Medical Terminology for Scribe Candidates PDF

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 v...

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. Anatomical Terms Anterior Situated toward the front of the body Diffuse Generalized; not localized to any specific location Distal Farther from the trunk of the body Inferior Lower on the body, farther from the head Lateral Farther from the midline Medial Nearer to the midline Posterior Situated towards the back of the body, opposite of anterior Proximal Nearer to the trunk of the body Superior Higher on the body, nearer to the head Diseases Abscess A collection of pus beneath the skin Appendicitis Dangerous infection of the appendix Arthritis Inflammation of the joints Atrial fibrillation (A fib) Irregular and o en very rapid heart rhythm (arrhythmia) Bronchitis Inflammation/Infection of the bronchi (upper airway) Cellulitis Infection of skin cells A stroke. Blood supply to the brain is restricted or absent due to hemorrhage or Cerebrovascular accident (CVA) blockage of a vessel resulting in brain damage and dysfunction Cholecystitis Inflammation of the gallbladder Chronic obstructive pulmonary disease (COPD) Chronic inflammatory lung disease that causes obstructed airflow to the lungs Chronic renal failure (CRF) Decrease in the kidneys' ability to filter waste and fluid from the blood Congestive heart failure (CHF) Serious condition in which the heart doesn't pump blood as efficiently as it should Conjunctivitis Infection of the outer layer of the eye Coronary artery bypass graft (CABG) Procedure used to treat coronary artery disease (heart disease) Coronary artery disease (CAD) Buildup of plaque in the arteries that supply oxygen-rich blood to your heart Deep venous thrombosis (DVT) A blood clot that forms in a vein located deep inside your body, typically in the leg 1 Diverticulitis Acute inflammation of the diverticula pouches Ectopic pregnancy Egg developing outside the uterus extremely dangerous due to risk of rupture Gastroenteritis General term for inflammation of the GI tract Gastroesophageal reflux Digestive disorder that occurs when acidic stomach juices, or food and fluids back up disease (GERD) from the stomach into the esophagus Hepatitis Inflammation of the liver Hyperglycemia High blood sugar due to diabetes Hyperlipidemia (HLD) High cholesterol Hypertension (HTN) High blood pressure (typically >140/90) Hypoglycemia Low blood-sugar Hypotension Low blood pressure (typically <100/65) Insulin dependent diabetes mellitus (IDDM) Diabetes requiring the use of insulin injections Myocardial infarction (MI) Heart attack. Death of cardiac muscle due to prolonged ischemia Nephrolithiasis / Renal calculi Kidney stone Non-insulin dependent diabetes mellitus (NIDDM) Diabetes not requiring the use of insulin injections Otitis media (OM) Infection inner ear (behind the eardrum) Pancreatitis Inflammation of the pancreas Peptic ulcer disease (PUD) Ulcers developing in the stomach causing pain and emesis Blood circulation disorder that causes the blood vessels (excluding the heart and Peripheral vascular disease (PVD) brain) to narrow, block, or spasm Pharyngitis Throat infection Pneumonia Infiltrate (infection) inside the lung tissue Pneumothorax Presence of air or gas in the pleural space; collapsed lung Pulmonary Embolism Blockage of the pulmonary artery or one of its branches due to a translocated clot Pyelonephritis Infection on the kidneys Sepsis Dangerous infection of the blood Transient ischemic attack (TIA) Transient “mini-stroke”, neurological function is regained completely with time Upper respiratory infection (URI) Contagious infection of the upper respiratory tract (sinuses, throat, lungs or airways) Urinary tract infection (UTI) Infection in any part of the urinary system — kidneys, ureters, bladder and urethra Constitutional Afebrile Without fever Ambulatory Able to move about, not confined to a bed Constitutional The general appearance and nature of a patient A patientʼs inability to tolerate their body-state, due to pain or respiratory failure. No Distress Acute Distress (NAD) is commonly written if a patient looks comfortable. 