Scribe

Front 1

Wheezing

Back 1

Hight pitched sound heard in the lungs with asthmatics or lung disease

Front 2

vertigo

Back 2

Room-spinning dizziness (not lightheaded)

Front 3

Ulcerations

Back 3

Blisters or open-sores

Front 4

Tachypnea

Back 4

Increased breathing rate

Front 5

Trismus

Back 5

Inability to open the jaw to do pain

Front 6

Tachycardia

Back 6

Fast Heart rate (HR > 100bpm)

Front 7

Syncope

Back 7

"Passing out", loss of consciousness or fainting

Front 8

Supine

Back 8

Body position lying face up

Front 9

Superior

Back 9

Higher or the body, nearer to the head

Front 10

Streptococcal Pharyngitis

Back 10

Strep Throat

Front 11

Small Bowel Obstruction

Back 11

Physical blockage of the small intestines

Front 12

Sinusitis

Back 12

Infection/inflammation of the nasal sinuses

Front 13

Sepsis

Back 13

Dangerous infection of the blood

Front 14

-scopy (suffix)

Back 14

Viewing with a scope (e.g. colonoscopy)

Front 15

Rhonchi

Back 15

Rattling noise of mucous in the lungs

Front 16

Rhinorrhea

Back 16

Clear nasal discharge, "runny nose"

Front 17

Rales

Back 17

Crackles; wet crackling noise in the lungs

Front 18

Purulence/Purulent

Back 18

Pus/Pus-like

Front 19

Pulmonary

Back 19

Relating to the lungs

Front 20

Proximal

Back 20

Nearer to the trunk of the body

Front 21

Prone

Back 21

Body position lying flat, face down

Front 22

Posterior/Dorsal

Back 22

Rear or backside of the body

Front 23

Pneumonia

Back 23

Bacterial infection of the lungs

Front 24

Pharyngitis

Back 24

Throat infection

Front 25

Palpitation

Back 25

To beat rapidly, irregularly, or forcibly (usually relating to the heart)

Front 26

Peritoneal signs

Back 26

Guarding/rebound/rigidity: PE finding indicating a rupture in the abdomen

Front 27

Palpation

Back 27

Examine by touch

Front 28

Pallor

Back 28

Pale Skin

Front 29

Myalgia

Back 29

Muscular pain, "muscle aches"

Front 30

Melena

Back 30

Black tarry stool

Front 31

Otitis Media

Back 31

Infection inner ear (behind the eardrum)

Front 32

Otitis externa

Back 32

Infection of the outer ear (ear canal)

Front 33

Meningitis

Back 33

Dangerous infection of the outer lining of the brain

Front 34

Medial

Back 34

Nearer to the midline

Front 35

Lethargic

Back 35

Septic, very sick, about to die

Front 36

Lateral

Back 36

Farther from the midline(a line that can be traced from nose to belly-button)

Front 37

Laceration

Back 37

Splitting of the skin due to trauma (a cut due to something sharp)

Front 38

-itis (suffix)

Back 38

Inflammation (e.g. appendicitis)

Front 39

Ischemia

Back 39

Lack of blood supply

Front 40

Inferior

Back 40

Lower on the body, farther from the head

Front 41

Infarct

Back 41

Area of dead tissue after a lack of blood supply

Front 42

ICD-10

Back 42

A system to classify and code diagnoses, symptoms, and procedures

Front 43

Hypoxia

Back 43

Low oxygen saturation of the body, not enough oxygen in the blood

Front 44

Hypotension

Back 44

Low blood pressure

Front 45

Hypertension

Back 45

High blood pressure

Front 46

Hyperlipidemia

Back 46

High cholesterol

Front 47

Hernia

Back 47

Protrusion of an organ through the wall of the cavity that normally contains it

Front 48

Hepatomegaly

Back 48

Enlarged liver

Front 49

Hemorrhage

Back 49

Excessive or profuse bleeding

Front 50

Hemoptysis

Back 50

Coughing up gross amounts of blood

Front 51

Hematuria

Back 51

Blood in the urine

Front 52

Hematemesis

Back 52

Gross amounts of blood in the vomits

Front 53

Grossly

Back 53

Obviously; a lot; wholly

Front 54

Febrile

Back 54

The state of having a fever (Temperature of more than 100.4)

Front 55

Exudates (tonsillar)

Back 55

Pus-pockets on the tonsils

Front 56

Erythema/Erythematous

Back 56

Redness/Red

Front 57

Epistaxis

Back 57

Nose bleed

Front 58

Epilepsy

Back 58

Seizure disorder

Front 59

Emesis

Back 59

Vomiting

Front 60

Edema

Back 60

Swelling

Front 61

-ectomy (suffix)

