Medical Terminology: Understanding the Language of Healthcare, Exams of Advanced Education

Download Medical Terminology: Understanding the Language of Healthcare and more Exams Advanced Education in PDF only on Docsity! Vituity Scribe Exam 2023 Questions and Answers Abduction - Answer- Movement of a body part away from the midline Adduction - Answer- Movement of a body part toward the midline Anatomical Position - Answer- The erect position of the body with arms at the side and palms of the hands facing forward. Anterior (Ventral) - Answer- Nearer to the front Bilateral - Answer- Paired structures having right and left members Contralateral - Answer- Occurring on the opposite side of the body Deep - Answer- Farther from the surface Depressor - Answer- A muscle whose contraction pulls down the part of the body to which it is attached. Distal - Answer- Farther from the trunk or site of attachment Dorsal - Answer- Situated toward the back of the body; also back of hand and top of foot Dorsiflexion - Answer- Backward flexion or bending (hand/foot) Extension - Answer- The straightening of a body part External - Answer- Situated outside; exterior (refers to wall of cavity or hollow form) Evert - Answer- To turn outward Flexion - Answer- Bending or angulation of a body part Frontal (Coronal) - Answer- Vertical planes that pass through the body at right angles to the median plane; divide the body into anterior and posterior parts Inferior - Answer- Nearer to the feet Internal - Answer- Inside (refers to wall of cavity or hollow form) Invert - Answer- To turn inward Ipsilateral - Answer- Occurring on the same side of the body Lateral - Answer- Farther from the median plane Levator - Answer- A muscle whose contraction raises the part of the body to which it is attached. Medial - Answer- Nearer to the median plane Midline - Answer- Divides body into a right and left side Palmar - Answer- Palmar surface of hand **Plantar - Answer- Sole side of foot **Plantar Flexion - Answer- Foot movement when toes flex down (pointing your toes) Posterior - Answer- Nearer to the back Pronator - Answer- Medial rotation of the forearm and hand so that the palm faces posteriorly Prone - Answer- Body lying face down (chest down and back up) Proximal - Answer- Nearer to the trunk or site of attachment **Supine - Answer- Body lying face up (chest up and back down) Superior - Answer- Nearer to the head Transverse (Horizontal) - Answer- Horizontal planes that pass through the body at right angles to long axis; divides body into upper (superior) and lower (inferior) parts. Volar - Answer- Relating to the palm of the hand or the sole of the foot **Afebrile - Answer- without fever Ambulation - Answer- to walk (with a cane/walker) Aneurysm - Answer- An excessive localized enlargement of an artery caused by a weakening of the artery wall. Inguinal - Answer- pertaining to the groin region Ischemia - Answer- An inadequate blood supply to an organ or part of the body Joint - Answer- articulation or junction between two or more bones or cartilage Keloid - Answer- scar formation consisting of dense tissue Lacrimal - Answer- to do with tears Lethargy - Answer- fatigue/exhaustion Ligament - Answer- fibrous tissue, binding bones together Lingual - Answer- belonging to the tongue Lymphadenopathy - Answer- enlargement of a lymph node Malaise - Answer- generalized feeling of discomfort or weakness Malignant - Answer- a tumor that can invade/destroy local tissues and spread to other parts of the body Malleolus - Answer- projections on either side of the ankle joint from the lower leg bones (tibia/fibula) Melena - Answer- Black, tarry-like stool Missed Ancillary - Answer- When a test or procedure is performed on a patient, but it is not documented in the medical chart to allow for generation of a bill. Myalgia - Answer- muscular pain **Myocardial Infarction - Answer- heart attack Nares - Answer- Nostrils Neuralgia - Answer- sharp pain along the course of a nerve or several nerves Occiput - Answer- back part of the skull Odynophagia - Answer- painful swallowing Olecranon - Answer- large bony projection of the ulna forming the elbow joint Orthopnea - Answer- shortness of breath while lying down flat Os - Answer- mouth; orifice Palpable - Answer- able to be touched or felt Palpitations - Answer- a noticeably rapid, strong, or irregular heartbeat Para - Answer- woman who has given birth to one or more viable offspring; the number of viable offspring born by a woman Paresthesia - Answer- abnormal tactile sensation often described as creeping, burning, tingling, or numbness Photophobia - Answer- Extreme sensitivity to light Pleurisy - Answer- inflammation of the pleural lining of lung which causes pain when taking a deep breath Polydipsia - Answer- excessive thirst Polyuria - Answer- excessive urination **Pruritis - Answer- Itchiness Purulent - Answer- consisting of pus Rhinorrhea - Answer- thin, watery discharge from the nose Sciatic - Answer- pertaining to the ischium or hip Shaft - Answer- long, slender portion of bone Sputum - Answer- any mixed matter with saliva that is expectorated through the mouth Stellate - Answer- star-shaped; radiating from a center Stenosis - Answer- narrowing of a body opening or passage **Syncope - Answer- passing out or fainting (near syncope is almost fainting) Tinnitus - Answer- ringing in the ears Torsion - Answer- the twisting of a bodily organ on its own axis (e.g. ovary, testicle) Transient - Answer- passing quickly into and out of existence (temporary condition) Vein - Answer- vessel carrying deoxygenated blood to the heart (excluding pulmonary veins) **Vertigo - Answer- dizziness, often described as the room spinning Waxing and Waning - Answer- constant symptom that increased and decreases in severity (such as pain) Somnolent - Answer- drowsy or sleepy disposition Cachectic/Emaciated - Answer- physically wasting (extremely thin) Morbidly Obese - Answer- Large body mass index (BMI) Nontoxic Appearing - Answer- Well-appearing patient in minimal distress (Often used to describe well-appearing pediatric patients) Normocephalic - Answer- normal appearance and size of the head Atraumatic - Answer- no signs of trauma present **Cyanosis - Answer- Bluish discoloration of the skin due to a lack of oxygen Pallor - Answer- An unhealthy paleness of the skin Erythema - Answer- Superficial reddening of the skin Jaundice - Answer- Yellowing of skin due to abnormal bilirubin build-up Abrasion - Answer- Superficial wound to the top most layer of the skin Contusion - Answer- A region of skin in which blood capillaries are ruptured; AKA bruise Ecchymosis - Answer- An area of ruptured blood vessels similar to a contusion; AKA bruise **Laceration - Answer- A cut in the the skin Puncture - Answer- A small hole in the skin Wheal - Answer- round, localized area of edema on the skin Wheal-and-Flare - Answer- (a reaction) rash or hives (irregular, blanch raised areas with redness) Pericoronitis - Answer- infection of the gums Parotid Mass - Answer- enlargement of the parotid gland Trismus - Answer- inability to open mouth normally due to spasm of the jaw muscles Normal Jaw Approximation - Answer- normal jaw alignment Malocclusion - Answer- misalignment of the teeth when mouth closed Uvula Midline - Answer- no deviation of the uvula to one side or another Pharyngeal Erythema - Answer- redness of the throat Pharyngeal Exudate - Answer- pus seen on the posterior throat Peritonsilar Abscess - Answer- deep abscess adjacent to infected tonsils (collection of pus/swelling which is usually only visible if drained) Carotid Bruit - Answer- abnormal flow of blood through the carotid artery Jugular Vein Distension (JVD) - Answer- swelling of the jugular vein (usually seen in heart failure patients) Cervical Vertebral Tenderness - Answer- pain along cervical spine No Step-offs or crepitus - Answer- no misalignment of the vertebral bodies (spinous processes) as the spine is palpated Anterior Cervical Lymphadenopathy - Answer- swollen lymph nodes under jaw and along anterior neck area Trachea Midline - Answer- no deviation of trachea from its usual location Meningismus - Answer- patient has neck stiffness, photophobia, and headache which may suggest meningitis Nuchal Rigidity - Answer- neck stiffness with neck movement **Bradycardia - Answer- Slow heart rate; less than 60 beats per minute **Tachycardia - Answer- Fast heart rate; greater than 100 beats per minute Murmur - Answer- An abnormal sound heard when listening to the heart. Systolic Murmur - Answer- Heart murmur heard during systole (active pumping) Diastolic Murmur - Answer- Heart murmur heard during diastole (rest/active filling) Distant Heart Sounds - Answer- Faint-sounding heart beat Rubs - Answer- Coarse sounds produced when the heart "rubs" on inflamed pericardium (heart tissue) during contractions Gallops - Answer- extra/abnormal heart sounds (should only hear 2 distinct sounds, but you hear 3 or 4 sounds) Bradypnea - Answer- Abnormally