Ecm1

Front 1

HTN

Back 1

hypertension

Front 2

EOM

Back 2

extra ocular muscles

Front 3

LMP

Back 3

last menstrual period

Front 4

Ext

Back 4

extremities

Front 5

DM

Back 5

diabetes mellitus

Front 6

NIDDM

Back 6

non insulin dependent DM

Front 7

DTR

Back 7

deep tendon reflexes

Front 8

Abd

Back 8

abdomen

Front 9

MI

Back 9

myocardial infarction

Front 10

CTA

Back 10

clear to auscultation

Front 11

OTC

Back 11

over the counter

Front 12

WDWN

Back 12

Well developed well nourished

Front 13

STDs

Back 13

Sexually transmitted diseases

Front 14

PERRLA

Back 14

pupils equal round reactive to light and accommodation

Front 15

ROM

Back 15

Range of motion

Front 16

NCAT

Back 16

normocephalic atraumatic

Front 17

TART

Back 17

Texture, temperature, asymmetry, range of motion, tenderness

Front 18

LAD

Back 18

Lympadenopathy (usually no LAD palpated)

Front 19

LMP

Back 19

last menstrual period

Front 20

B/L

Back 20

bilateral or bilaterally or circled B

Front 21

UE

Back 21

upper extremity

Front 22

LE

Back 22

lower extremity

Front 23

w/

Back 23

with (or c with line above)

Front 24

w/o

Back 24

without (or s with line above) or symbol for empty set (zero with line from 1:30 to 7:30)

Front 25

ppd

Back 25

packs per day

Front 26

m

Back 26

male or symbol (circle with arrow at 1:30)

Front 27

f

Back 27

female or symbol (circle with t at 6:00)

Front 28

yo

Back 28

years old

Front 29

CVA

Back 29

Cerebrovascular accident

Front 30

TIA

Back 30

Transient Ischemic Attack

Front 31

NKA

Back 31

no known allergies

Front 32

tinnitus

Back 32

ringing

Front 33

rhinorrhea

Back 33

runny nose

Front 34

dyspnea

Back 34

shortness of breath

Front 35

orthopnea

Back 35

shortness of breath lying down

Front 36

melena

Back 36

black tarry stool

Front 37

hematochezia

Back 37

bloody stool

Front 38

dysuria

Back 38

pain or difficulty w/ urination

Front 39

hematuria

Back 39

blood in urine

Front 40

puritis

Back 40

itching

Front 41

syncope

Back 41

loss of consciousness

Front 42

intro

Back 42

knock, enter, wash hands, introduction, (hi how are you doing <squirt>, I'm student doctor Jason Shupe, what's your name? Do you prefer Mr/Misses Smith?)

Front 43

CC

Back 43

Chief Complaint (in patients own words), e.g. routine physical, physical exam (what brings you in today? any thing else you also want to look at or discuss today?)

Front 44

HPI

Back 44

History of Present Illness, OPQRST, e.g. 36 yo female, seeking physical exam, reports no changes since last exam.

Front 45

Allergies

Back 45

Rx, Environment, Food, and what the rxn is, e.g. allergic to lactose - gas, diarrhea, no other food, drug, or env allergies. (any allergies? medication, food, environment (dust, insects, pollen))

Front 46

Meds

Back 46

Immunizations, Rx, OTC, supplements & herbals (name, dosage, frequency), e.g. current immunizations & tetanus, no RX, 500mg acetaminophen for head aches (1/month), centrum multivitm.. 1/day ukn dose, no other supplements or herbals. (are you taking any medications, supplements, herbals, OTC?)

Front 47

PMH

Back 47

Past medical history: chronic conditions, childhood illnesses, e.g. chicken pox age 5, birth of 2 children (ever been admitted to the hosptial? Any childhood illnesses?)

Front 48

PSH

Back 48

past surgical history: anything with general anesthesia e.g. tonsils removed age 10, no wisdom teeth removed, no other surgeries. (Any surgeries, (wisdom teeth removed?))

