COMPLETE PHYSICAL EXAM ABBREVIATIONS

1 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.

2 CardiovascularRRR, S1S2nl, m/r/g, PMI non displaced/non sustained, HJR, CR <2secsRegular rate and rhythm, S1 and S2 are normal, no murmurs/rubs/or gallops, point of maximal intensity non displaced and non sustained, no Hepatojugular Reflux, capillary refill less than 2 secondsLUNGS:CTAB, r/r/w, egophany, tactile fremitus, nl percussionClear to auscultation bilaterally, no rales/rhonchi/wheezes, no egophany, no tactice fremitus, normal percussionABD: abdomenObese, no pulsatile masses, +BS nl x4, high pitched or tinkling sounds, resonant to percussion, Soft, ND/NT, rebound/guarding, CVA tenderness, HSMO bese, no pulsatile masses, normal bowel sounds normal in all four quadrants, no high pitched or tinkling sounds, resonant to percussion, Soft, non-distended/non-tender, no rebound or guarding, no costovertebral angle tenderness, no hepatosplenomegaly EXT: extremities c/c/eNo cyanosis/clubbing/or edemaNEURO: neurologicCN II-XII intact, no focal deficitCranial Nerve II through XII intact, no focal deficityPSYCH.

3 Psychiatricnl affect, hallucinations, nl speech, dysarthriaNormal affect, no hallucinations, normal speech, no dysarthriaSKINI ntact, rashes, lesions, errythemaIntact, no rashes, no lesions, no errythemaTanya Oberoi Pandya , : (genitourinary)Male: rashes, penile discharge, penile shaft s masses or lesions, inguinal hernia, inguinal LAD, b/l testicles nl in consistency s hydrocele or varicocele, hypospadias/epispadias Male: no rashes, no penile discharge, penile shaft without masses or lesions, no inguinal hernia, no inguinal lymphadenopathy, bilateral testicles normal in consistency without hydrocele or varicocele, no hypospadias or epispadiasPelvic: rashes, nl bartholin gland, vaginal mucosa nl consistency s atrophy or discharge, cervical os s dischargeBimanual: CMT VB discharge massesNo rashes, normal bartholin gland, vaginal mucosa of normal consistency without atrophy or discharge, cervical os without dischargeBimanual.

4 No cervical motion tenderness, no vaginal bleeding, no discharge, no massesRECTAL BRBPR, melena, masses, nl sphincter tone, ext/int hemorrhoids, prostate walnut size s nodularity or hypertrophy, prostate tenderness No bright red blood per rectum, no melena, no masses, normal sphincter tone, no external or internal hemorrhoids, prostate walnut size without nodularity or hypertrophy, no prostate tendernessLYMPH: (lymphatic) LADNo lymphadenopathyMmsk: (musculoskeletal) nl ROM, joint swelling or errythemaNormal range of motion, no joint swelling or errythemaTanya Oberoi Pandya , ABREVIATIONS ENCOUNTERED IN PRACTICE:CCChief complaintHPIH istory of Present IllnessROSR eview of SystemPMHPast Medical HistoryNKDANo known Drug AllergiesCPChest PainSOBS hortness of BreathDOED yspnea on exertionPNDIf talking cardiac: Paroxysmal Nocturnal DyspneaIf talking Upper respiratory: Post Nasal DripJVDJ ugular Venous DistentionHJRH epato-Jugular RefluxLE edemaLower Extremity edemaNo c/c/eNo cyanosis/clubbing/edemaNo r/r/wNo Rales/rhonchi/wheezesNo m/r/gNo murmurs/rubs/gallopsCTABC lear To Auscultation BilaterallyRRRR egular Rate and RhythmS1S2 nlS1 (first heart sound) and S2 (second heart sound) are normal in auscultationEKG.