slow breathing Tachypnea - Answer- Abnormally rapid breathing **Apnea - Answer- temporary absence or cessation of breathing Prolonged Inspiratory Expiratory Phase - Answer- increased time between inspiratory and expiratory phases Rales - Answer- wet, crackling sound with respirations (aka crackles) Rhonchi - Answer- a whistling or snoring sound heard on auscultation of the chest when air channels are partially obstructed; plural of rhonchus Wheezes - Answer- difficult breathing with a whistling sound resulting from narrowing of the lumen of the respiratory passageways Stridor - Answer- harsh or high-pitched respiratory sound, caused by an obstruction of the air passages Intercostal Retractions - Answer- use of intercostal muscles with breathing (indicates severe respiratory distress/work of breathing) - sunken intercostal muscles (can see ribs) Accessory Muscle Use - Answer- using extra muscles to breath (you can usually see an emphasis on use of diaphragm and intercostal muscles) Costovertebral Angle Tenderness (CVAT) - Answer- angle in back where kidneys are (HCP taps); left, right and bilateral - if pain then possible kidney pathology Paraspinal Muscle Tenderness - Answer- tenderness in muscles adjacent to spine Midline Tenderness - Answer- tenderness directly over spine No Step-offs - Answer- no misalignment of thoracic/lumbar spine Straight Leg Raise - Answer- if pain, indicative of herniated disk Saddle Anesthesia - Answer- loss of sensation around buttocks area Distension - Answer- bloating **Gravid - Answer- pregnant Ascites - Answer- accumulation of fluid in the peritoneal cavity Tympanitic - Answer- sound generated by examiner tapping his/her finger in contact with the a belly distended due to extra gas/air in the large or small bowel Organomegaly - Answer- enlarged organ Hepatomegaly - Answer- enlarged liver Splenomegaly - Answer- enlarged spleen Murphy's Sign - Answer- pain in right upper quadrant that may indicate gallbladder infection Rovsing's Sign - Answer- palpation of the left lower quadrant causes right lower quadrant pain that may indicate appendicitis Psoas Sign - Answer- pain produced with bending of the patient's knees to chest that may indicate appendicitis Heel Tap Test - Answer- tap the heal to see if it causes pain, also done by having the patient jump up to see if pain is felt in the abdomen - may indicate appendicitis McBurney's Point Tenderness - Answer- tenderness to palpation in the mid-point of the right lower quadrant (RLQ) which can indicate appendicitis Umbilical hernia - Answer- outward protrusion of intra-abdominal tissue and/or bowel through belly button Grey Turner's Sign - Answer- bruising in flank area (lower back area) Cullen's Sign - Answer- bruising in the skin around the umbilicus Inguinal Hernia - Answer- protrusion in the groin Cremasteric Reflex - Answer- upward pull of testicles and scrotum due to touch Atherosclerosis - Answer- a condition in which "plaque" builds up on the walls of the blood vessels; worsened by a diet high in cholesterol Coronary Artery Disease (CAD) - Answer- a condition caused by atherosclerosis that reduces blood flow through the coronary arteries (and thus oxygen delivery) to the heart muscle Acute Coronary Syndrome (ACS) - Answer- a term used to describe sudden reduced blood flow to one or more coronary arteries that can result in cardiac muscle death if left untreated. Angina - Answer- chest pain caused by an inadequate blood supply to the heart muscle. Unstable Angina - Answer- a condition in which blood flow and oxygen in one or more of the coronary arteries is partially blocked causing chest pain. Myocardial Infarction (MI) - Answer- a condition in which blood flow and oxygen in one or more of the coronary arteries is suddenly completely blocked. This results in heart muscle death. (AKA - "heart attack") ST Elevation Myocardial Infarction (STEMI) - Answer- a sudden blockage of a coronary artery with EKG findings significant for ST segment elevation Non-ST Elevation Myocardial Infarction (NSTEMI) - Answer- a sudden blockage of a coronary artery without EKG findings significant for ST segment elevation Cardiac Dysrhythmia - Answer- an abnormality in the physiological rate or rhythm of the heart Supraventricular Tachycardia (SVT) - Answer- an abnormal heart rhythm arising from aberrant electrical activity in the heart; originates at or above the AV node. Atrial Fibrillation (A Fib) - Answer- an irregular and often very fast heart rate