Front 49

FmHx

Back 49

Family medical history: parents still living, any siblings, any diseases(HTN, DM, high cholesterol, heart disease, cancer) e.g. mother living 85 stroke 3 years ago, father living 88 HTN, older sister healthy, two children (is your family healthy? Are you parents living? How old are/were they? What diseases did/do they have? Any siblings? Are they healthy? Any diseases in your family? (High blood pressure, high cholesterol, heart disease, DM, stroke, cancer?)

Front 50

SocHx

Back 50

EtOH, drugs, tobacco, living situation, relationships, e.g. married w/ 2 children lives in Ontario, no EtOH, no self RX, no tobacco use (do you live alone, are you in a relationship, any drug use? Any tobacco use? Do you drink EtOH? How much? How often?)

Front 52

S: General

Back 52

Fevers, chills, fatigue, weight changes. e.g. reports fatigue last 6 mo. No fevers, no chills, no weight changes. (any fevers, chills, fatigue, unplanned weight changes?)

Front 53

S: Skin

Back 53

Rashes, itchy, dryness, changes in moles, lumps, soars. e.g. sensitive to sun, bruises easily, no rashes, no sun burns (any problems with your skin (rashes, itchy, dryness, changes in moles, soars, lumps?))

Front 54

S:H

Back 54

Head: Headache, head injury, dizziness, lightheadedness, e.g. occasional headache (see Rx), no dizziness, no light headed, no head injury (any headaches, ever feel dizzy, or lightheaded?)

Front 55

S:E

Back 55

Eyes: vision changes, itchy, pain or redness, e.g. no changes, not itchy, dry from contacts, no pain. (any trouble with your eyes? changes in vision? pain or redness?)

Front 56

S:E

Back 56

Ears: hearling changes, tinnitus, vertigo, e.g. no change, no tinnitus, no dizzy (any problems w/ your ears (hearling changes? Any ringing or vertigo?))

Front 57

S:N

Back 57

Nose: nose bleeds, sinus trouble, rhinorrhea, congestion, e.g. no sinus, no runny, no bleeing (any sinus problems? Runny nose, bloody nose?)

Front 58

S:T

Back 58

Throat: sore throat, hoarseness, teeth/gums, e.g. no soar throat, no hoarseness, no problems w/ teeth/gums (any problems with your throat (sore throat, hoarseness) any problems with teeth/gums?)

Front 59

S:Neck

Back 59

stiffness, swollen glands, pain, e.g. no stiffness, no swollen glands, no pain (any neck problems ( pain, swollen glands or stiffness?))

Front 60

S:Breasts

Back 60

lumps/masses, pain, discharge, e.g. no lumps, pain or discharge (any problems with your breasts? (lumps/masses, pain, discharge), last mammogram)

Front 61

S:Resp.

Back 61

cough, dyspnea, wheezing, dyspnea on exercise, e.g. no cough, no wheezing, no dyspnea, no dyspnea on exercise. (any problem with your lungs? (coughing, wheezing or shortness of breath? Shortness of breath on exercise?))

Front 62

S:C/V

Back 62

Chest pain, heart palpitations, orthopnea, claudication, e.g. no chest pain, no paplitation, no orthopnea, no claudication (any problems w/ your heart? chest pain, heart palpitations, or shortness of breath lying down, any leg cramps?)

Front 63

S:G/I

Back 63

Abd pain, trouble swallowing, vomiting, diarrhea, constipation, hemorrhoids, melena, hematochezia

Front 64

S:female G of GU

Back 64

dysuria, increase urge/frequency, hematuria, flank pain, last menstrual period, last pap, vaginal discharge or puritis, abnormal bleeding, irregular period, # of sexual partners, sexual orientation, birth control/protection, STDs, e.g. no prob/pain urinating, no blood, no flank pain, regular periods, LMP 3 weeks ago, last pap 1 year ago, no puritis, no discharge, 3 partners, hetero, no STDs, the pill (any problems urinating? (blood, pain, urge, frequency) any flank pain?) when was your last menstrual period, anything unusual about your period?, any discharge or itching? How many sexual partners have you had? What is your sexual orientation? (heterosexual, homosexual, bisexual, other), do you use protection/birth control? have you had any STDs?)

