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COMPLETE PHYSICAL EXAM ABBREVIATIONS

COMPLETE PHYSICAL EXAM ABBREVIATIONS :Vital Signs: T (temperature)HR (pulse)RR (respiration rate)BP (systolic/diastolic)SPO2 pulse oxSYSTEMP hysical Exam DocumentationDetailed Abbreviation ExplanationGEN: GeneralNAD, AAOX4, WDWN (AAM, AAF, WM, WF)No acute distress, alert, awake, and oriented times 4 to name, place, time, purpose, Well developed well nourished (African American Male, African American Female, White Male, White Female)HEENT: Head, eyes, ears, nose, throatNCAT, MMM, EOMI, PERRLA, b/l TM intact & reactive to light, b/l sclera anicteric, conjunctival injectionNormocephalic atraumatic, mucous membranes moist, extraocular muscles intact, pupils equally round and reactive to light and accommodation bilaterally, bilateral tympanic membrane intact and reactive to light, bilateral sclera anicteric, no conjunctival injectionNECK:Supple, JVD, LAD, carotid bruit, thyromegallySupple, no jugular venous distention, no lymphadenopathy, no carotid bruitCV: cardiovascularRRR, S1S2nl, m/r/g, PMI non displaced/non sustained, H

CNII-XII intact Cranial Nerves two through twelve intact MMSE Mini Mental Status Exam No T/A/D No Tobacco/Alcohol/IV drug use Ctx Contractions Fx Fracture or function (depending on context) P.V. Per Vagina P.R. Per Rectum SBP Systolic Blood Pressure DBP Diastolic Blood Pressure HR Heart Rate RR Respiratory Rate SPO2 Pulse Oximetry

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