Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
28 Cards in this Set
- Front
- Back
H&P
|
History and Physical
Documentation of patient history and physical examination |
|
Subjective Information
|
Information obtained from the patient including his or her personal perceptions
|
|
Hx
|
History
Record of subjective information regarding the patient's personal medical history including past injuries, illnesses, operations, defects, and habits. |
|
CC
|
Cheif complaint
|
|
c/o
|
Complains of
Patient's description of what brought him or her to the doctor or hospital; it is usually brief and is often documented in the patient's own words indicated within quotes (i.e. CC: left lower back pain; patient states, "I feel like I swallowed a stick and it got stuck in my back") |
|
PI
|
Present illness
|
|
HPI
|
History of present illness
Amplification of the cheif complaint recording details of the duration and severity of the condition (i.e. PI: the patient has had lower back pain for the past 2 weeks since slipping on a rug and landing on her left side; the pain worsens after sitting upright for any extended period but gradually subsides after lying in a supine position |
|
Sx
|
Symptom
Subjective evidence (from the patient) that indicates an abnormality |
|
PH
|
Past history
|
|
PMH
|
Past medical history
A record of information about the patient's past illnesses starting with childhood, including surgical operations, injuries, physical defects, medications, and allergies |
|
UCHD
|
Usual childhood diseases
An abbreviation used to note that the patient had the "usual" or commonly contracted illnesses during childhood (i.e. measles, mumps, chickenpox) |
|
NKA
|
No known allergies
|
|
NKDA
|
No known drug allergies
|
|
FH
|
Family history
State of health of immediate family members |
|
A&W
L&W |
Alive and well
Living and well (i.e. father, age 92, L & W; mother, age 91, died, stroke) |
|
SH
|
Social history
A record of the patient's recreational interests, hobbies, and use of tobacco and drugs, including alcohol (i.e. SH: plays tennis twice/wk; tobacco-none; alcohol-drinks 1-2 beers per day) |
|
OH
|
Occupational History
Record of work habits that may involve work-related risks (i.e. OH: the patient has been employed as a coal mine engineer for the past 16 years) |
|
ROS
|
Review of systems
|
|
SR
|
Systems review
A documentation of the patient's response to questions organized by a head-to-toe review of the function of all body systems (note: this review allows evaluation of other symptoms that may not have been mentioned) |
|
PE
|
Physical Examination
|
|
Px
|
Documentation of a physical examination of a patient, including notations of positive and negative object findings
|
|
HEENT
|
Head, Eyes, Ears, Nose, Throat
|
|
PERRLA
|
Pupils equal, round, reactive to light and accomodation
|
|
WNL
|
Within normal limits
|
|
Dx
|
Diagnosis
|
|
IMP
|
Impression
|
|
A
|
Assessment
Identification of a disease or condition after evaluation of the patient's history, symptoms, signs, and results of laboratory tests and diagnostic procedures |
|
R/O
|
Rule out
[used to indicate differential diagnosis when two or more possible diagnosis are suspect (note: each possible diagnosis is outlined and then either verified or eliminated after further testing is performed, (i.e. diagnosis: R/O pancreatitis, R/O gastroenterisits) this documentation indicates that either of these two diagnosises is suspected and that further testing is required to eliminate one)] |