5 LADRADRAELAELVHNSRLeft Axis DeviationRight Axis DeviationRight Atrial EnlargementLeft Atrial EnlargementLeft Ventricular HypertrophyNormal Sinus RhythmLADL ymphadenopathyEOMIE xtra-ocular muscles intactPERRLP upils Equally Round and Reactive to light CNII-XII intactCranial Nerves two through twelve intactMMSEMini Mental Status ExamNo T/A/DNo Tobacco/Alcohol/IV drug useCtxContractionsFxFracture or function (depending on context) RectumSBP Systolic Blood PressureDBPD iastolic Blood PressureHR Heart RateRRRespiratory RateSPO2 Pulse OximetryBRBPRB right Red Blood Per RectumDTRDeep Tendon ReflexesARFA cute Renal FailureCRIC hronic Renal InsufficiencyCRFC hronic Renal Failure FEN/GIFluids, Electrolytes, and Nutrition/GastroenterologyAAOX3 Alert, awake, and Oriented times 3 (to person, time, place)NADNo Acute DistressMMMM ucus Membranes MoistND/NTNon Distended/Non TenderBSx4 Bowel Sounds present in all 4 quadrantsN, VNausea, Transluminal Coronary AngioplastyPCIP ercutaneous Intervention (cardiac)

6 CADC oronary Artery DiseaseICDI mplantable Cardioverter DefibrillatorCABGC oronary Artery Bypass GraftVBVaginal BleedingFMFetal MovementCMTC ervical motion tendernessLMPLast menstrual periodNSVDN ormal Spontaneous Vaginal DeliveryPPROMP reterm Premature Rupture of MembranesPROMP remature Rupture of MembranesLTCSLow Transverse Cesarean SectionVBACV aginal Birth After Cesarean SectionEBLE stimated Blood LossEGAE xpected Gestational AgeEDCE xpected Date of Confinement (baby s due date)Tanya Oberoi Pandya , PregnancyFHTF etal Heart TonesTAH/BSOT otal Abdominal Hysterectomy with Bilateral Salpigoopherectomy ( no uterus/ tubes, no ovaries)TAHT otal abdominal hysterectomyBTL Bilateral Tubal LigationPTLP reterm LaborCVAC erebrovascular accidentTIAT ransient Ischemic AttackNo T/A/DNo tobacco/ WtWeightHAHeadachePalpPalpitationsSptmSp utumAGEA cute gastroenteritisURIU pper respiratory infectionFH or FHxFamily HistorySH or SHxSocial historyPVDP eripheral vascular diseaseDJDD egenerative joint diseaseOA OsteoarthritisPODPost Op DayLap.

7 CholecystectomyLap. AppyLaparoscopic appendectomy AKAA bove the Knee AmputationBKAB elow the Knee AmputationNKDANo Known Drug AllergiesHbHemoglobinHctHematocrit H/HHemoglobin and hematocritCXRC hest X-rayBALB ronchio-Alveolar Lavages/pStatus h/oHistory Within normal limitsNCNon contributory (if written under family history)OAOsteoarthritisRCTR otator cuff tearRTCR eturn to ClinicFOBF ecal Occult BloodAAAA bdominal Aortic Aneurysm MURMURS:AIASMRMSTIPSPIA ortic InsufficiencyAortic StenosisMitral RegurgitationMitral StenosisTricuspid InsufficiencyPulmonic StenosisPulmonic InsufficiencyAVRA ortic Valve ReplacementMVRM itral Valve ReplacementMVPM itral Valve ProlapseAVAtrioventricular AVM Arterio-Venous MalformationUA c C&SUrinalysis with Culture and SensitivityVSSV ital Signs StableTURPT rans Uretheral ProstatectomyTABT herapeutic AbortionVIPV oluntary Interruption of PregnancyPNAP neumoniaddxDifferential DiagnosisabxAntibioticsbxBiopsy cxCultureAd libAs much as neededc/oComplain ofQDEvery daybidTwice a daytidThree times a dayqidFour times a Other Day Tanya Oberoi Pandya.