originating from abnormal conduction in the atria. Ventricular Tachycardia - Answer- an abnormal heart rhythm that arises from improper electrical conduction in the ventricles. Congestive Heart Failure (CHF) - Answer- a condition in which the heart cannot pump blood well enough to meet the body's needs resulting in build-up of fluid in the extremities and/or lungs Hypertension (HTN) - Answer- high blood pressure Hyperlipidemia - Answer- high lipid levels Hypercholesterolemia - Answer- high cholesterol levels Upper Respiratory Infection (URI) - Answer- an infection of the upper respiratory tract caused by bacteria or viruses. Also known as the common cold. Influenza - Answer- an infection of the upper respiratory tract caused by influenza viruses. Also known as the flu. Bronchitis - Answer- an inflammation of the lining of the bronchial tubes Pneumonia - Answer- an inflammation/infection of one or both lungs. Pleural Effusion - Answer- excess fluid that accumulates in the pleural cavity and can impair breathing by limiting the expansion of the lungs. Empyema - Answer- the presence of pus in a body cavity Pneumothorax (PTX) - Answer- An abnormal collection of air in the pleural space which can cause all or part of the lung to collapse. Hemothorax (HTX) - Answer- An abnormal accumulation of blood in the pleural cavity. Asthma - Answer- chronic inflammatory lung disease in which airways become inflamed, resulting in excess mucous production and airway narrowing. Chronic Obstructive Pulmonary Disease (COPD) - Answer- chronic inflammatory lung disease that causes obstructed airflow in the lungs and is not fully reversible. This is often associated with years of smoking. Pulmonary Embolism (PE) - Answer- a blood clot in one or more of the pulmonary arteries Deep Venous Thrombosis (DVT) - Answer- a blood clot in the deep venous system of the arms or legs which can break off and cause a PE. (Not a respiratory system disease, but related to PE's so included here.) Appendicitis - Answer- inflammation of appendix, generally caused by an infection Gastritis - Answer- inflammation of lining of stomach Gastroesophageal Reflux Disease (GERD) - Answer- acid reflux (aka heartburn) Gastroenteritis - Answer- inflammation/infection of the stomach and intestines which causes nausea, vomiting, and diarrhea. Biliary Colic - Answer- pain in the gallbladder caused by gallstones obstructing bile flow Cholecystitis - Answer- Inflammation/infection of the gallbladder Cholelithiasis - Answer- the presence of stones in the gallbladder Choledocholithiasis - Answer- gallstones that become stuck in the bile ducts Pancreatitis - Answer- inflammation of pancreas Hepatitis - Answer- inflammation of liver Cirrhosis - Answer- liver disease; a chronic degenerative disease in which normal liver cells are damaged and replaced by scar tissue Ascites - Answer- fluid in the peritoneal cavity, most often caused by liver cirrhosis or tumors Small Bowel Obstruction (SBO) - Answer- blockage in the intestinal tract Diverticulosis - Answer- Finger-like projections in the large intestine called diverticuli Diverticulitis - Answer- inflammation/infection of diverticuli requiring antibiotic treatment Gastrointestinal Bleed (GI Bleed) - Answer- bleeding in the upper or lower GI tract Hemorrhoids - Answer- swollen veins in lower rectum Cerebrovascular Accident (CVA) - Answer- a stroke - two types exist (ischemic and hemorrhagic) Ischemic CVA - Answer- a stroke caused by sudden blockage of a blood vessel in the brain Hemorrhagic CVA - Answer- a stroke caused by sudden bleeding in the brain Subarachnoid Hemorrhage (SAH) - Answer- bleeding within the subarachnoid space, an area between brain and thin tissues that cover the brain; usually caused by a ruptured brain aneurysm or AVM (arteriovenous malformation) Transient Ischemic Attack (TIA) - Answer- stroke-like symptoms that completely resolve in less than 24 hours Bell's Palsy - Answer- paralysis of the facial nerve (cranial nerve 7), causing muscular weakness to one side of the face; can be confused with a stroke BID - Answer- 2 times a day Bilat - Answer- bilateral BKA - Answer- below the knee amputation BLE - Answer- bilateral lower extremities BLS - Answer- basic life support BM - Answer- bowel movement BOM - Answer- bilateral otitis media (infection in both ears) BP - Answer- blood pressure BPH - Answer- benign prostatic hypertrophy BPM - Answer- beats per minute (heart rate) BPV - Answer- benign positional vertigo BS - Answer- bowel sounds and/or breath sounds BSA - Answer- body surface area BUE - Answer- bilateral upper extremities BUN - Answer- blood urea nitrogen BVM - Answer- Bag-valve mask c - Answer- with CA - Answer- cancer C1 - C7 - Answer- 1st through 7th cervical vertebrae CABG - Answer- coronary artery bypass graft **CAD - Answer- coronary artery disease **CBC - Answer- complete blood count c/c - Answer- chief complaint CCU - Answer- coronary care unit CHF - Answer- congestive heart failure CK - Answer- creatine kinase CMT - Answer- cervical motion tenderness CN - Answer- cranial nerve CN II-XII - Answer- cranial nerves 2-12 CNS - Answer- central nervous system **COPD - Answer- chronic obstructive pulmonary disease CP - Answer- chest pain or cerebral palsy CPAP - Answer- continuous positive airway pressure CPR - Answer- cardiopulmonary resuscitation C/S - Answer- cesarean section **CSF - Answer- cerebrospinal fluid CT - Answer- computed tomography CVA - Answer- cerebrovascular accident (stroke) or costovertebral angle CVAT - Answer- costovertebral angle tenderness **CXR - Answer- chest x-ray DBP - Answer- diastolic blood pressure D/C - Answer- discontinue D&C - Answer- dilation and curettage DC - Answer- discharge DDX - Answer- differential diagnosis **DKA - Answer- diabetic ketoacidosis DM - Answer- diabetes mellitus DNI - Answer- do not intubate **DNR - Answer- do not resuscitate DO - Answer- doctor of osteopathic medicine DOA - Answer- dead on arrival DOB - Answer- date of birth DT's - Answer- delirium tremens DTR - Answer- deep tendon reflex **DVT - Answer- deep venous (vein) thrombosis DDx - Answer- differential diagnosis Dx - Answer- diagnosis ED - Answer- emergency department EENT - Answer- eyes, ears, nose, throat EKG/ECG - Answer- electrocardiograph EMT - Answer- emergency medical technician ETOH - Answer- alcohol ETT - Answer- endotracheal tube FB - Answer- foreign body FHT - Answer- fetal heart tones FROM - Answer- full range of motion F/U - Answer- follow up Fx - Answer- fracture GCS - Answer- Glasgow Coma Scale MVA/MVC - Answer- motor vehicle accident/collision NAD - Answer- no acute disease OR no acute distress NCAT - Answer- normocephalic, atraumatic NG - Answer- nasogastric NICU - Answer- neonatal intensive care unit NKA - Answer- no known allergies NKDA - Answer- no known drug allergies nl - Answer- normal NP - Answer- nurse practitioner **NPO - Answer- nothing per os (mouth) NS - Answer- normal saline (type of IV fluid) NSAID - Answer- nonsteroidal anti-inflammatory drug NSR - Answer- normal sinus rhythm NSTEMI - Answer- non-ST elevation myocardial infarction NSVD - Answer- normal spontaneous vaginal delivery NT - Answer- naso-tracheal N/V/D - Answer- nausea, vomiting, diarrhea OB/GYN - Answer- obstetric/gynecologic (women's doctor) OR - Answer- operating room p - Answer- post (after) PA - Answer- physician's assistant PCN - Answer- penicillin PCP - Answer- primary care physician **PE - Answer- pulmonary embolism PEA - Answer- pulseless electrical activity PERRL - Answer- pupils equal, round and reactive to light PMD - Answer- primary medical doctor PO - Answer- per mouth PNA - Answer- pneumonia PVC - Answer- premature ventricular contraction PRN - Answer- as needed PTA - Answer- prior to arrival PTX - Answer- pneumothorax QD - Answer- everyday QID - Answer- 4 times a day QH - Answer- every hour Q2H - Answer- every 2 hours R - Answer- right RBBB - Answer- right bundle branch block RBC - Answer- red blood count RLE - Answer- right lower extremity RLL - Answer- right lower lobe **RLQ - Answer- right lower quadrant RML - Answer- right middle lobe RN - Answer- registered nurse ROM - Answer- range of motion ROS - Answer- review of systems RR - Answer- respiratory rate RRR - Answer- regular rate and rhythm RSV - Answer- respiratory syncytial virus RUE - Answer- right upper extremity RUQ - Answer- right upper quadrant **Rx - Answer- prescription R/O - Answer- rule out **SBO - Answer- small bowel obstruction SBP - Answer- systolic blood pressure SNF - Answer- skilled nursing facility SOAP - Answer- subjective, objective, assessment, plan **SOB - Answer- shortness of breath s/p - Answer- status post STD/STI - Answer- sexually transmitted disease/infection STEMI - Answer- ST-elevation myocardial infarction SVT - Answer- supraventricular tachycardia Sx - Answer- symptoms T - Answer- temperature TB - Answer- tuberculosis TIA - Answer- transient ischemic attack TID - Answer- 3 times a day **TM - Answer- tympanic membrane