Scribe Need to Know

  1. AAA
    Abdominal Aortic Aneurysm
  2. Abd
    abdominal
  3. abrasion
    superficial wound to the top most layer of skin (scratch)
  4. Abx
    antibiotics
  5. afebrile
    without fever
  6. afib
    atrial fibrilation
  7. afib with RVR
    Atrial fibrillation with rapid ventricular response
  8. ambulate
    to walk (ambulatory, ambulated)
  9. anti-emetic
    nausea medication
  10. antipyretic
    fever reducing medication
  11. aphasia
    no speech ( can be expressive or receptive)
  12. Appy
    appendicitis, appendectomy
  13. AKI
    Acute Kidney Injury
  14. ASA
    aspirin
  15. Avulsion
    forcible tearing of the skin from the body
  16. GCS
    glasgow coma scale
  17. BLE
    bilateral Lower extremity
  18. BM
    bowel movement
  19. BP
    blod pressure
  20. Bradycardia
    slow heart rate below 60 ppm
  21. BS
    bowel sounds, breath sounds, blood sugar
  22. BUE
    bilateral upper extremities
  23. CABG
    coronary artery bypass graft
  24. Cachectic
    physical wasting appearance
  25. CAD
    coronary artery disease
  26. CAP
    Community acquired pneumonia
  27. Carotid Bruit
    abnormal blood flow into the carotid artery
  28. c.c.
    chief complaint
  29. Cellulitis
    bacterial skin infection
  30. cerumen
    earwax
  31. cerumen impaction
    excessive earwax
  32. Cervial Motion tenderness (CMT)
    paint with movement of the cervix
  33. CHF
    Congestive Heat Failure
  34. FHI
    Close Head Injury
  35. Cholecystectomy (chole)
    surgical remove of the gallbladder
  36. Cholecystitis
    inflammation of the gallbladder
  37. Cholelithiasis
    gallstones
  38. Clear rhinorrhea
    clear nasal drainage, "runny" nose
  39. Contusion
    blunt force trauma to tissue under the skin (deep Bruise)
  40. COPD
    chronic obstructive pulmonary disease
  41. Costovertebral Angle Tenderness (CVAT)
    pain with tapping on the back in the region of the kidneys
  42. CP
    Chest Pain
  43. CPR
    Cardiopulmonary resuscitation
  44. Crepitus
    cracking or popping sounds under the skin (chest wall)
  45. CT
    Computerized tomography scan
  46. CVA
    cerebrovascular accident (stroke)
  47. CXR
    Chest x-ray
  48. DC
    discharged
  49. Debridement
    removal of foreign matter or dead tissue from the wound
  50. Diaphoresis
    sweating (diaphoretic)
  51. DM
    diabetes mellitus
  52. DNR
    do not resuscitate
  53. DTR
    deep tendon reflexes
  54. Dx
    Diagnosis
  55. Dyspnea
    difficulty breathing
  56. Dyspnea on exertion (DOE)
    difficulty reaching with movement/ambulation
  57. Dysuria
    difficulty/painful urination
  58. Ecchymosis
    large area of ruptured blood vessels (superficial bruise)
  59. ED
    emergency department
  60. EENT
    eyes, ears, nose, throat
  61. EKG
    electrocardiogram
  62. Emesis
    vomit
  63. EPI
    epinephrine
  64. Epistaxis
    nose bleed
  65. Erythema
    redness
  66. ESRD
    End Stage Renal Disease
  67. EtOH
    alcohol
  68. Extra Ocular Movements Intact (EMOI)
    physical exam of eye movement
  69. Exudate
    oozing fluid from the throat
  70. FB
    foreign body
  71. Febrile
    having a fever
  72. FROM
    full range of motion
  73. F/U
    follow-up
  74. Fx
    fracture
  75. Gait
    manner of walking
  76. GERD
    gastroesophageal reflux disease
  77. GI
    gastrointestinal
  78. Gravid
    pregnant (gravida=number of pregnancies, para=number of live births)
  79. GU
    genitourinary
  80. Guaiac
    test detecting the presence of fecal occult blood
  81. GYN
    gynecology
  82. HA
    headache
  83. Hematemesis
    blood in vomit
  84. hematochezia
    blood in stool (red in color)
  85. hematoma
    damage to the blood vessels that causes a lump under the skin
  86. hematuria
    blood in urine
  87. HI
    Homicidal Ideation
  88. H/O
    history of
  89. H&P
    History and physical
  90. HPI
    history of present illness
  91. HR
    heart rate
  92. HTN
    hypertension
  93. Hx
    history
  94. Hypercholesterolemia
    high cholesterol
  95. hyperkalemia
    high potassium levels
  96. Hyperlipidemia
    High cholesterol
  97. Hypernatremia
    high sodium levels
  98. hysterectomy (hys)
    surgical removal of the uterus
  99. IBS
    Irritable bowel syndrome
  100. Icterus
    yellowing of the sclera
  101. I&D
    incision and drainage
  102. IM
    intremuscular
  103. Incontinence
    loss of control of bladder/bowel
  104. Induration
    localized hardening of the soft tissue
  105. IV
    Intravenous
  106. Jaundice
    yellow skin color
