Term
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Definition
| fever, malaise, weight change, Diet: intention to gain or loose weight, appetite |
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Term
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Definition
| pruritis, rash, change in pigmentation, diaphoresis, dry skin or thinning hair. Complains of male-pattern baldness |
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Term
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Definition
| headache, dizziness, syncope, past head injury or loss of consciousness |
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Term
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Definition
| blurry vision or vision change, scotoma, diplopia, photophobia, Denies history of eye trauma, glaucoma |
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Term
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Definition
| hearing loss, tinnitus, vertigo, pain or discharge |
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Term
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Definition
| anosmia, rhinorhea, epistaxis, postnasal discharge or sinus pain |
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Term
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Definition
| hoarseness or change in voice, frequent sore throat, bleeding gums, tooth abscess, sore tongue, ulcers, or change in taste |
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Term
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Definition
| enlargement or tenderness |
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Term
|
Definition
| chest pain, dyspnea, cyanosis, wheezing, cough, sputum, (character and quantity), hemoptysis, no exposure to TB, (reason for, date, and result of last CXR) |
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Term
|
Definition
| pain, tenderness, discharge, lumps, glactorrhea, (last mammogram result and date, breastfeeding history) |
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Term
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Definition
| chest pain or pressure (OLD CARTS, NVD), palpitations, dyspnea, orthopnea, edema, hypertension, previous MI or revascularization, exercise tolerance (especially change), Past tests like EKG, Echo or Stress |
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Term
|
Definition
| claudication (frequency, severity, tolerance), bruising or bleeding, thrombosis, thrombophlebitis |
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Term
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Definition
| past anemias or transfusions |
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Term
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Definition
| good appetite, Denies food intolerance, dysphagia, heartburn, nausea, vomiting, hematemesis, bowels regular QD, brown and well-formed (3X/day- Q3days or change), Denies diarrhea (volume, color, floating),flatulence, hemorrhoids, (past colon screenings -where, when, why, what) |
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Term
|
Definition
| dysuria, urgency, frequency, nocturia, hematuria, polyuria, stress incontinence, hernias, hesitency, dribbling, passage of stone |
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Term
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Definition
| puberty onset, erections, libido, infertility, emissions, STD (history, treatment, and risk factors) |
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Term
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Definition
| Menses onset, regularity, duration, quantity, dysmenorrhea, LMP, midcycle bleeding, pruritis, last pap smear, age at menopause, libido, intercourse frequency, sexual satisfaction, infertility, STD (history, treatment, and risk factors), Pregnancy |
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Term
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Definition
| Pregnancy number, living children, multiple births, elective and spontaneous abortions, pregnancy length, type of delivery, complications with pregnancy or delivery or neonate, use of contraceptives (kind and dates and compliance), infertility |
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Term
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Definition
| Joint pain or stiffness, restriction of motion, swelling, redness, heat, bony deformity, clicking, audible pop at injury |
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Term
|
Definition
| syncope, seizures, weakness or paralysis, abnormal sensations, discoordination, tremors, loss of memory |
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Term
|
Definition
| depression, mood changes, difficulty concentrating, nervousness, suicidal thoughts, irritability, sleep or appetite changes |
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