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cc:

chief complaint

HPI

history of present illness

PH

past history

SH

social history

PMH

past medical history

yo

years old

b/l

bilateral

MCP

metacarpal

mo.

months

N/V/D/C

nausea, vomiting, diarrhea, constipation

F/U/D

frequency, urgency, dysuria (pain while urinating)

HTN

hypertension

ceseran

c-sections

NKDA

no known drug allergies

PPd

packs per day

A&W

alive and well

FH

family history

HTN x 5 yrs

hypertension for 5 years

NAD

no acute distress

HEENT

head, eyes, ears, nose and throat

NCAT

normacephalic, atraumatic

EOMI

extraocular muscles intact

PERRLA

pupils equal round and reactive to light and accomodation

TMI

tympanic membrane intact

MMM

moist mucus membranes

RRR

regular rate and rhythm

m/r/g

murmurs, rubs or gallops

CTA

clear to auscultation

w/r/r

wheals, rales, ronchi

NTND

non-tender, non-distended

BS

bowel sounds

HSM

hepatosplenomegaly

LROM

limited range of motion

DTRs

deep tendon reflexes

RA

rheumatoid arthritis

SLE

systemic lupus erythematosus

Osteoarthritis

OA

GC

gonorrhea

CBC

complete blood count

ANA

anti-nuclear antibodies

ESR

erythrocyte sedimentation rate

F/U

follow up

S1S2

normal S1S2

PSH

past surgical history

ROS

review of systems

abd

abdomen

CXR

chest x-ray

US

ultrasound

U/L

urinalysis

CHF

congestive heart failure

DM

diabetes mellitus

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