The Complete Physical Examination form serves as a comprehensive tool for healthcare professionals to document a patient's physical examination findings thoroughly. This form includes a wide range of abbreviations and terms to streamline the documentation process, covering vital signs like temperature (T), heart rate (HR), respiration rate (RR), blood pressure (BP), and pulse oximetry (SPO2). Each section of the form is devoted to specific systems of the body, such as the general appearance (GEN), head, eyes, ears, nose, throat (HEENT), cardiovascular (CV), lungs, abdomen (ABD), extremities (EXT), neurological (NEURO), psychiatric (PSYCH), skin, genitourinary (GU), rectal, lymphatic (LYMPH), and musculoskeletal (Mmsk), with details on normal findings and potential abnormalities. The form is structured to ensure no detail is missed, from the general appearance to the examination of more complex systems. Additionally, it lists common abbreviations found in medical records, aiding in the interpretation of a patient's history and the current physical state. Authored by Tanya Oberoi Pandya D.O., M.B.A., it stands as a valuable resource for both seasoned and newly practicing clinicians to perform thorough physical assessments, ensuring high-quality patient care.
| Question | Answer |
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| Form Name | Complete Physical Examination |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | complete physical examination, physical assessment fill in, physical exam template, comprehensive physical exam documentation |
COMPLETE PHYSICAL EXAM ABBREVIATIONS:
Vital Signs: T (temperature) |
HR (pulse) |
RR (respiration rate) |
BP (systolic/diastolic) |
SPO2 pulse ox |
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SYSTEM |
Physical Exam Documentation |
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Detailed Abbreviation Explanation |
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GEN: General |
NAD, AAOX4, WDWN (AAM, AAF, WM, WF) |
No acute distress, alert, awake, and oriented times 4 to name, |
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place, time, purpose, Well developed well nourished (African |
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American Male, African American Female, White Male, |
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White Female) |
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HEENT: Head, |
NCAT, MMM, EOMI, PERRLA, b/l TM intact & |
Normocephalic atraumatic, mucous membranes moist, |
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eyes, ears, nose, throat |
reactive to light, b/l sclera anicteric, Ø |
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extraocular muscles intact, pupils equally round and reactive |
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conjunctival injection |
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to light and accommodation bilaterally, bilateral tympanic |
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membrane intact and reactive to light, bilateral sclera |
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anicteric, no conjunctival injection |
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NECK: |
Supple, Ø JVD, Ø LAD, Ø carotid bruit, Ø |
Supple, no jugular venous distention, no lymphadenopathy, |
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thyromegally |
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no carotid bruit |
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CV: cardiovascular |
RRR, S1S2nl, Ø m/r/g, PMI non displaced/non |
Regular rate and rhythm, S1 and S2 are normal, no |
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sustained, Ø HJR, CR <2secs |
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murmurs/rubs/or gallops, point of maximal intensity non |
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displaced and non sustained, no Hepatojugular Reflux, |
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capillary refill less than 2 seconds |
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LUNGS: |
CTAB, Ø r/r/w, Ø egophany, Ø tactile fremitus, |
Clear to auscultation bilaterally, no rales/rhonchi/wheezes, no |
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nl percussion |
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egophany, no tactice fremitus, normal percussion |
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ABD: abdomen |
Obese, no pulsatile masses, +BS nl x4, |
Ø high |
Obese, no pulsatile masses, normal bowel sounds normal in |
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pitched or tinkling sounds, resonant to |
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all four quadrants, no high pitched or tinkling sounds, |
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percussion, Soft, ND/NT, Ø rebound/guarding, Ø |
resonant to percussion, Soft, |
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CVA tenderness, Ø HSM |
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rebound or guarding, no costovertebral angle tenderness, no |
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hepatosplenomegaly |
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EXT: extremities |
Ø c/c/e |
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No cyanosis/clubbing/or edema |
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NEURO: |
CN |
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Cranial Nerve II through XII intact, no focal deficity |
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neurologic |
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PSYCH: psychiatric |
nl affect, Ø hallucinations, nl speech, Ø |
Normal affect, no hallucinations, normal speech, no |
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dysarthria |
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dysarthria |
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SKIN |
Intact, Ø rashes, Ø lesions, Ø errythema |
Intact, no rashes, no lesions, no errythema |
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Tanya Oberoi Pandya D.O., M.B.A.
