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1、COMPLETEPHYSICALEXAMABBREVIATIONS:VitalSigns:T(temperature)HR(pulse)RR(respirationrate)BP(systolic/diastolic)SPO2pulseoxSYSTEMPhysicalExamDocumentationDetailedAbbreviationExplanationGEN:GeneralNAD,AAOX4,WDWN(AAM,AAF,WM,WF)Noacutedistress,alert,awake,andorientedtimes4toname,p
2、lace,time,purpose,Welldevelopedwellnourished(AfricanAmericanMale,AfricanAmericanFemale,WhiteMale,WhiteFemale)HEENT:Head,NCAT,MMM,EOMI,PERRLA,b/lTMintact&Normocephalicatraumatic,mucousmembranesmoist,eyes,ears,nose,throatreactivetolight,b/lscleraanicteric,Øextraocularmusclesin
3、tact,pupilsequallyroundandreactiveconjunctivalinjectiontolightandaccommodationbilaterally,bilateraltympanicmembraneintactandreactivetolight,bilateralscleraanicteric,noconjunctivalinjectionNECK:Supple,ØJVD,ØLAD,Øcarotidbruit,ØSupple,nojugularvenousdistention,nolymphadenopathy
4、,thyromegallynocarotidbruitCV:cardiovascularRRR,S1S2nl,Øm/r/g,PMInondisplaced/nonRegularrateandrhythm,S1andS2arenormal,nosustained,ØHJR,CR<2secsmurmurs/rubs/orgallops,pointofmaximalintensitynondisplacedandnonsustained,noHepatojugularReflux,capillaryrefilllessthan2secondsLUNG
5、S:CTAB,Ør/r/w,Øegophany,Øtactilefremitus,Cleartoauscultationbilaterally,norales/rhonchi/wheezes,nonlpercussionegophany,notacticefremitus,normalpercussionABD:abdomenObese,nopulsatilemasses,+BSnlx4,ØhighObese,nopulsatilemasses,normalbowelsoundsnormalinpitchedortinklingsounds,r
6、esonanttoallfourquadrants,nohighpitchedortinklingsounds,percussion,Soft,ND/NT,Ørebound/guarding,Øresonanttopercussion,Soft,non-distended/non-tender,noCVAtenderness,ØHSMreboundorguarding,nocostovertebralangletenderness,nohepatosplenomegalyEXT:extremitiesØc/c/eNocyanosis/clubb
7、ing/oredemaNEURO:CNII-XIIintact,nofocaldeficitCranialNerveIIthroughXIIintact,nofocaldeficityneurologicPSYCH:psychiatricnlaffect,Øhallucinations,nlspeech,ØNormalaffect,nohallucinations,normalspeech,nodysarthriadysarthriaSKINIntact,Ørashes,Ølesions,ØerrythemaIntact,norashes,no
8、lesions,noerrythemaTanyaOberoiPandyaD.O.,M.B.A.GU:(genitourinary)Male:Ørash
