A

• Allergies – Adverse immune system responses to substances (e.g., medications, foods, environmental triggers).

• Anamnesis – The process of collecting a patient’s medical history.

C

• Chief Complaint (CC) – The primary symptom or concern that prompts a patient to seek medical care, recorded in the patient’s own words.

• Comorbidities – The presence of one or more additional conditions co-occurring with a primary condition.

• Current Medications – All prescription, over-the-counter, herbal, and supplemental drugs a patient is currently taking.

D

• Duration – How long a symptom has been present.

• Differential Diagnosis – A list of possible conditions that might explain a patient’s symptoms.

F

• Family History – A record of health conditions present in a patient’s family, particularly hereditary diseases (e.g., diabetes, hypertension, cancer).

H

• HPI (History of Present Illness) – A detailed chronological narrative of the development of the patient’s current complaint.

• Hospitalizations – A record of prior admissions, including reasons, treatments, and outcomes.

• Habits – Lifestyle behaviors such as smoking, alcohol use, recreational drug use, and diet.

L

• Location – Where a symptom (e.g., pain) is felt on or in the body.

M

• Medical History – A review of previous illnesses, chronic conditions, surgeries, and ongoing treatments.

• Menstrual History – For female patients, information about cycle regularity, menarche, menopause, and any gynecological concerns.

• Mnemonic “OLD CARTS” – A common tool for symptom analysis:

  • O – Onset

  • L – Location

  • D – Duration

  • C – Character

  • A – Aggravating/Alleviating factors

  • R – Radiation

  • T – Timing

  • S – Severity

O

• Onset – The time and manner a symptom began (e.g., sudden vs. gradual).

P

• Past Medical History (PMH) – Summary of prior diagnoses, hospitalizations, surgeries, and chronic illnesses.

• Past Surgical History (PSH) – A list of surgeries the patient has undergone.

• Pain Scale – A tool to assess severity of pain, usually from 0 (no pain) to 10 (worst possible pain).

• Provocative/Palliative – Factors that worsen (provocative) or relieve (palliative) symptoms.

R

• Review of Systems (ROS) – A systematic review of each body system to check for additional symptoms not directly related to the chief complaint.

• Radiation – Refers to whether pain spreads to other areas (e.g., chest pain radiating to the left arm).

S

• Severity – The intensity of a symptom.

• Social History – Includes details about occupation, living conditions, substance use, marital status, and other psychosocial aspects.

• SOAP Note – A structured format for documentation:

  • S – Subjective (what the patient tells you)

  • O – Objective (exam findings, vitals)

  • A – Assessment (clinical impression)

  • P – Plan (treatment or further evaluation)

T

• Timing – How symptoms vary over time (e.g., intermittent, constant, worsening).

• Travel History – Important in assessing exposure risks for infectious diseases and tropical illnesses.

V

• Vaccination History – Records of immunizations, important in assessing risk for certain diseases.