GU: (genitourinary) |
Male: Ø rashes, Ø penile discharge, penile shaft s |
Male: no rashes, no penile discharge, penile shaft without |
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masses or lesions, Ø inguinal hernia, Ø inguinal |
masses or lesions, no inguinal hernia, no inguinal |
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LAD, b/l testicles nl in consistency s hydrocele or |
lymphadenopathy, bilateral testicles normal in consistency |
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varicocele, Ø hypospadias/epispadias |
without hydrocele or varicocele, no hypospadias or |
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epispadias |
Pelvic: |
Ø rashes, nl bartholin gland, vaginal mucosa nl |
No rashes, normal bartholin gland, vaginal mucosa of normal |
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consistency s atrophy or discharge, cervical os s |
consistency without atrophy or discharge, cervical os without |
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discharge |
discharge |
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Bimanual: Ø CMT Ø VB Ø discharge Ømasses |
Bimanual: No cervical motion tenderness, no vaginal |
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bleeding, no discharge, no masses |
RECTAL |
Ø BRBPR, Ø melena, Ø masses, nl sphincter |
No bright red blood per rectum, no melena, no masses, |
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tone, Ø ext/int hemorrhoids, prostate walnut size |
normal sphincter tone, no external or internal hemorrhoids, |
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s nodularity or hypertrophy, Ø prostate tenderness |
prostate walnut size without nodularity or hypertrophy, no |
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prostate tenderness |
LYMPH: |
Ø LAD |
No lymphadenopathy |
(lymphatic) |
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Mmsk: |
nl ROM, Ø joint swelling or errythema |
Normal range of motion, no joint swelling or errythema |
(musculoskeletal) |
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Tanya Oberoi Pandya D.O., M.B.A.
COMMON ABREVIATIONS ENCOUNTERED IN PRACTICE:
CC |
Chief complaint |
HPI |
History of Present Illness |
ROS |
Review of System |
PMH |
Past Medical History |
NKDA |
No known Drug Allergies |
CP |
Chest Pain |
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SOB |
Shortness of Breath |
DOE |
Dyspnea on exertion |
PND |
If talking cardiac: Paroxysmal Nocturnal Dyspnea |
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If talking Upper respiratory: Post Nasal Drip |
JVD |
Jugular Venous Distention |
HJR |
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LE edema |
Lower Extremity edema |
No c/c/e |
No cyanosis/clubbing/edema |
No r/r/w |
No Rales/rhonchi/wheezes |
No m/r/g |
No murmurs/rubs/gallops |
CTAB |
Clear To Auscultation Bilaterally |
RRR |
Regular Rate and Rhythm |
S1S2 nl |
S1 (first heart sound) and S2 (second heart sound) |
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are normal in auscultation |
EKG: |
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LAD |
Left Axis Deviation |
RAD |
Right Axis Deviation |
RAE |
Right Atrial Enlargement |
LAE |
Left Atrial Enlargement |
LVH |
Left Ventricular Hypertrophy |
NSR |
Normal Sinus Rhythm |
LAD |
Lymphadenopathy |
EOMI |
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PERRL |
Pupils Equally Round and Reactive to light |
Cranial Nerves two through twelve intact |
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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 |
BRBPR |
Bright Red Blood Per Rectum |
DTR |
Deep Tendon Reflexes |
ARF |
Acute Renal Failure |
CRI |
Chronic Renal Insufficiency |
CRF |
Chronic Renal Failure |
FEN/GI |
Fluids, Electrolytes, and |
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Nutrition/Gastroenterology |
AAOX3 |
Alert, awake, and Oriented times 3 (to person, |
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time, place) |
NAD |
No Acute Distress |
MMM |
Mucus Membranes Moist |
ND/NT |
Non Distended/Non Tender |
BSx4 |
Bowel Sounds present in all 4 quadrants |
N, V |
Nausea, Vomiting |
S.Q. |
Subcutaneous |
PTCA |
Percutaneous Transluminal Coronary Angioplasty |
PCI |
Percutaneous Intervention (cardiac) |
CAD |
Coronary Artery Disease |
ICD |
Implantable Cardioverter Defibrillator |
CABG |
Coronary Artery Bypass Graft |
VB |
Vaginal Bleeding |
FM |
Fetal Movement |
CMT |
Cervical motion tenderness |
LMP |
Last menstrual period |
NSVD |
Normal Spontaneous Vaginal Delivery |
PPROM |
Preterm Premature Rupture of Membranes |
PROM |
Premature Rupture of Membranes |
LTCS |
Low Transverse Cesarean Section |
VBAC |
Vaginal Birth After Cesarean Section |
EBL |
Estimated Blood Loss |
EGA |
Expected Gestational Age |
EDC |
Expected Date of Confinement (baby’s due date) |
Tanya Oberoi Pandya D.O., M.B.A.
