What's in a Name
Affecting both sides
Bilateral
Primary symptom patient states as the reason for seeking medical care
Chief Complaint
CC
Chief Complaint
ROS
Review of Systems
Swollen lymph nodes
Lymphadenopathy
Swelling caused by excess fluid trapped in your body's tissues
Edema
HPI
History of Present Illness
PRN
PO
By Mouth
Sound heard over an artery or vascular channel reflecting turbulence of flow
Bruit
Head and all major organs of the head are in a normal condition and without significant abnormalities
Normocephalic
Information that you receive from the patient
Subjective Data
PMH
Past Medical History
BID
Twice a Day
Abnormal redness of the skin or mucous membranes
Erythema
Median line or plane of bilateral symmetry, especially that of the body
Midline
Physical data we can observe using our senses
Objective Data
PSH
Past Surgical History
N/V/D
Nausea, Vomiting, Diarrhea
PERRLA
Pupils Equal, Round, & Reactive to Light and Accommodation
Inflammation that involves glandular tissue or lymph nodes
Adenopathy
Act of touching or feeling
Palpation
NKDA
No Known Drug Allergies
HEENT
Head, Eyes, Ears, Nose, & Throat
Action of listening to sounds from the heart, lungs, or other organs
Auscultation