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Plantar ✔✔Sole side of foot Plantar flexion ✔✔Foot movement when toes flex down (pointing your toes) Supine ✔✔Body lying face up (chest up and back down) Afebrile ✔✔without fever diaphoresis ✔✔excessive sweating dysuria ✔✔painful urination emesis ✔✔vomiting epistaxis ✔✔bleeding from the nose gait ✔✔a person's manner of walking
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Plantar ✔✔Sole side of foot Plantar flexion ✔✔Foot movement when toes flex down (pointing your toes) Supine ✔✔Body lying face up (chest up and back down) Afebrile ✔✔without fever diaphoresis ✔✔excessive sweating dysuria ✔✔painful urination emesis ✔✔vomiting epistaxis ✔✔bleeding from the nose gait ✔✔a person's manner of walking hematochezia ✔✔Bright red, bloody stools hematuria ✔✔blood in the urine hemoptysis ✔✔coughing up blood
incontinence ✔✔inability to control bowel movements or urine myocardial infarction (MI) ✔✔heart attack pruritis ✔✔itching syncope ✔✔fainting vertigo ✔✔Condition of dizziness, "room spinning" cyanosis ✔✔bluish discoloration of the skin laceration ✔✔to cut Bradycardia ✔✔slow heart rate Tachycardia ✔✔fast heart rate apnea ✔✔absence of breathing gravid ✔✔pregnant melena ✔✔Black tarry stool colectomy ✔✔surgical removal of the colon mastectomy ✔✔surgical removal of a breast ABG ✔✔arterial blood gas
MI ✔✔myocardial infarction NPO ✔✔Nothing per os (by mouth) PE ✔✔pulmonary embolism RLQ ✔✔right lower quadrant Rx ✔✔prescription SBO ✔✔small bowel obstruction SOB ✔✔shortness of breath TM ✔✔tympanic membrane URI ✔✔upper respiratory infection UTI ✔✔urinary tract infection UA ✔✔urinalysis ASA ✔✔aspirin ABx ✔✔antibiotics AKA ✔✔above knee amputation BID ✔✔Twice daily
BKA ✔✔below knee amputation BM ✔✔bowel movement BUE ✔✔bilateral upper extremity CABG ✔✔coronary artery bypass graft CHF ✔✔congestive heart failure FROM ✔✔full range of motion GPA ✔✔gravida, para, abortus HA ✔✔headache HTN ✔✔hypertension LBBB ✔✔left bundle branch block LLE ✔✔left lower extremity MVA ✔✔motor vehicle accident LLQ ✔✔left lower quadrant Splenectomy ✔✔surgical removal of the spleen
Aggravating factors Relieving factors Treatment Not included in HPI ✔✔ ROS definition ✔✔A list of question arranged by organ system that the provider asks a patient during the process of taking a history. It is designated to uncover dysfunction and disease social history, SHX ✔✔Tobacco use, alcohol use (ETOH), illicit drug use, occupation, living circumstances PMHx, PSHx, FHx, SHx ✔✔Past medical history, past surgical history, family history, social history HPI ✔✔subjective information, third person epigastric region, periumbilical region, pelvic region ✔✔superior to the umbilical region ESI ✔✔Emergency Severity Index Level 5 chart ✔✔HPI- 4 ROS- 10 PFSH- 2 PE- 8 ESI- 1 RED Cardiac arrest Level 4 chart ✔✔HPI- 4
Orange Level 3 chart ✔✔HPI- 1 - 3 ROS- 1 PFSH- 0 PE- 2 ESI- 3 YELLOW Level 2 chart ✔✔HPI- 1 - 3 ROS- 1 PFSH- 0 PE- 2 ESI- 4 Laceration GREEN Level 1 Chart ✔✔HPI- 1 - 3 ROS- 0 PFSH- 0 PE- 0 ESI- 5 Medication refill BLUE DM ✔✔diabetes mellitus
Region and radiation Severity Time (history) PMFSH ✔✔past medical, family, social history ICD- 10 ✔✔A system to classify and code diagnoses, symptoms, and procedures The patients diagnosis