IUP |
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FHT |
Fetal Heart Tones |
TAH/BSO |
Total Abdominal Hysterectomy with Bilateral |
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Salpigoopherectomy (i.e. no uterus/ tubes, no |
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ovaries) |
TAH |
Total abdominal hysterectomy |
BTL |
Bilateral Tubal Ligation |
PTL |
Preterm Labor |
CVA |
Cerebrovascular accident |
TIA |
Transient Ischemic Attack |
No T/A/D |
No tobacco/alcohol/drugs |
Supp. |
Suppository |
Wt |
Weight |
HA |
Headache |
Palp |
Palpitations |
Sptm |
Sputum |
AGE |
Acute gastroenteritis |
URI |
Upper respiratory infection |
FH or FHx |
Family History |
SH or SHx |
Social history |
PVD |
Peripheral vascular disease |
DJD |
Degenerative joint disease |
OA |
Osteoarthritis |
POD |
Post Op Day |
Lap. chole. |
Laparoscopic Cholecystectomy |
Lap. Appy |
Laparoscopic appendectomy |
AKA |
Above the Knee Amputation |
BKA |
Below the Knee Amputation |
NKDA |
No Known Drug Allergies |
Hb |
Hemoglobin |
Hct |
Hematocrit |
H/H |
Hemoglobin and hematocrit |
CXR |
Chest |
BAL |
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s/p |
Status post… |
h/o |
History of… |
wnl |
Within normal limits |
NC |
Non contributory (if written under family history) |
OA |
Osteoarthritis |
RCT |
Rotator cuff tear |
RTC |
Return to Clinic |
FOB |
Fecal Occult Blood |
AAAAbdominal Aortic Aneurysm
MURMURS:
AI |
Aortic Insufficiency |
AS |
Aortic Stenosis |
MR |
Mitral Regurgitation |
MS |
Mitral Stenosis |
TI |
Tricuspid Insufficiency |
PS |
Pulmonic Stenosis |
PI |
Pulmonic Insufficiency |
AVR |
Aortic Valve Replacement |
MVR |
Mitral Valve Replacement |
MVP |
Mitral Valve Prolapse |
AV |
Atrioventricular |
AVM |
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UA c C&S |
Urinalysis with Culture and Sensitivity |
VSS |
Vital Signs Stable |
TURP |
Trans Uretheral Prostatectomy |
TAB |
Therapeutic Abortion |
VIP |
Voluntary Interruption of Pregnancy |
PNA |
Pneumonia |
ddx |
Differential Diagnosis |
abx |
Antibiotics |
bx |
Biopsy |
cx |
Culture |
Ad lib |
As much as needed |
c/o |
Complain of |
QD |
Every day |
bid |
Twice a day |
tid |
Three times a day |
qid |
Four times a day |
Q.O.D. |
Every Other Day |
Tanya Oberoi Pandya D.O., M.B.A.
