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, 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, JVD, LAD, carotid bruit, Supple, no jugular venous distention, no lymphadenopathy,
thyromegally no carotid bruit
CV: cardiovascular RRR, S1S2nl, m/r/g, PMI non displaced/non Regular rate and rhythm, S1 and S2 are normal, no
sustained, 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, r/r/w, egophany, 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, 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, rebound/guarding, resonant to percussion, Soft, non-distended/non-tender, no
CVA tenderness, HSM rebound or guarding, no costovertebral angle tenderness, no
hepatosplenomegaly
EXT: extremities 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, hallucinations, nl speech, Normal affect, no hallucinations, normal speech, no
dysarthria dysarthria
SKIN Intact, rashes, lesions, errythema Intact, no rashes, no lesions, no errythema

Tanya Oberoi Pandya D.O., M.B.A.

GU: (genitourinary) Male: rashes, penile discharge, penile shaft s Male: no rashes, no penile discharge, penile shaft without
masses or lesions, inguinal hernia, inguinal masses or lesions, no inguinal hernia, no inguinal
LAD, b/l testicles nl in consistency s hydrocele orlymphadenopathy, bilateral testicles normal in consistency
varicocele, hypospadias/epispadias without hydrocele or varicocele, no hypospadias or
epispadias
Pelvic: 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: CMT VB discharge masses Bimanual: No cervical motion tenderness, no vaginal
bleeding, no discharge, no masses
RECTAL BRBPR, melena, masses, nl sphincter No bright red blood per rectum, no melena, no masses,
tone, ext/int hemorrhoids, prostate walnut size normal sphincter tone, no external or internal hemorrhoids,
s nodularity or hypertrophy, prostate tenderness prostate walnut size without nodularity or hypertrophy, no
prostate tenderness
LYMPH: LAD No lymphadenopathy
(lymphatic)
Mmsk: nl ROM, 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: SBP Systolic Blood Pressure
CC Chief complaint DBP Diastolic Blood Pressure
HPI History of Present Illness HR Heart Rate
ROS Review of System RR Respiratory Rate
PMH Past Medical History SPO2 Pulse Oximetry
NKDA No known Drug Allergies BRBPR Bright Red Blood Per Rectum
CP Chest Pain DTR Deep Tendon Reflexes
SOB Shortness of Breath ARF Acute Renal Failure
DOE Dyspnea on exertion CRI Chronic Renal Insufficiency
PND If talking cardiac: Paroxysmal Nocturnal Dyspnea CRF Chronic Renal Failure
If talking Upper respiratory: Post Nasal Drip
FEN/GI Fluids, Electrolytes, and
JVD Jugular Venous Distention
Nutrition/Gastroenterology
HJR Hepato-Jugular Reflux AAOX3 Alert, awake, and Oriented times 3 (to person,
LE edema Lower Extremity edema time, place)
No c/c/e No cyanosis/clubbing/edema NAD No Acute Distress
No r/r/w No Rales/rhonchi/wheezes MMM Mucus Membranes Moist
No m/r/g No murmurs/rubs/gallops ND/NT Non Distended/Non Tender
CTAB Clear To Auscultation Bilaterally BSx4 Bowel Sounds present in all 4 quadrants
RRR Regular Rate and Rhythm N, V Nausea, Vomiting
S1S2 nl S1 (first heart sound) and S2 (second heart sound) S.Q. Subcutaneous
are normal in auscultation PTCA Percutaneous Transluminal Coronary Angioplasty
EKG: PCI Percutaneous Intervention (cardiac)
LAD Left Axis Deviation
CAD Coronary Artery Disease
RAD Right Axis Deviation
RAE Right Atrial Enlargement ICD Implantable Cardioverter Defibrillator
LAE Left Atrial Enlargement CABG Coronary Artery Bypass Graft
LVH Left Ventricular Hypertrophy VB Vaginal Bleeding
NSR Normal Sinus Rhythm FM Fetal Movement
LAD Lymphadenopathy CMT Cervical motion tenderness
EOMI Extra-ocular muscles intact LMP Last menstrual period
PERRL Pupils Equally Round and Reactive to light NSVD Normal Spontaneous Vaginal Delivery
CNII-XII intact Cranial Nerves two through twelve intact PPROM Preterm Premature Rupture of Membranes
MMSE Mini Mental Status Exam PROM Premature Rupture of Membranes
No T/A/D No Tobacco/Alcohol/IV drug use LTCS Low Transverse Cesarean Section
Ctx Contractions VBAC Vaginal Birth After Cesarean Section
Fx Fracture or function (depending on context) EBL Estimated Blood Loss
P.V. Per Vagina EGA Expected Gestational Age
P.R. Per Rectum EDC Expected Date of Confinement (babys due date)

Tanya Oberoi Pandya D.O., M.B.A.

IUP Intra-Uterine Pregnancy NC Non contributory (if written under family history)
FHT Fetal Heart Tones OA Osteoarthritis
TAH/BSO Total Abdominal Hysterectomy with Bilateral RCT Rotator cuff tear
Salpigoopherectomy (i.e. no uterus/ tubes, no RTC Return to Clinic
ovaries) FOB Fecal Occult Blood
TAH Total abdominal hysterectomy AAA Abdominal Aortic Aneurysm
BTL Bilateral Tubal Ligation
MURMURS:
PTL Preterm Labor AI Aortic Insufficiency
CVA Cerebrovascular accident AS Aortic Stenosis
TIA Transient Ischemic Attack MR Mitral Regurgitation
No T/A/D No tobacco/alcohol/drugs MS Mitral Stenosis
Supp. Suppository TI Tricuspid Insufficiency
Wt Weight PS Pulmonic Stenosis
HA Headache PI Pulmonic Insufficiency
Palp Palpitations AVR Aortic Valve Replacement
Sptm Sputum MVR Mitral Valve Replacement
AGE Acute gastroenteritis MVP Mitral Valve Prolapse
URI Upper respiratory infection AV Atrioventricular
FH or FHx Family History AVM Arterio-Venous Malformation
SH or SHx Social history UA c C&S Urinalysis with Culture and Sensitivity
PVD Peripheral vascular disease VSS Vital Signs Stable
DJD Degenerative joint disease TURP Trans Uretheral Prostatectomy
OA Osteoarthritis TAB Therapeutic Abortion
POD Post Op Day VIP Voluntary Interruption of Pregnancy
Lap. chole. Laparoscopic Cholecystectomy PNA Pneumonia
Lap. Appy Laparoscopic appendectomy ddx Differential Diagnosis
AKA Above the Knee Amputation abx Antibiotics
BKA Below the Knee Amputation bx Biopsy
NKDA No Known Drug Allergies cx Culture
Hb Hemoglobin Ad lib As much as needed
Hct Hematocrit c/o Complain of
H/H Hemoglobin and hematocrit QD Every day
CXR Chest X-ray bid Twice a day
BAL Bronchio-Alveolar Lavage tid Three times a day
s/p Status post qid Four times a day
h/o History of Q.O.D. Every Other Day
wnl Within normal limits

Tanya Oberoi Pandya D.O., M.B.A.