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17 Cards in this Set
- Front
- Back
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Constitutional/General Appearance
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ROS: generalized symptoms (fever, weakness, weight loss)
PE: Provider's assessment of the patient's general presentation |
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Head
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pertaining to the scalp and bony structure of the head
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Eyes
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pertains to vision and physical appearance of the eyes, lids and lashes
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ENT
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refers to ears, nose and throat
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Neck
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refers to the exterior appearance, bony structure and range of motion of the neck
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Chest
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refers to the external and bony structure of the chest
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Cardiovascular
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refers to the heart's rate, sounds and rhythm as well as body circulation
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Respiratory
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refers to breathing effort and lung sounds
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Abdomen/GI (gastrointestinal)
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pertains to the external abdomen, internal organs and gastrointestinal tract (including the rectum)
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GU (genitourinary)
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referring to the genitals and urinary tract
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Back
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pertains to the exterior appearance, bony structure and range of motion of the back
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Musculoskeletal/Extremities
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refers to the exterior appearance, bony structure, reflexes, circulation and range of motion of both arms and legs
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Skin
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pertaining to general appearance, moisture and temperature of the skin
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Neuro
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refers to neurological function as controlled by the brain
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Psych
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pertains to patient's mood, interaction and personality attributes when interacting with others
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Allergies/Endocrine
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allergies = describes allergy symptoms
Endrocrine = findings associated with hormone secretion/glands |
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Heme/Lymph
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pertaining to the blood and lymphatic system
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