Extra ocular movements
Hypertension or high blood pressure
head, eyes, ears, nose, throat
number of pregnancies
justified to the left side of the page
tabbed over and aligned
pupils equally react to light and accommodation
bad/painful/abnormal menstrual flow
inflammation of the gallbladder
ringing in the ear
first period for female
excessive uterine bleeding
Atrophy of the optic nerve and increased intraocular pressure
pink eye, inflammation of the mucous membranes of the eye
head to foot
varicos veins, distended, knotted or swollen veins
dryness, scaling, eruptions, rash, dicoloration, palor
Diagnosis and Impression
they have the same meaning on report also called assessment or conclusion
4 parts of PE
Inspection, palpation, percussion, and auscultation
short stay record
used for outpatient or surgical center in place of an H&P
patient returns to the hospital within a month
name, address, phone #, SS, place of work
4 parts of a HX
CC, ROS, HPI, PFSH
history of present illness
past family social history
how do you list allergies on a report
bold/ underline could be life or death to the patient
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