Back 61

Surgical removal (e.g. tonsillectomy)

Front 62

Ecchymosis

Back 62

A bruise

Front 63

Dysuria

Back 63

Painful urination

Front 64

Dyspnea

Back 64

Difficulty breathing

Front 65

Distal

Back 65

Farther from the trunk of the body

Front 66

Diffuse

Back 66

Spread out (not localized)

Front 67

Diaphoresis

Back 67

Sweating

Front 68

Dialysis

Back 68

Process of removing waste from the blood for people with renal failure

Front 69

Conjunctivitis

Back 69

Infection of the outer layer of the eye

Front 70

Cellulites

Back 70

Infection of skin cells

Front 71

Chronic

Back 71

Long-standing, constant. Opposite of acute

Front 72

Catheter

Back 72

Tube inserted into vessels or body cavities to permit injection or withdrawal of fluids or to keep a passage open

Front 73

Bronchiolits

Back 73

Infection of the bronchioles (Smaller air-tubes in the lungs)

Front 74

Bronchitis

Back 74

Infection of the bronchi (upper airway)

Front 75

Bradycardia

Back 75

Slow heart-rate (HR<60bpm)

Front 76

Benign

Back 76

Normal, of no danger to health

Front 77

Auscultation

Back 77

Listening to sounds arising within organs (as the lungs)

Front 78

Appendicitis

Back 78

Dangerous infection of the appendix

Front 79

Anterior

Back 79

Located towards the front of the body

Front 80

Afebrile

Back 80

Without a fever (Temperature of less than 100.4)

Front 81

Acute

Back 81

New, usually of rapid onset and of concern, opposite of chronic

Front 82

Antipyretic

Back 82

Medication used to reduce a fever

Front 83

Abscess

Back 83

Collection of pus underneath the skin

Front 84

Abrasion

Back 84

Scrape of the skin due to something abrasive

Front 85

Abd

Back 85

Abdomen, Abdominal

Front 86

Abx

Back 86

Antibiotics

Front 87

A fib

Back 87

Atrial fibrillation

Front 88

AOM

Back 88

Acute Otitis Media (new ear infection)

Front 89

A/P

Back 89

Assessment and Plan

Front 90

ASA

Back 90

Acetylsalicylic Acid (aspirin)

Front 91

BID

Back 91

Twice Daily

Front 92

Bilat LE

Back 92

Bilateral Lower Extremeties

Front 93

BM

Back 93

Bowel Movement

Front 94

BP

Back 94

Blood Pressure

Front 95

c(with a line on top)

Back 95

With

Front 96

CA

Back 96

Cancer, Carcinoma

Front 97

CABG

Back 97

Coronary Artery Bypass Graft

Front 98

CAD

Back 98

Coronary Artery Disease

Front 99

CBC

Back 99

Complete Blood Count (bloodwork to look for infection or anemia)

Front 100

CHF

Back 100

Congestive Heart Failure

Front 101

CP

Back 101

Chest Pain

Front 102

c/o

Back 102

Complains of

Front 103

COPD

Back 103

Chronic Obstructive Pulmonary Disease

Front 104

CRF

Back 104

Chronic Renal Failure

Front 105

C-section

Back 105

Caesarean Section

Front 106

C-spine

Back 106

Cervical spine

Front 107

CT or CAT

Back 107

Computerized Assisted Tomography

Front 108

CTA

Back 108

Clear to auscultation

Front 109

CV

Back 109

Cardiovascular

Front 110

CVA

Back 110

Cerebrovascular Accident

Front 111

CXR

Back 111

Chest X-ray

Front 112

DM

Back 112

Diabetes Mellitus

Front 113

DOE

Back 113

Dyspnea on Exertion

Front 114

DP/PT (pulse)

Back 114

Dorsalis Pedis/ Posterior Tibialis

Front 115

DVT

Back 115

Deep Vein Thrombosis

Front 116

Dx

Back 116

Diagnosis

Front 117

EKG/ECG

Back 117

Electrocardiogram

Front 118

EOMI

Back 118

Extraocular Movements Intact

Front 119

EtOH

Back 119

Alcohol

Front 120

FHx

Back 120

Family History

Front 121

F/U

Back 121

Follow-up (i.e. Follow-up in 3 days for a re-evaluation)

