General Medical Terminology

Acute - Sudden onset or short duration

Chronic - Long-lasting or recurring

Benign - Not harmful or cancerous

Malignant - Harmful; potentially cancerous

Idiopathic - Unknown cause

Etiology - Cause of disease

Pathology - Study of disease

Prognosis - Expected outcome

Differential diagnosis (DDx) - List of possible conditions explaining a patient's symptoms

 

Anatomical Directions (Important for Physical Exams)

Anterior - Front side of the body

Posterior - Back side of the body

Lateral - Side

Medial - Toward midline of the body

Proximal - Closer to trunk

Distal - Further from trunk, closer to extremities like hands or feet

Superior - Above

Inferior - Below

 

Vitals

BP - Blood pressure

HR - Heart rate

RR - Respiratory rate

Temp - Temperature

O2 sat/Pulse ox - Oxygen saturation

 

Common Abbreviations

c/o - Complains of

Hx - History

FHx - Family history

PMHx - Past medical history

SHx - Social history

ROS - Review of systems

PE - Physical exam

NAD - No acute distress

WNL - Within normal limits

R/O - Rule out

SOB - Shortness of breath

N/V - Nausea/vomiting

CP - Chest pain

AMS - Altered mental status

 

Labs/Imaging

CBC - Complete blood count; measures red blood cells, white blood cells, hemoglobin, hematocrit, and platelets. Used to detect infections, anemia, clotting problems, and more.

BMP - Basic metabolic panel; assesses electrolytes (Na⁺, K⁺, Cl⁻), kidney function (BUN, creatinine), and glucose levels. Used for hydration, kidney function, and diabetes screening.

CMP - Comprehensive metabolic panel; includes BMP plus liver enzymes (AST, ALT, ALP), bilirubin, and proteins (albumin, total protein). Gives a broader view of metabolic and liver function.

D-dimer – Measures clot breakdown products. Elevated levels may indicate a PE (pulmonary embolism) or DVT (deep vein thrombosis), but not specific.

PT/INR - Prothrombin Time / International Normalized Ratio; measures how long blood takes to clot. Used to monitor patients on blood thinners like warfarin.

PTT - Partial Thromboplastin Time; another test for blood clotting, especially for heparin therapy monitoring.

Troponin – Cardiac enzyme released when heart muscle is damaged. High levels suggest a heart attack (MI).

UA - Urinalysis; evaluates urine for signs of infection (UTI), blood, glucose, protein, or kidney disease.

CXR - Chest X-ray; visualizes lungs, heart, ribs. Commonly used to detect pneumonia, heart failure, pneumothorax, fractures.

CT - Computed tomography; cross-sectional images using X-rays. Used to evaluate head trauma, stroke, abdominal pain, chest pain, fractures, etc. Often enhanced with contrast.

MRI - Magnetic resonance imaging; uses magnetic fields to produce detailed images. Best for soft tissue: brain, spinal cord, joints, ligaments, and tumors.

EKG/ECG - Electrocardiogram; measures electrical activity of the heart. Used to diagnose arrhythmias, heart attacks, electrolyte issues.

XR - X-ray (General); used for imaging bones, chest, abdomen, joints. Lower resolution than CT, but quick and inexpensive.

Echo - Echocardiogram; ultrasound of the heart. Assesses heart function, valve problems, ejection fraction.

Lipid Panel – Measures cholesterol (LDL, HDL, total) and triglycerides. Used for heart disease risk assessment.

 

Common Diagnoses

HTN - Hypertension (high BP)

DM - Diabetes mellitus

CAD - Coronary artery disease

MI - Myocardial infarction (heart attack)

CVA - Stroke

TIA - Transient ischemic attack

CHF - Congestive heart failure

COPD - Chronic obstructive pulmonary disease

PNA - Pneumonia

UTI - Urinary tract infection

DKA - Diabetic ketoacidosis

 

Common Medications (IMPORTANT)

Antihypertensives - Lisinopril, Amlodipine, Hydrochlorothiazide

Antibiotics - Amoxicillin, Azithromycin, Flagyl, Keflex, Cefalexin, Doxycycline, Erythromycin

Anticoagulants - Warfarin, Eliquis, Plavix, Heparin, Xarelto, Apixaban

Analgesics - Tylenol, Ibuprofen, Morphine, Naproxen, Oxycodone

Diuretics - Furosemide (Lasix) 

 

Procedures

Intubation - Insertion of a breathing tube; to help a patient breathe when they cannot do so on their own (e.g. respiratory failure, surgery, overdose).

Lumbar puncture - Spinal tap; to diagnose conditions like meningitis, subarachnoid hemorrhage, or multiple sclerosis.

Laparoscopy - Minimally invasive abdominal surgery; used for diagnosing or treating conditions like appendicitis, gallbladder issues, or ectopic pregnancy.

