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Nursing

History Physical and progress

QuestionAnswer
CC CHEIF COMPLAINT
C/0 COMPLAINS OF
Dx DIAGNOSIS
FH FAMILY HISTORY
HEENT HEAD, EAR, EYES, NOSE THROAT
H AND P HISTORY AND PHYSICAL
HPI, PI HISTORY OF PRESENT ILLNESS, PRESENT ILLNESS
Hx HISTORY
IMP IMPRESSION
L AND W LIVING AND WELL
NAD NO ACUTE DISTRESS
NKA, NKDA NO KNOWN ALLERGIES, NO KNOWN DRUG ALLERGIES
O OBJECTIVE INFORMATION
OH OCCUPATIONAL HISTORY
P PLAN (RECOMMENDATION, DISPOSITION
PE OR Px PHYSICAL EXAMINATION
PERRLA PUPILS EQUAL, ROUND & REACTIVE TO LIGHT AND ACCOMMODATION
PH, PMH PAST HISTORY, PAST MEDICAL HISTORY
R/O RULE OUT
ROS, SR REVIEW OF SYSTEMS, SYSTEMS REVIEW
S SUBJECTIVE INFORMATION
SH SOCIAL HISTORY
Sx SYMPTOM
UCHD USUAL CHILDHOOD DISEASES
WNL WITHIN NORMAL LIMITS
ACUTE SHARP, HAVING INTENSE, SEVERE SYMPTOMS & A SHORT COURSE
CHRONIC CONDITION THAT DEVELOPS SLOWLY & PERSIST OVER A PERIOD OF TIME
BENIGN MILD OR NONCANCEROUS
MALIGNANT HARMFUL OR CANCEROUS
DEGENERATION GRADUAL DETERIORATION OF NORMAL CELLS AND BODY FUNCTIONS
DEGENERATIVE DISEASE ANY DISEASE IN WHICH DETERIORATION OF THE STRUCTURE OR FUNCTION OF THE TISSUE OCCURS
DIAGNOSIS DETERMINATION OF THE PRESENCE OF A DISEASE BASED ON AN EVALUATION OF SYMPTOMS, SIGNS AND TEST FINDINGS
ETIOLOGY STUDY OF THE CAUSE OF A DISEASE
EXACERBATION INCREASE IN SEVERITY OF DISEASE WITH AGGRAVATION OF SYMPTOMS
REMISSION A PERIOD IN WHICH SYMPTOMS AND SIGNS STOP OR ABATE
FEBRILE RELATING TO A FEVER (ELEVATED TEMPERATURE
IDIOPATHIC A CONDITION OCCURRING WITHOUT A CLEARLY IDENTIFIED CAUSE
LOCALIZED LIMITED TO A DEFINITE AREA OR PART
SYSTEMIC RELATING TO THE WHOLE BODY, RATHER THAN A PART
MALAISE FEELING OF UNEASINESS OR DISCOMFORT, OFTEN FIRST INDICATION OF ILLNESS
MARKED SIGNIFICANT
MORBIDITY SICK, A DISEASED STATE
MORTALITY BEING SUBJECT TO DEATH
PROGNOSIS PREDICTION OF THE LIKELY OUTCOME OF A DISEASE, BASED ON THE GENERAL HEALTH STATUS OF THE PATIENT (PROGNOSIS "GOOD")
PROGRESSIVE THE ADVANCE OF A CONDITION AS SIGNS & SYMPTOMS INCREASE IN SEVERITY
PROPHYLAXIS A PROCESS OR MEASURE THAT PREVENTS DISEASE
RECURRENT TO OCCUR AGAIN; A RETURN OF SYMPTOMS AND SIGNS AFTER A PERIOD OF INACTIVITY
SEQUELA A DISORDER OR CONDITION USUALLY RESULTING FROM A PREVIOUS DISEASE OR INJURY
SIGN AM MARK; OBJECTIVE EVIDENCE OF DISEASE THAT CAN BE SEEN OR VERIFIED BY AN EXAMINER
SYMPTOM EVIDENCE OF DISEASE THAT IS PERCEIVED BY THE PATIENT, OFTEN NOTED IN THEIR OWN WORDS
SYNDROME COMBINATION OF SYMPTOMS THAT GIVE A DISTINCT CLINICAL PICTURE INDICATING A CONDITION OR DISEASE
NONCONTRIBUTORY NOT INVOLVED IN BRINGING ON THE CONDITION OR RESULT
UNREMARKABLE COMMON, NOT OF THE ORDINARY OR SIGNIFICANT
A ASSESSMENT
A AND W ALIVE AND WELL
Created by: gillygun