BIO 335 Module 2
chief complaint - ✅✅-the main reason for the patient's visit
history of present illness - ✅✅-the story of the patient's problem
review of systems - ✅✅-description of individual body systems in order to discover
any symptoms not directly related to the main problem
past medical history - ✅✅-other significant past illnesses, like high blood pressure,
asthma, or diabetes
family history -✅✅-any significant illnesses that run in the patient's family
Social History - ✅✅-a record of habits like smoking, drinking, drug abuse, and
sexual practices that can impact health
S- ✅✅-subjective
O - ✅✅-objective
A - ✅✅-assessment
P - ✅✅-Plan
Subjective - ✅✅-what the patient say
objective - ✅✅-physical exam findings and tests
assessment - ✅✅-the analysis of the subjective and objective information
Ddx formulated
Plan - ✅✅-course of action
Medical symptom - ✅✅-noticed by patient, subjective, cannot measured
Medical sign - ✅✅-objective and detected physical examination
Different diagnosis - ✅✅-The other possible alternatives
Intesity - ✅✅-rate your pain
location - ✅✅-where is the pain
, Onset and pattern - ✅✅-When did it start, how often
Extension and radiation - ✅✅-Pain move to other ares
Duration - ✅✅-how long pain last
Character or quality - ✅✅-Descriptions such as sharp dull
Precipitating, aggravating - ✅✅-What starts the pain, what makes it worse
Associated manifestations - ✅✅-Anorexia, nausea
Effect on daily activities - ✅✅-Sleep, appetite, focus
acute - ✅✅-it just started recently or is a sharp, severe symptom
chronic - ✅✅-it has been going on for a while now
exacerbation - ✅✅-it is getting worse
abrupt - ✅✅-all of a sudden
febrile - ✅✅-to have a fever
Afebrile - ✅✅-to not have a fever
malaise - ✅✅-not feeling well
progressive - ✅✅-more and more each day
symptom - ✅✅-something a patient feels
noncontributory - ✅✅-not related to this specific problem
lethargic - ✅✅-a decrease in level of consciousness; in a medical record, this is
generally an indication that the patient is really sick
genetic/ hereditary - ✅✅-it runs in the family
alert -✅✅-able to answer questions; responsive; interactive
oriented - ✅✅-being aware of who he or she is, where he or she is, and the current
time; a patient who is aware of all three is "oriented x 3"
chief complaint - ✅✅-the main reason for the patient's visit
history of present illness - ✅✅-the story of the patient's problem
review of systems - ✅✅-description of individual body systems in order to discover
any symptoms not directly related to the main problem
past medical history - ✅✅-other significant past illnesses, like high blood pressure,
asthma, or diabetes
family history -✅✅-any significant illnesses that run in the patient's family
Social History - ✅✅-a record of habits like smoking, drinking, drug abuse, and
sexual practices that can impact health
S- ✅✅-subjective
O - ✅✅-objective
A - ✅✅-assessment
P - ✅✅-Plan
Subjective - ✅✅-what the patient say
objective - ✅✅-physical exam findings and tests
assessment - ✅✅-the analysis of the subjective and objective information
Ddx formulated
Plan - ✅✅-course of action
Medical symptom - ✅✅-noticed by patient, subjective, cannot measured
Medical sign - ✅✅-objective and detected physical examination
Different diagnosis - ✅✅-The other possible alternatives
Intesity - ✅✅-rate your pain
location - ✅✅-where is the pain
, Onset and pattern - ✅✅-When did it start, how often
Extension and radiation - ✅✅-Pain move to other ares
Duration - ✅✅-how long pain last
Character or quality - ✅✅-Descriptions such as sharp dull
Precipitating, aggravating - ✅✅-What starts the pain, what makes it worse
Associated manifestations - ✅✅-Anorexia, nausea
Effect on daily activities - ✅✅-Sleep, appetite, focus
acute - ✅✅-it just started recently or is a sharp, severe symptom
chronic - ✅✅-it has been going on for a while now
exacerbation - ✅✅-it is getting worse
abrupt - ✅✅-all of a sudden
febrile - ✅✅-to have a fever
Afebrile - ✅✅-to not have a fever
malaise - ✅✅-not feeling well
progressive - ✅✅-more and more each day
symptom - ✅✅-something a patient feels
noncontributory - ✅✅-not related to this specific problem
lethargic - ✅✅-a decrease in level of consciousness; in a medical record, this is
generally an indication that the patient is really sick
genetic/ hereditary - ✅✅-it runs in the family
alert -✅✅-able to answer questions; responsive; interactive
oriented - ✅✅-being aware of who he or she is, where he or she is, and the current
time; a patient who is aware of all three is "oriented x 3"