Front 65

S:male G of GU

Back 65

penil discharge, scrotal pain/mass/lumps, testicular pain/mass/lumps, problems urinating/not urinating, increased urge/frequency, blood, flank pain, # of sexual partners, sexual orientation, birth control/protection, STDs, e.g no problems urinating,no discharge, no pain/lumps in scrotum/testes, 3 partners, hetero, no STDs, codoms, (any problems with you penis? discharge, any pain/mass/lumps in your scrotum or testes? Any problems urinating/not urinating? Increased urge/frequency? blood, flank pain, how many sexual partners have you had? What's your sexual orientation (heterosexual, homosexual, bisexual, other) have you had any STDs, do you use protection? What kind?)

Front 66

M/S

Back 66

Muscle or joint pain, joint swelling, back pain, e.g. no mm or joint or back pain, no joint swelling (Any trouble with your muscles or joints? (pain, swelling) any back pain?)

Front 67

Neuro

Back 67

syncope, seizures, confusion, memory loss, numbness, tingling, e.g. no syncope, seizures, confusion, memory loss, numbness or tingling (have you ever lost consciousness? have you had any seizures, confusion, memory loss, numbness or tingling?)

Front 68

Psych

Back 68

mood, depression, anxiety, suicidal thoughts or attempts e.g. generally happy, some stress – managed with exercise, diet, no suicidal thoughts or attempts (how's your mood? Any stress/anxiety/depression? Any suicidal thoughts or attempts?)

Front 69

O: Vitals

Back 69

BP 105/70, Resp 20, Pulse 60 (take b/p, measure pulse, measure resperation

Front 70

O:General

Back 70

WDWN female, cooperative, pleasant, well groomed, no apparent distress (notice appearance, odor, grooming, anxiety/stress)

Front 71

O:H

Back 71

Head: NCAT, scalp w/o lesions (feel head, look through hair)

Front 72

O:E

Back 72

Eyes: PERRLA, Red Reflux present B/L, 20/20 B/L, EOM intact B/L, unable to visualize optic disc. (H test, accommodation test, acuity test, otoscopic exam)

Front 73

O:E

Back 73

Ears: tymp. memb. Intact B/L, vis. cone of light B/L, heard finger rub B/L (look in both ears, test both ears for sound)

Front 74

O:N

Back 74

Nose: pink mucosa and turbinates vis. B/L, max. and frontal sinus not tender B/L (look in nose press on frontal and maxillary sinuses)

Front 75

O:T

Back 75

Throat: uvula and tongue midline, oral mucosa moist, good dentition (look in mouth, look at teeth, tongue, tonsils, uvula, cheeks)

Front 76

O: Neck

Back 76

No thyromegally, no LAD, trachea midline (feel thryroid, feel lymph nodes, look trachea)

Front 77

O: C/V

Back 77

RRR, pulse equal B/L radial and dorsal pedis, (listen to 4 valves on skin APT M2255, test pulse radial and dorsal pedis B/L)

Front 78

O: Resp.

Back 78

CTA B/L, good breath sounds, 10th rib displacement equal B/L posterior, 3 locations B/L ant. & post. resonant to percussion. (Listen three spots B/L front and back (ladder), percuss 3 spots B/L front and back (ladder), feel post rib motion at 10th rib posterior)

Front 79

O: Abd

Back 79

appears soft, nondistended, no scars, bowel sounds present 4 quadrents, no tenderness, no masses. (look, listen, percuss, palpate).

Front 80

O: M/S

Back 80

good ROM UE & LE B/L, joints supple UE & LE B/L, UE & LE appear symmetric B/L (test range of motion on joints UE and LE B/L, articulate joints UE and LE B/L, look at arm/leg B/L symmetry)

Front 81

O: Neuro

Back 81

A&Ox3, DTRs +2/4 B/L brachio radialas & patellar tendon, equal sensation UE & LE B/L, muscle test 5/5 B/L UE & LE, good balance B/L, even gate (test DTR UE & LE B/L, test sensation on skin UE & LE BL, muscle test UE & LE B/L, test balance and observe gait).