  107. K+
    potassium
  108. Laceration
    cut
  109. LBBB
    left bundle branch block
  110. Lethargy
    fatigue or exhaustion
  111. LLE
    left lower extremity
  112. LLQ
    left lower quadrant
  113. LMP
    last menstrual period
  114. LOC
    Loss of consciousness/level of consciousness
  115. LP
    lumbar puncture
  116. LUE
    left upper extremity
  117. LUQ
    left upper quadrant
  118. LVH
    left ventricular hypertrophy
  119. Macular papular
    flat, red area covered with small, confluent bumps
  120. MAE
    moves all extremities
  121. Malaise
    vague feeling of discomfort
  122. Malocclusion
    misalignment of the teeth and dental arches
  123. Mastectomy
    surgical removal of the breasts
  124. Melena
    black, tarry stools
  125. Meningismus
    collection of symptoms including neck stiffness, photophobia, and headache
  126. MVC
    Motor Vehicle Collision
  127. NG
    nasogastric
  128. NKDA
    no known drug allergies
  129. NI
    normal
  130. Nontoxic appearing
    minimal distress
  131. Normocephalic atraumatic
    normal appearance of the head
  132. NPO
    nothing per os (nothing by mouth)
  133. NSR
    normal sinus rhythm
  134. Nuchal rigidity
    neck stiffness
  135. Nystagmus
    involuntary rapid eye movement
  136. O2
    oxygen
  137. OD
    overdose
  138. Orthopnea
    difficulty breathing when laying down
  139. Otitis media
    middle ear infection
  140. PAC
    premature atrial contractions
  141. Pallor
    pale
  142. Palpable
    able to be touched or easily perceived
  143. Paraspinal tenderness
    pain adjacent to the spine
  144. PCP
    primary care physician
  145. PE
    physical exam; pulmonary embolism
  146. PEA
    pulseless electrical activity
  147. Peds
    pediatric
  148. Pharyngeal erythema
    redness of the throat
  149. Photophobia
    abnormal intolerance of light/sensitivity to light
  150. PO
    per os (by mouth)
  151. Polyuria
    excessive urination
  152. PRN
    as needed
  153. pruritus
    itchiness
  154. PTA
    prior to arrival
  155. Puncture wound
    wound caused by an object piercing the skin, causing a small hole
  156. purulent
    the presence of pus
  157. pustules
    small collection of pus under the skin
  158. PVC
    premature ventricular contractions
  159. Rales (crackles)
    wet, crackly sound upon inspiration
  160. RBBB
    right bundle branch block
  161. Rectal tone
    anal elasticity of rectal sphincter
  162. Rhinorrhea
    runny nose
  163. RLE
    right lower extremity
  164. RLQ
    right lower quadrant
  165. R/O
    ruled out
  166. RRR
    regular rate and rhythm
  167. Rubs
    scratching or clicking sound of the heart
  168. RUE
    right upper extremity
  169. RUQ
    right upper quadrant
  170. Rx
    prescription
  171. Saddle anesthesia
    a loss of sensation near the buttocks
  172. SBO
    small bowel obstruction
  173. septal deviation
    displacement of the nasal septum
  174. SI
    suicidal ideation
  175. snuff box tenderness
    pain around the thumb area (possible indication of scaphoid fracture)
  176. SOB
    shortness of breath
  177. Somnolent
    drowsy or sleepy
  178. s/p
    status post
  179. STEMI
    ST elevated myocardial infarction
  180. Subconjuctival hemorrhage
    bright red patch in whites of eyes
  181. Sx
    symptoms
  182. Syncope
    fainting
  183. Tachycardia
    rapid heart rate above 100bpm
  184. tachypnea
    rapid respiration rate (tachyneic)
  185. Thrombocytopenia
    disorder in which there is an abnormally low platelet count
  186. TIA
    transient ischemic attack (mini stroke)
  187. Tinnitus
    ringing in the ears
  188. Tonsillectomy
    surgical removal of the tonsils
  189. Transient
    passing into and out of existence
  190. Trismus
    inability to open mouth normally
  191. Tubal ligation
    tying of the fallopian tubes
  192. Tx
    treatment
  193. Tympanic membrane (TM)
    eardrum
  194. UA
    urinalysis
  195. URI
    Upper respiratory infection
  196. US
    ultrasound
  197. Vertigo
    room spinning sensation
  198. Visual acuity
    acuteness/sharpness of vision based off eye chart exam
  199. VS
    vital signs
  200. Waxing and waning
    gradual increase or decrease in severity of constant pain
  201. Wheals and flares
    irregular blanched raised area surrounding redness
  202. Wheezes
    continuous whistling sounds
  203. WNL
    within normal limits
  204. y/o
    year old
  205. yr
    year
Author
eamparano
ID
331497
Card Set
Scribe Need to Know
Description
Terminology
Updated