Complete Physical Examination PDF Details

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.

QuestionAnswer
Form NameComplete Physical Examination
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namescomplete physical examination, physical assessment fill in, physical exam template, comprehensive physical exam documentation

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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

 

 

 

 

membrane intact and reactive to light, bilateral sclera

 

 

 

 

anicteric, no conjunctival injection

 

NECK:

Supple, Ø JVD, Ø LAD, Ø carotid bruit, Ø

Supple, no jugular venous distention, no lymphadenopathy,

 

thyromegally

 

 

no carotid bruit

 

 

CV: cardiovascular

RRR, S1S2nl, Ø m/r/g, PMI non displaced/non

Regular rate and rhythm, S1 and S2 are normal, no

 

sustained, Ø HJR, CR <2secs

 

murmurs/rubs/or gallops, point of maximal intensity non

 

 

 

 

displaced and non sustained, no Hepatojugular Reflux,

 

 

 

 

capillary refill less than 2 seconds

 

LUNGS:

CTAB, Ø r/r/w, Ø egophany, Ø tactile fremitus,

Clear to auscultation bilaterally, no rales/rhonchi/wheezes, no

 

nl percussion

 

 

egophany, no tactice fremitus, normal percussion

ABD: abdomen

Obese, no pulsatile masses, +BS nl x4,

Ø high

Obese, no pulsatile masses, normal bowel sounds normal in

 

pitched or tinkling sounds, resonant to

 

all four quadrants, no high pitched or tinkling sounds,

 

percussion, Soft, ND/NT, Ø rebound/guarding, Ø

resonant to percussion, Soft, non-distended/non-tender, no

 

CVA tenderness, Ø HSM

 

rebound or guarding, no costovertebral angle tenderness, no

 

 

 

 

hepatosplenomegaly

 

EXT: extremities

Ø c/c/e

 

 

No cyanosis/clubbing/or edema

 

 

 

 

 

NEURO:

CN II-XII intact, no focal deficit

 

Cranial Nerve II through XII intact, no focal deficity

neurologic

 

 

 

 

 

 

PSYCH: psychiatric

nl affect, Ø hallucinations, nl speech, Ø

Normal affect, no hallucinations, normal speech, no

 

dysarthria

 

 

dysarthria

 

 

SKIN

Intact, Ø rashes, Ø lesions, Ø errythema

Intact, no rashes, no lesions, no errythema

 

 

 

 

 

 

 

 

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

 

masses or lesions, Ø inguinal hernia, Ø inguinal

masses or lesions, no inguinal hernia, no inguinal

 

LAD, b/l testicles nl in consistency s hydrocele or

lymphadenopathy, bilateral testicles normal in consistency

 

varicocele, Ø hypospadias/epispadias

without hydrocele or varicocele, no hypospadias or

 

 

epispadias

Pelvic:

Ø rashes, nl bartholin gland, vaginal mucosa nl

No rashes, normal bartholin gland, vaginal mucosa of normal

 

consistency s atrophy or discharge, cervical os s

consistency without atrophy or discharge, cervical os without

 

discharge

discharge

 

Bimanual: Ø CMT Ø VB Ø discharge Ømasses

Bimanual: No cervical motion tenderness, no vaginal

 

 

bleeding, no discharge, no masses

RECTAL

Ø BRBPR, Ø melena, Ø masses, nl sphincter

No bright red blood per rectum, no melena, no masses,

 

tone, Ø ext/int hemorrhoids, prostate walnut size

normal sphincter tone, no external or internal hemorrhoids,

 

s nodularity or hypertrophy, Ø prostate tenderness

prostate walnut size without nodularity or hypertrophy, no

 

 

prostate tenderness

LYMPH:

Ø LAD

No lymphadenopathy

(lymphatic)

 

 

Mmsk:

nl ROM, Ø joint swelling or errythema

Normal range of motion, no joint swelling or errythema

(musculoskeletal)

 

 

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

 

 

SOB

Shortness of Breath

DOE

Dyspnea on exertion

PND

If talking cardiac: Paroxysmal Nocturnal Dyspnea

 

If talking Upper respiratory: Post Nasal Drip

JVD

Jugular Venous Distention

HJR

Hepato-Jugular Reflux

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)

 

are normal in auscultation

EKG:

 

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

Extra-ocular muscles intact

PERRL

Pupils Equally Round and Reactive to light

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

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

 

Nutrition/Gastroenterology

AAOX3

Alert, awake, and Oriented times 3 (to person,

 

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

Intra-Uterine Pregnancy

FHT

Fetal Heart Tones

TAH/BSO

Total Abdominal Hysterectomy with Bilateral

 

Salpigoopherectomy (i.e. no uterus/ tubes, no

 

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 X-ray

BAL

Bronchio-Alveolar Lavage

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

Arterio-Venous Malformation

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.

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