Front 122

Fx

Back 122

Fracture

Front 123

GERD

Back 123

Gastroesophageal Reflux Disease

Front 124

GI

Back 124

Gastrointestinal

Front 125

G/P/Ab

Back 125

Gravida/Para/Abortion

Front 126

GU

Back 126

Genitourinary

Front 127

HA

Back 127

Headache

Front 128

HEENT

Back 128

Head, Ears, Eyes, Nose, Throat

Front 129

HIPAA

Back 129

Health Insurance Portability and Accountability Act

Front 130

HLD

Back 130

Hyperlipidemia

Front 131

HPI

Back 131

History of Present Illness

Front 132

HTN

Back 132

Hypertension (high blood pressure)

Front 133

Hx

Back 133

History

Front 134

H&H

Back 134

Hemoglobin and Hematocrit

Front 135

I&D

Back 135

Incision and Drainage

Front 136

IDDM

Back 136

Insulin Dependent Diabetes Mellitus

Front 137

IUP

Back 137

Intrauterine Pregnancy

Front 138

LLE

Back 138

Left Lower Extremity

Front 139

LLQ

Back 139

Left Lower Quadrant

Front 140

LNMP

Back 140

Last Normal Menstrual Period

Front 141

LOC

Back 141

Loss of Consciousness

Front 142

L-spine

Back 142

Lumbar spine

Front 143

LUE

Back 143

Left Upper Extremity

Front 144

LUQ

Back 144

Left Upper Quadrant

Front 145

MI

Back 145

Myocardial Infarction

Front 146

N/A

Back 146

Not applicable

Front 147

NAD

Back 147

No Acute Distress, No Acute Disease

Front 148

NIDDM

Back 148

Non-Insulin Dependent Diabetes Mellitus

Front 149

NKDA

Back 149

No known Drug Allergies

Front 150

nl/nml

Back 150

Normal

Front 151

NSAID

Back 151

Non steroidal Anti-inflammatory Drug

Front 152

NSR

Back 152

Normal Sinus Rhythm

Front 153

N/V/D

Back 153

Nausea/Vomiting/Diarrhea

Front 154

O2 Sat

Back 154

Oxygen Saturation (a.k.a. SaO2 or SpO2 or Pulse Ox or Sat)

Front 155

OB/GYN

Back 155

Obsterics and gynecology

Front 156

OD

Back 156

Overdose

Front 157

OM

Back 157

Otitis Media (inner ear infection)

Front 158

OP

Back 158

Oropharynx (mouth and throat)

Front 159

ORIF

Back 159

Open Reduction and Internal Fixation (orthopedic surgery)

Front 160

PCP/PMD

Back 160

Primary Care Physician/Primary Medical Doctor

Front 161

PE

Back 161

Physical exam/ Pulmonary Embolism

Front 162

PERRL

Back 162

Pupils are Equal, Round, and Reactive, to Light

Front 163

PO

Back 163

Per Os (by mouth)

Front 164

prn

Back 164

As needed

Front 165

Pt

Back 165

Patient

Front 166

PTA

Back 166

Prior to Arrival -or- Peritonsillar Abscess

Front 167

PVD

Back 167

Peripheral Vascular Disease

Front 168

q

Back 168

every

Front 169

QD

Back 169

Every Day

Front 170

QHS

Back 170

At every Bedtime

Front 171

QID

Back 171

Four times a day

Front 172

RLE

Back 172

Right Lower Extremity

Front 173

RLQ

Back 173

Right Lower Quadrant

Front 174

ROM

Back 174

Range of Motion

Front 175

ROS

Back 175

Review of System

Front 176

RRR

Back 176

Regular rate and rhythm (normal heart sounds)

Front 177

RUE

Back 177

Right Upper Extremity

Front 178

RUQ

Back 178

Right Upper Quadrant

Front 179

Rx

Back 179

Prescription

Front 180

r/o

Back 180

Rule Out

Front 181

SOB

Back 181

Shortness of Breath

Front 182

SOAP

Back 182

Subjective, Objective, Assessment, and Plan

Front 183

s/p

Back 183

Status Post (after)

Front 184

Sx

Back 184

Symptoms

Front 185

T&A

Back 185

Tonsillectomy and Adenoidectomy (tonsils and adenoids removal surgery)

Front 186

TIA

Back 186

Transient Ischemic Attack

Front 187

TID

Back 187

Three Times a Day

Front 188

TM

Back 188

Tympanic Membrane (Ear Drum)

Front 189

Tx

Back 189

Treatment

Front 190

T-spine

Back 190

Thoracic spine

Front 191

UA

Back 191

Urinalysis

Front 192

URI

Back 192

Upper Respiratory Infection

Front 193

US

Back 193

Ultrasound

Front 194

UTD

Back 194

Up to date

Front 195

UTI

Back 195

Urinary Tract Infection

Front 196

WNL

Back 196

Within Normal Limits ( normal, not of concern)

Front 197

y/o

Back 197

Year(s) Old