Thoracentesis - Removing fluid from the chest; to relieve shortness of breath or diagnose the cause of a pleural effusion (fluid buildup).

Central line - Large IV into central vein; for giving long-term medications, fluids, or when peripheral IV access is difficult. Also used for measuring central venous pressure.

 

Physical exam findings (normal findings)

Constitutional: These are general descriptions of the patient's overall appearance, disposition, affect...

Patient is alert and oriented x3 - This means the person is awake, responding to commands/questions and is oriented to person, place, and time. A person is AxO x3 if they know who they are, where they are, and what the date is.

In no acute distress - This is exactly what it sounds like. Patients are usually in no acute distress, and if they are, you'll know.

Qualitative terms - Unkempt, dishelved, foul-smelling, pleasant, healthy, well-nourished, etc. these are other constitutional terms providers might throw in to describe the patient

Eyes

Conjunctivae are normal/No scleral icterus - Eyes/sclera (white part of eyes) appear clear and moist without redness, swelling, or any signs of irritation. 

EOMI - Extraocular movements intact; eyes are moving normally 

PERRL - Pupils are equal, round, and reactive to light

(No) Nystagmus - If positive, this is a big sign of vertigo. It is a rapid movement of the eyes from side to side or up or down, therefore can be horizontal or vertical on exam

HENT: Head, Ear, Nose, and Throat findings

Head:

Normocephalic and atraumatic - Means the head has no obvious deformities or traumas that might indicate injury to the head

Ear (otoscope exam):

TM non-bulging and non-ruptured - Refers to the tympanic membrane, or ear drum.

No drainage, fluid, or blood 

Acute otitis media - Diagnosed by red, bulging TM; this is a middle ear infection

Nose:

No rhinnorhea - No obvious runny nose

No congestion - Self explanatory :)

No epistaxis - No nose bleeds

Mouth/Throat: 

Mucous membranes moist - Indicates adequate hydration

No tonsillar swelling or exudates - Tonsils are not swollen and are not producing any sort of purulent (pus-like) discharge

Neck

Supple/No Meningismus - Absence of acute meningeal irritation, significant cervical spine pathology, or muscular spasm

Full range of motion - Able to move neck in all directions and all anatomical planes without difficulty

No lymphadenopathy - Lymph nodes do not appear swollen

No thyromegaly - No thyroid enlargement

No masses - No abnormal enlargement, lump, or swelling in the neck, including lymph nodes, thyroid, salivary glands, or other soft tissues that might indicate malignancy

No JVD - No jugular vein distention, which would likely be a sign of heart failure as blood is backing up into the jugular vein. Can also be caused by constrictive pericarditis, cardiac tamponade, restrictive cardiomyopathy, and severe tricuspid valve disease

Cardiovascular 

Regular rate and rhythm, no murmurs, rubs, or gallops - Heart sounds are normal and there are no obvious arrhythmias or extra beats

Pulses intact and symmetric - Could be radial, carotid, PT (posterior tibial), or DP (dorsalis pedis) pulses

No lower extremity edema - No swelling in the lower legs which could be related to heart failure, chronic venous insufficiency, renal disease, hepatic dysfunction, lymphedema, or medication side effects; if unilateral (on one side), could indicate blood clot; some providers like this in cardiovascular, others like it in musculoskeletal

Respiratory

Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi -Normal lung sounds 

Normal respiratory effort/No accessory muscle use - Patient is not using accessory abdominal muscles to breathe; their work of breathing is normal 

Abdomen

Soft - No areas of guarding or induration

Non-tender - There is no pain with palpation (pressing on) the abdomen

Non-distended - No obvious fluid or air accumulation

Normal bowel sounds - Peristalsis sounds (gurgling or rumbling noises) indicate ongoing gastrointestinal motility which is a reassuring sign if concerned for bowel obstruction; not a diagnostic or absolute finding

No masses, organomegaly, or hernias - organomegaly is enlargement of certain organs; hernias are when an organ or tissue pushes through a weak spot in the surrounding muscle or connective tissue, can appear like a small lump, often palpable and many different types, such as inguinal, hiatal, umbilical, femoral

Signs - Murphy's sign (pain with inspiration during right upper quadrant palpation, seen in cholecystitis), McBurney point tenderness (appendicitis), Rovsing, psoas, and obturator signs (appendicitis), Carnett sign (abdominal wall pain)

Musculoskeletal

Full range of motion - Restricted passive (person moves your joint for you) or active (patient moves the joint him or herself) movement may indicate joint pathology (e.g., osteoarthritis, contracture, or effusion) or pain from soft tissue injury

No deformities, swelling, or tenderness - Deformities may indicate fractures; bony swelling is specific for osteoarthritis; synovial effusion may indicate inflammation or infection

Neurologic 

Alert - The patient is awake and responsive to questions

Oriented (x4) - Patient is oriented to person, place, time, and situation, emaning they know who they are, where they are, what the time and date is, and why or how they are in the clinic 

