Abbreviation Physical Exam
COMPLETE PHYSICAL EXAM ABBREVIATIONS:
Vital Signs: T (temperature)
HR (pulse)
RR (respiration rate)
BP (systolic/diastolic)
SPO2 pulse ox
SYSTEM
Physical Exam Documentation
Detailed Abbreviation Explanation
GEN: General
NAD, 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,
NCAT, MMM, EOMI, PERRLA, b/l TM intact & Normocephalic atraumatic, mucous membranes moist, eyes, ears, nose, throat reactive to light, b/l sclera anicteric, Ø extraocular muscles intact, pupils equally round and reactive conjunctival injection to light and accommodation bilaterally, bilateral tympanic …show more content…
GU: (genitourinary)
Pelvic:
RECTAL
LYMPH:
Male: Ø rashes, Ø penile discharge, penile shaft s masses or lesions, Ø inguinal hernia, Ø inguinal
LAD, b/l testicles nl in consistency s hydrocele or varicocele, Ø 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 epispadias Ø rashes, nl bartholin gland, vaginal mucosa
Vital Signs: T (temperature)
HR (pulse)
RR (respiration rate)
BP (systolic/diastolic)
SPO2 pulse ox
SYSTEM
Physical Exam Documentation
Detailed Abbreviation Explanation
GEN: General
NAD, 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,
NCAT, MMM, EOMI, PERRLA, b/l TM intact & Normocephalic atraumatic, mucous membranes moist, eyes, ears, nose, throat reactive to light, b/l sclera anicteric, Ø extraocular muscles intact, pupils equally round and reactive conjunctival injection to light and accommodation bilaterally, bilateral tympanic …show more content…
GU: (genitourinary)
Pelvic:
RECTAL
LYMPH:
Male: Ø rashes, Ø penile discharge, penile shaft s masses or lesions, Ø inguinal hernia, Ø inguinal
LAD, b/l testicles nl in consistency s hydrocele or varicocele, Ø 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 epispadias Ø rashes, nl bartholin gland, vaginal mucosa