MT Training > Terminology > Systems

CONSTITUTIONAL:

had some shaking

negative fever or chills

no fever, generalized weakness or malaise

no pyrexia or chills. No weakness or fatigue.

no significant weight changes

no unexplained weight loss

no weight loss, fever, chills, weakness or fatigue

the patient denies fever, weight loss, night sweats, fatigue or bleeding

the patient is rather clammy, pale-looking

HEENT:

arcus senilis

aural fullness

conjunctivae pink, no scleral icterus

contact lens worn

double vision

ears and nose externally normal

goiter

hard of hearing

Head is normocephalic and atraumatic. Eyes, ears, nose and throat are unremarkable

moist buccal mucosa

mouth has no sores

nasal discharge

negative for false teeth

negative for glaucoma or cataracts

negative for masses, hoarseness or snoring

no bleeding gingivae

no change in hearing

no diplopia or blurred vision

no dysgeusia

no dysphagia, dysphonia.

no earache, sore throat or runny nose

no epistaxis or rhinorrhea.

no eye pain

no glossodynia

no hearing loss

no lid lag, no exophthalmos, no xanthelasma

no mucosal lesions

no mucosal pallor

no otalgia, otorrhea

no photophobia

no postnasal drip

no scleral icterus

no scotomata

no sneezing or congestion

No tenderness or difficulty in swallowing

no thrush

no tinnitus or vertigo

no vision disturbances
no visual loss

no xerostomia

patient has full denture plates

PERRL, EOMI

pharynx normal

sinus congestion

The patient wears corrective glasses for reading

ulcerations in mouth secondary to chemotherapy

visual field deficit

wears dentures

PULMONARY OR RESPIRATORY SYSTEM:

clear to auscultation bilaterally

denies any tuberculosis, pneumonia, asthma, pleurisy, bronchitis or sinusitis

dyspnea on exertion

negative shortness of breath, cough, sputum production

no cough or difficulty breathing

no hemoptysis

no hiccups

no history of pulmonary TB

no pleurisy

no PND or orthopnea

there was good respiratory effort

CARDIOVASCULAR SYSTEM:

chest pressure

denies history of heart attack

denies night cramps

denies orthostasis

denies substernal or radiating chest pain

negative chest pain on exertion or palpation

no angina

No chest pain, chest pressure, chest discomfort

no history of valve disease

no palpitations or syncope

no precordial pain

No squeezing, strangling, tightness, heaviness or aching about the chest, neck or axilla

positive/negative for hypertension

GASTROINTESTINAL SYSTEM:

bright red blood per rectum

denies abdominal fullness

denies black tarry stools

has GERD

melena

no abdominal pain or blood

no acid reflux, heartburn

no anorexia

no constipation

no epigastric pain

no GI bleed

no hematemesis

no hematochezia

no hemorrhoids

no melanotic stools

no melenemesis

no nausea, vomiting or diarrhea

no odynophagia

no rectal bleeding

GENITOURINARY SYSTEM:

anuric

burning on urination

denies any CVA or suprapubic tenderness

denies pregnancy

diminished urine output

flank pain

has vaginal bleeding

history of carcinoma of the prostate

LMP is current

microscopic hematuria

no difficulty urinating

no dysuria, polyuria, frequency, urgency, hesitancy

no female discharge

no gross blood in the urine

no hematuria or dysuria

no incontinence of bowel or bladder

no kidney stones in the past

no nocturia

no pyuria

no urinary retention

no urinary tract infections

on hemodialysis

pregnancy, last menstrual period

urinary incontinence

varicocele

MUSCULOSKELETAL SYSTEM:

no arthritis

no focal joint pain or stiffness

no joint swelling

no muscle pains

no muscle, back pain, joint pain or stiffness

no myalgias or arthralgias

no neck pain or back pain

no trauma

NEUROLOGIC SYSTEM:

change in level of consciousness

denies any seizures, convulsions, unconsciousness, speech difficulty or ataxia.

difficult to perform because of poor patient cooperation

negative/positive for migraines

no change in bowel or bladder control

no confusion

no focal weakness

no headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities

no history of TIA, CVA

no lightheadedness or slurred speech

no motor or sensory loss

no paresthesias, fasciculations, seizures or weakness

no strokes or seizures

numbness and tingling, stocking/glove distribution

PSYCHIATRIC SYSTEM:

no delusions

no depression, no loss of interest in normal activity or change in sleep pattern

no disorder of thought or mood

no hallucinations or suicidal ideations

no history of depression or anxiety

no mania

INTEGUMENTARY OR SKIN SYSTEM:

no change in skin, hair, nails

no dermatitis

no evidence of squamous or basal cell CA

no rash or itching

no skin rash or skin lesions

no unusual skin spots

positive for hives

vesicular lesions

ENDOCRINE SYSTEM:

negative for thyroid abnormalities

negative/positive for diabetes

no fibroid abnormalities

no heat or cold intolerance, polyuria or polydipsia

no sweating

HEMATOLOGIC/ONC SYSTEM:

denies abnormal bleeding

denies bleeding disorder

negative for anemia or blood dyscrasias

no abnormal hemorrhaging

no anemia

no easy bruisability

no easy bruising or bleeding

no history of blood clots

no unusual infections or bleeding

LYMPHATICS SYSTEM:

no enlarged nodes

no history of splenectomy

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