ALOC ✔✔Altered Level of Consciousness
BM ✔✔bowel movement
DOE ✔✔Dyspnea on exertion
EOMI ✔✔Extraocular Movement Intact (Appropriate
... [Show More] function of the extra ocular muscles,
tested with "follow my finger")
HA ✔✔headache
MI ✔✔Myocardial infarction
NAD ✔✔no acute distress
NSR ✔✔Normal Sinus Rhythm
PNA ✔✔pneumonia
UTI ✔✔Urinary Tract Infection
ASA ✔✔Aspirin
CA ✔✔Cancer
PCN ✔✔Penicillin
DM ✔✔Diabetes Mellitus
PTX ✔✔Pneumothorax
SOB ✔✔Shortness of breath
FB ✔✔Foreign Body
CVA ✔✔Cerebral Vascular Accident (Stroke) - Can be ischemic or hemorrhagic)
TIA ✔✔transient ischemic attack (mini stroke)
TX ✔✔treatment
earwax ✔✔cerumen
runny nose ✔✔rhinorrhea
Vomiting blood ✔✔hematemesis
fainting ✔✔syncope
Sweating ✔✔diaphoresis
bruising ✔✔ecchymosis
itchiness ✔✔pruritus
cardiac bypass ✔✔CABG (coronary artery bypass graft)
Hernia repair ✔✔herniorrhaphy
Removal of gallbladder ✔✔cholecystectomy
Removal of uterus ✔✔hysterectomy
Rales ✔✔wet, crackling sound with respirations (aka crackles)
Four main components of the medical chart you are responsible for? ✔✔1. HPI
2. ROS
3. PMhxFhxShx
4. PE
Name the 8 elements of the HPI ✔✔1. Location
2. Quality
3. Severity
4. Context
5. Timing
6. Duration
7. associated signs and symptoms
8. modifying factors
True or False: The HPI and ROS are subjective ✔✔True: these are from the patient's perspective
True or False: Patient's past surgeries should be documented in the Physical Exam (PE)?
✔✔False: Should be in past medical history
True or False: Whether a patient smokes or not should be documented in the PMFSH? ✔✔True:
This is social history
True or False: The physical exam is objective ✔✔True: From the doctor's point of view
Fever ✔✔febrile
vomiting ✔✔emesis
pain with urination ✔✔dysuria
RRR ✔✔Regular Rate and Rhythm (cardio finding)
CVAT ✔✔Costal Vertebral Angle Tenderness (Back finding sometimes GU)
BS present ✔✔bowel sounds present
SNF ✔✔Skilled Nursing Facility
BIBA ✔✔brought in by ambulance
CP ✔✔chest pain, cerebral palsy
ATX ✔✔atelectasis
Pregnancy ✔✔Gravid
oophorectomy ✔✔surgical removal of one of both ovaries
Tubal pregnancy ✔✔Ectopic
Tying of tubes ✔✔tubal ligation
clipping of vas deferens ✔✔vasectomy
tonsil removal ✔✔tonsillectomy
CAD ✔✔Coronary Artery Disease
DVT ✔✔Deep Vein Thrombosis
PE ✔✔Pulmonary Embolism
PUD ✔✔Peptic Ulcer Disease
PTA ✔✔Prior to Arrival
NTG ✔✔Nitroglycerin
FS ✔✔Fingerstick (blood sugar)
AMS ✔✔Altered Mental Status
a-fib ✔✔atrial fibrillation
abnormal heart rhythm ✔✔Arrhythmia
blood in urine ✔✔hematuria
VB ✔✔vaginal bleeding
COPD ✔✔Chronic Obstructive Pulmonary Disease (chronic bronchitis, emphysema)
JVD ✔✔Jugular vein distention
breathing tube placement ✔✔endotracheal intubation
FX ✔✔fracture
Bi-PAP ✔✔Bilevel Positive Airway Pressure
NEB ✔✔nebulizer
peripheral numbness, abnormal tactile sensation described as creeping, burning, tingling or
numbness ✔✔paresthesia
HTN ✔✔Hypertension
High cholesterol ✔✔hyperlipidemia
DKA ✔✔Diabetic Ketoacidosis
MTF ✔✔Metabolize to Freedom
ETOH ✔✔alcohol
BKA ✔✔Below knee amputation
AKA ✔✔above knee amputation
TKA ✔✔Total knee arthroplasty
LOC ✔✔loss of consciousness
HGB ✔✔hemoglobin
induration ✔✔a hardened area of normally soft tissue
fluctuance ✔✔Movable and compressible
cachectic ✔✔Physically wasting, extremely thin
rash from a virus ✔✔viral exanthem
Tachypneic ✔✔increased rate of respiration
Bradypneic ✔✔Slow breathing rate (less than 16 per minute)
retractions ✔✔Movements in which the skin pulls in around the ribs during inspiration.
