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Training Class 3
Scribe America terminology, abbreviations and diagnoses
73
Medical
Professional
01/31/2015

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Cards

Term
SL
Definition
sublingual
Term
CAD Dx
Definition
positive cardiac catheterization (not in ED)
Term
MI CC, Dx
Definition
CP with diaphoresis, N/V, SOB; EKG (STEMI), elevated troponin (non-STEMI)
Term
cardiac risk factors
Definition
CAD, HTN, HLD, DM, smoker, FHx of CAD <55 y.o.
Term
MI assoc. med.
Definition
ASA, NTG, ß-blocker, thrombolytic (Heparin)
Term
CHF Dx
Definition
CXR or elevated B-type Natriuretic Peptide (BNP)
Term
pedal edema
Definition
foot swelling
Term
orthopnea
Definition
worse with lying flat
Term
A Fib PE, Dx, assoc. med., ED Tx
Definition
palpitations; irregularly irregular rhythm, tachycardia; EKG; Coumadin (Warfarin); rapid ventricular response (RVR), "cardioverted" to NSR
Term
pericarditis
Definition
inflammation of the sac surrounding the heart causing CP
Term
pleurisy
Definition
inflammation of the sac surrounding the lungs causing pleuritic CP
Term
costochondritis
Definition
irritation of the ribs causing CP worsened by pressing on the sternum
Term
chest wall pain
Definition
irritation of the chest wall causing pain with palpation of the chest
Term
pleural effusion
Definition
fluid collecting around the lungs causing SOB or CP
Term
angina Dx
Definition
exertional CP with Hx of CAD
Term
PE Dx
Definition
CTA chest (CT Chest with IV contrast)
Term
PTX Dx
Definition
pneumothorax; CXR
Term
PNA Dx
Definition
pneumonia; CXR
Term
COPD Dx
Definition
CXR with Hx of smoking
Term
Asthma Dx
Definition
clinically
Term
Ischemic CVA CC, PE, Dx, Scribe Alert
Definition
unilateral focal neurological deficits: hemiparesis, unilateral paresthesias, aphasia, visual field deficits, Dx clinically, ALWAYS document date and time they were "last known well" (baseline) as well as source of info
Term
Ischemic CVA risk factors
Definition
HTN, HLD, DM, Hx TIA/CVA, smoking, FHx CVA, AFib
Term
hemorrhagic CVA note
Definition
tPA ineligibility
Term
ischemic CVA note
Definition
tPA eligibility
Term
meningitis note
Definition
HA, fever, neckpain
Term
spinal cord injury note
Definition
bilateral extremity weakness
Term
TIA note
Definition
when did Sx resolve?
Term
seizure note
Definition
post-ictal state
Term
Bell's Palsy
Definition
absence of other facial nerve damage (FND)
Term
HA/Migraine note
Definition
similar Sx in past?
Term
AMS
Definition
infection? DM? drugs? baseline?
Term
syncope note
Definition
before, during, after, current status
Term
vertigo note
Definition
N/V, nystagmus (involuntary movement of lens/pupil in eye)
Term
Dix-Hallpike test
Definition
for vertigo: pt sits up in bed, turns head and falls backward; exacerbation of Sx implies vertigo
Term
Epigastrium Dz
Definition
GERD, MI
Term
RUQ Dz
Definition
cholecystitis
Term
LUQ Dz
Definition
pancreatitis
Term
Periumbilical Dz
Definition
small bowel obstruction (SBO)
Term
RLQ Dz
Definition
appendicitis
Term
LLQ Dz
Definition
diverticulitis
Term
Suprapubic Dz
Definition
Ovarian torsion, ovarian cyst, UTI
Term
Flanks Dz
Definition
pyelonephritis, renal calculi
Term
McBurney's point tenderness
Definition
point tenderness in appendix area
Term
rebound
Definition
pain when physician releases pressure of palpation
Term
guarding
Definition
pt literally guards area from palpation due to pain
Term
rigidity
Definition
involuntary guarding (contraction of muscles around area of pain)
Term
Murphy's sign
Definition
2 fingers under ribcage and pain during breathing implies cholecyst problem
Term
hematochezia
Definition
brighter red blood in stool (in contrast with melena)
Term
appendicitis Dx
Definition
CT A/P with PO
Term
SBO Dx
Definition
CT A/P with PO, acute abdominal series (AAS)
Term
cholecystitis Dx
Definition
US RUQ
Term
GI bleed Dx
Definition
Guaiac positive
Term
Diverticulitis Dx
Definition
CT A/P with PO
Term
Pancreatitis Dx
Definition
elevated lipase
Term
GERD Dx
Definition
endoscopy (not in ED)
Term
UTI Dx
Definition
UA (WBC, Nitrite, Bacteria)
Term
pyelo Dx
Definition
CT A/P, UTI with costovertebral angle (CVA) tenderness on exam
Term
Kidney stone Dx
Definition
CT A/P (RBC in UA may be clue)
Term
ectopic pregnancy Dx
Definition
US pelvis
Term
Ovarian torsion
Definition
US pelvis
Term
Testicular torsion
Definition
US scrotum
Term
CSMT
Definition
circulation, sensory, motor, tendon
Term
AAA Dx
Definition
CT A/P with IV contrast
Term
Aortic Dissection Dx
Definition
CT Chest with IV contrast
Term
DVT PE, Dx
Definition
cords (hardened veins felt by palpating), Homan's sign (pain in flexing foot); US/Doppler of the extremity
Term
Allergic reaction
Definition
rash, itching, swelling, SOB due to airway swelling
Term
Adverse reaction
Definition
N/V/D, Ab pain, dizziness
Term
DKA risk factors, Dx
Definition
DM; arterial blood gas (ABG or VBG) showing low pH (acidosis) or positive serum ketones
Term
SI
Definition
suicidal ideation
Term
HI
Definition
homicidal ideation
Term
hemiparesis
Definition
unilateral weakness
Term
paresthesias
Definition
sensation of tingling, tickling, prickling or burning
Term
aphasia
Definition
language disorder
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