/Palpation of skin and subcutaneous tissue
    • • Lymphatic
    • • Palpation of nodes in 2 or more areas: Neck, Axillae, Groin, Supraclavicular, Other
  372. psychiatric
    • • Orientation to time/place/person
    • • Recent and remote memory
    • • Mood and affect
Card Set
Scribe Terms