erythema/erythematous ✔✔redness of the skin
cellulitis ✔✔an inflammation of body tissue (especially that below the skin) characterized by
fever and swelling and redness and pain
afebrile ✔✔no fever
ablation ✔✔partial destruction of the pathway of the electrical conduction system of the heart to
treat irregular heart rhythms
PND ✔✔Paroxysmal Nocturnal Dyspnea (intermittent nighttime difficulty breathing)
Paroxysmal ✔✔Intermittent, Beginning suddenly or abruptly. (A-Fib can be)
fibroids ✔✔benign tumors in the uterus
excessive urination ✔✔polyuria
excessive thirst ✔✔polydipsia
irregularly irregular ✔✔no predictable pattern to cardiac cycle, A-Fib typically
anticoagulants ✔✔medication to stop blood clotting
PSVT ✔✔Paroxysmal supraventricular tachycardia
PVD ✔✔peripheral vascular disease
GERD ✔✔gastroesophageal reflux disease (acid reflux/heartburn)
ESRD ✔✔end-stage renal disease
CRI ✔✔Chronic Renal Insufficiency
PID ✔✔pelvic inflammatory disease
N/V/D ✔✔Nausea, Vomiting, Diarrhea
BTL ✔✔Bilateral tubal ligation
FTT ✔✔failure to thrive
PERRL ✔✔Pupils Equal, Round, Reactive to Light (Normal evaluation of the size, shape of the
pupils and their reaction to light)
EOM ✔✔Extraocular Movement
NC ✔✔Nasal Cannula
RA ✔✔Room Air
NRB ✔✔Non-Rebreather
AAA ✔✔Aortic Abdominal Aneurysm
numbness ✔✔paresthesia
DJD ✔✔degenerative joint disease
STD ✔✔sexually transmitted diease
SBO ✔✔small bowel obstruction
Adenopathy ✔✔Enlargement of lymph nodes
Accessory muscle use ✔✔Struggling for breath using muscles in the neck; using extra muscles
to breathe (You can usually see an emphasis on use of diaphragm and intercostal muscles)
Adduction ✔✔movement toward the midline of the body
AED ✔✔Automated External Defibrillator
Afebrile ✔✔without fever
Ambulatory ✔✔able to walk about
Aneurysm ✔✔Any abnormal widening of a blood vessel
Angina ✔✔Chest pain due to lack of blood flow to heart muscle
Unstable angina ✔✔a condition in which blood flow and oxygen in one or more of the coronary
arteries is partially blocked causing chest pain
Anion gap ✔✔Difference between the concentrations of serum cations and anions: determined
by measuring the concentrations of sodium cations and chloride and bicarbonate anions.
Anisocoria ✔✔Unequal Pupil Size
Arthralgia ✔✔pain in a joint or joints
Articulation ✔✔Connection between bones
Atelectasis (ATX) ✔✔Partial collapse of the small airways in the lungs
Avulsion ✔✔A forcible tearing away of a part or structure
Brudzinski's sign ✔✔Sign of meningitis; positive when a patient's legs lift involuntarily when
lifting a patient's head
Bruit ✔✔A murmur or sound heard in auscultation indicating narrowing of a vessel
C/O ✔✔complains of
Carotid bruit ✔✔Abnormal flow of blood through the carotid artery/Noise from carotid artery
narrowing heard with stethoscope
Cholecystitis ✔✔inflammation of the gall bladder
Cholelithiasis ✔✔Gallstone formation in the gallbladder
Cirrhosis ✔✔chronic degenerative disease of the liver
CMT ✔✔cervical motion tenderness;pain with movement of cervix [Show Less]