Cranial nerves II-XII intact - Sensory and motor function of the head and neck are intact; deficits can localize lesions to the brainstem, cranial nerve nuclei, or peripheral nerves, and may be seen in stroke, tumors, or demyelinating disease

Normal strength and sensation - Weakness or atrophy may indicate upper or lower motor neuron lesions, radiculopathy, neuropathy, or myopathy; loss of sensation may indicate peripheral neuropathy, radiculopathy, or central lesions

Normal reflexes and coordination - Deep tendon reflexes (e.g., biceps, patellar, ankle) test the integrity of the sensory and motor pathways at specific spinal levels. Hyperreflexia and clonus suggest upper motor neuron lesions; hyporeflexia or areflexia suggest lower motor neuron or peripheral nerve dysfunction.[3][5] Pathologic reflexes (Babinski, Hoffmann) indicate corticospinal tract involvement; tests (finger-to-nose, heel-to-shin, tandem gait) assess cerebellar function and proprioception; abnormal gait may indicate central or peripheral nervous system disease

No ataxia or dysmetria - Muscle control intact; movements are smooth and accurate

Kernig and Brudzinski signs - indicate meningeal irritation (e.g., meningitis)

Psychiatric

Appropriate mood and affect - Mood refers to the patient's sustained internal emotional state, while affect is the observable expression of emotion. When both are appropriate, meaning they are congruent with the situation and with each other, it suggests the patient is not experiencing significant mood disturbances such as depression, mania, or anxiety disorders

Normal thought process - Patient's thinking is logical, coherent, and goal-directed, without evidence of disorganization, tangentiality, or flight of ideas

No SI/HI - No suicial or homicidal ideation

No AVH - No auditory or visual hallucinations

Pro Scribe Tip #1: Know Your Terms 

You will be expected to know medical terminology, not just recognize it, but actually spell it, say it out loud, and type it fast. My scribe training involved memorizing a general list of terms, especially ones heard often in the ED. But if you're working in a specialty (like ortho, derm, or GI), tailor your study list to fit that field.

Some of the hardest terms you'll encounter are physical exam findings, things like nystagmus, crepitus, or pronator drift, and providers often rattle them off at lightning speed outside the patient’s room, while you're still catching up. It can feel awkward to ask, “Can you spell that?” but trust me, it’s way better than getting it wrong in the note.

That said, don’t beat yourself up. You’re not in med school (yet), and no one expects you to be a walking dictionary. Just keep practicing. Say terms out loud, quiz yourself on spelling, and know that every scribe starts out feeling overwhelmed, and then gradually levels up.

 

Pro Scribe Tip #2: Doctors Are People Too (Just Really Tired Ones)

Working with physicians can be intimidating, especially if you’re a recent or current undergrad. Chances are, you’ll be younger than most of the staff, and definitely younger than the doctors, after all, they’ve gone through years of intense training and have the eye bags and experience to prove it.

So here’s the truth: some will be warm and chatty, some will be laser-focused and barely look up. And many are just plain exhausted. But don’t let that stop you from introducing yourself at the start of your shift. You don’t need to launch into small talk or try to become besties. A quick, professional hello goes a long way.

Doctors are often so focused on patients that they forget you're there to make their life easier. So gently remind them. Make your presence known early, and if the moment’s right, ask if they have any preferences for how you write their notes or whether they want you to follow them into every room.

And when they do start making conversation, which they often will once they have a breather, don’t be afraid to share a little about yourself. You’ll be surprised how many will take an interest in your goals, especially if you’re pre-med or considering a healthcare career.

Bottom line: don’t be invisible. Be professional, be available, and let them know you’ve got their back.

 

Pro Scribe Tip #3: Master the EMR. It’s Ugly, But It’s Home

Let’s be honest: EMRs are not designed with beauty, simplicity, or sanity in mind. They’re not cute. They’re not clean. They’re not intuitive. Most screens look like they were designed by a committee that hates both color coordination and new users.

But you’ve got to get familiar... fast. Spend time outside of the chaos clicking around, exploring different views, filters, and tabs. Learn how to pull up lab results, imaging, vitals, and past workups without fumbling. Because during a shift, your provider might turn to you in the middle of a patient encounter and say, “Can you pull up their old head CT?” or “What were their last three glucose readings?” and you don’t want to be stuck squinting at a sea of tabs like it’s a puzzle you’ve never seen before.

Your goal is to become your provider’s second hand, not someone they need to babysit or guide through the chart. The better you know the EMR, the more helpful, and impressive, you’ll be.

Bonus: once you really learn the system, you’ll be faster, more confident, and way less stressed. Ugly interface or not, it’s your new habitat, so make yourself at home.

 

https://www.typingtest.com is a great website that offers free typing tests and exercises to practice your typing skills! This is what my program used to test us on our typing speed during interviews, so I know that it works!