2 Eye Extraocular muscles intact (EOMI) Testing that examines the function of the eye muscle Pale conjunctiva Pale inner aspect of the eyelid most o en due to anemia Pupils are Equal, Round, and Reactive, to Light (PERRL) Common normal eye exam finding Scleral icterus Yellowing of the sclera (whites of the eye) due to jaundice Ear, Nose, and Throat (ENT) Cerumen Earwax Dry mucosa Dry tongue, mouth, and lips, indicating significant dehydration Epistaxis Nose bleed Oropharynx The back of the mouth, where it meets the throat Rhinorrhea Clear nasal discharge. "Runny" nose Tinnitus “Ringing in the ears”, the perception of ringing even with no external stimuli Tonsillectomy & Adenoidectomy (T&A) Tonsils and adenoids removal surgery Tympanic membrane (TM) Tympanic membrane, the clear membrane inside the ear; (ear drum) Neck Carotid bruit Whooshing blood flow heard with auscultation (carotid narrowing or plaque) Lymphadenopathy Enlarged lymph nodes Supple Flexible, not-stiff Thyromegaly Enlarged thyroid Jugular vein distention (JVD) Jugular vein distention, sign of heart dysfunction Cardiovascular (CV) Aneurysm Localized ballooning of a vessel due to a weakened vessel wall Arrhythmia Irregular heartbeat Artery Blood vessel carrying blood away from the heart, muscular, contractile Bradycardia Slow heart rate (HR<60) Cardiomegaly Enlarged heart Murmur Abnormal heart sound rated on 1-6 scale Normal sinus rhythm (NSR) The rhythm of a healthy heart Palpitation To beat rapidly, irregularly, or forcibly (usually relating to the heart) Regular rate and rhythm (RRR) Normal heart sounds with a regular rate (60-100 bpm) Stenosis Narrowing of a body opening or passage 3 Tachycardia Fast heart rate (HR>100 bpm) Vein Vessel carrying blood towards the heart, so , compressible Respiratory / Pulmonary Clear to auscultation (CTA) No abnormal sounds when listening to the lungs with a stethoscope Dyspnea Difficulty/labored breathing, shortness of breath Hypoxia Low oxygen saturation of the body, not enough oxygen in the blood Pleurisy General term for pain with breathing Rales Crackles; Wet crackling heard in the lungs, typically due to pneumonia or CHF Rhonchi Sound of mucous rolling around in the bronchioles/bronchi Shortness of breath (SOB) Air hunger, difficulty breathing, or breathlessness Sputum Any mixed matter with the saliva that is passed through the mouth Stridor Upper airway noise; common sign in croup Tachypnea Increased respiratory rate Wheezing High pitched sound heard in the lungs with asthmatics or lung disease Gastrointestinal (GI) Emesis Vomiting Hematemesis Gross amounts of blood in the vomit Hepatomegaly Enlarged liver Hernia Protrusion of part of an internal organ or tissue bulges through a weak area of muscle Melena Black tarry stool indicative of an upper GI bleed N/V/D Nausea/Vomiting/Diarrhea Peritoneal signs (Rebound, guarding, or rigidity ) Signs indicative of acute abdominal inflammation (peritonitis) Genitourinary (GU) C-section Cesarean Section CVA tenderness Costovertebral Angle tenderness; tenderness over the kidneyʼs Dysuria Painful urination Foley catheter A tube inserted through the urethra to drain urine, o en le in place Gravida (The # of times pregnant / Para (The # of live children born) / Abortion (The # G / P / Ab of failed pregnancies) Hematuria Blood in the urine Intrauterine pregnancy (IUP) When a fertilized egg implants and starts to develop within the uterus Last normal menstrual period (LNMP) The first day of one's period 4 Integumentary / Skin Abrasion Scrape of the skin due to something abrasive Cyanosis Blue color of the skin due to lack of oxygen Diaphoresis Sweating Ecchymosis Bruising Edema Swelling Erythema / Erythematous Redness/Red Fluctuance Palpable fluid beneath the skin indicative of infection/pus/abscess Laceration Splitting of the skin due to trauma (a cut due to something sharp) Maculopapular rash Rash that is both red and raised Pallor Pale skin typically due to anemia Purulence / Purulent Pus/Pus-like Urticarial rash / Wheals A patchy red, raised rash, consistent with allergic reactions Neurological Absence of the ability to neurologically generate or understand language. Either Aphasic inability to create words or inability to understand spoken words Epilepsy Seizure disorder Hemiparesis Weakness of one half of the body Hemiplegia Paralysis of one half of the body Loss of consciousness (LOC) Passing out Meningitis Infection of the meninges, the outer lining of the brain and spinal cord DTRs Deep tendon reflexes Oriented x3 Oriented to person, place, and time Syncope "Passing out", loss of consciousness or fainting Vertigo Room-spinning dizziness (not light-headed) Miscellaneous Acute New onset, likely concerning. Opposite of chronic Chronic Long-standing, constant. Opposite of acute Benign Normal, of no danger to health -ectomy (suffix) Surgical removal (e.g. tonsillectomy) -itis (suffix) Inflammation (e.g. appendicitis) -scopy (suffix) Viewing with a scope (e.g. colonoscopy) 5