Common Physical Assessment terms: Abd – abdominal

Tachycardia – condition makes heart beat more than 100 times per minute. BRBPR – bright red blood per rectum

Bradycardia – condition make heart beat slower. BS – breath sounds

Tachypnea – fast, shallow breathing. CM – coccidioidomycosis

Apnea – temporary cessation of breathing, especially during sleep. HJR – hepatojugular reflux

Cheyne-Strokes – abnormal pattern of breathing characterized by HSM – high-grade squamous intraepithelial lesion
progressively deeper, faster.
LLQ – left lower quadrant
Kussmaul’s Respiration – deep labored breathing pattern often associated with
severe metabolic acidosis, particularly diabetic ketoacidosis. NABS – normoactive bowel sounds

Macules – circumscribed change in color of skin NTND – non-tender, non-distended

Cysts – closed sac like structure within tissue that contain a liquid, gaseous or RUQ – right upper quadrant
semi solid substance.
AI – artificial intelligence
Pustules – small collection of pus in the top layer of skin
AS – left ear
Erythematous – redness of the skin of mucous membrane, caused by
hyperemia JVP – jugular venous pressure

Maculopapular Eruption – type of rash characterized by a flat, red area of the MAP – mean arterial pressure
skin that is covered with small confluent bumps.
MR – mitral regurgitation
Eczematoid – inflammation condition of skin attended with itching
MS – morphine sulfate; multiple sclerosis
Hirsutism – having excessive facial and bodily hair.
MVP – mitral value prolapse
Hypertrichosis – abnormal hair growth may cover the face and body or occur
in small patterns. RRR – regular rate and rhythm

Clubbing – physical sign characterized by bulbous, enlargement of the ends of S1 – first sound
fingers or toes.
USB – upper sternal border
Normocephalic – referring to a person whose head and all major organs of the
head are in normal condition. AKA – above the knee

Hydrocephalic – buildup of cerebrospinal fluid in the ventricles of the brain CCE – cholesterol crystal embolization

Atraumatic – designed to minimize tissue damage CVAT – costovertebral angle tenderness

Strabismus – inability of one eye to attain binocular vision with other FROM – full range of motion
imbalance of muscles.
LLE – left lower extremities
Nystagmus – vision condition in which the eyes make repetitive, uncontrolled
movements. IOP – intraocular pressure

Anisocoria – unequal pupils in the eye NR – nasal resistance

Epistaxis – medical term for nosebleed PERRIA – pupils, equal, round reactive to light and accommodate

Xerostomia – dry mouth, associated with change in composition of saliva SHEENT – skin, head, eye, ear, nose & throat

Kyphosis – exaggerated curvature of the upper spine that creates hunchback TM – transverse myelitis
appearance
ABW – adjusted body weight
Fremitus – palpable vibration produced during breathing caused by partial
airway obstruction A&W – alive and well

Galactorrhea – excessive or inappropriate production of milk BX – biopsy

Gynecomastia – excessive development of male breast DBP – diastolic blood pressure

Hepatomegaly – enlarged liver LBW – low birth weight

Cholecystitis – inflammation of gallbladder NAD – no appreciable disease

Phimosis – condition which the foreskin of penis is too tight to be pulled back SBP – spontaneous bacterial peritonitis

Hernia – general term referring to protrusion of a tissue through the wall of VSS – vital signs stable
cavity
WDWN – well developed, well nourished
Fasciculation – involuntary contraction or twitching of group f muscles fibers.
WNL – within normal limits
Ataxia – lack of muscle control or coordination of voluntary movements
Medical Abbreviations:
Common Physical Assessment abbreviations:
CC – chief complaint
R leg – right leg 0.9 NaCl 1L IV 2 q12h – 1 liter of 0.9 Sodium Chloride every 12hours for
2days
HPI – history of present illness
Ampi-sulbactam 1.5g IV q12h – Give ampi-sulbactam 1.5g intravenous every
DM – Diabetes Mellitus 12hours

pt. – patient TeANA 0.5mL IM – Tetanus toxoid anaphylaxis 0.5mL intramuscular

PTA – prior to admission ATS 3000 u IM ANST – Anti-tetanus serum 3000 units intramuscular after
negative skin test
FBS – fasting blood sugar
BT of 2 u PRBC – Blood transfusion of 2 units of Pack Red Blood Cell
ROS – review of systems
CBG q1h – Monitor capillary blood glucose every 1hour
PND – paroxysmal nocturnal dyspnea
FC, UO q1h – insert Foley catheter, check urine output every 1hour
HA – headache
BKA – below knee amputation
3 P’s – Polydipsia, Polyuria, Polyphagia

PMHx – past medical history

Medical terms:
HTN – Hypertension
Polyuria – frequent urination
HD – Heart disease
Polyphagia – rise of appetite
PTB – Pulmonary Tuberculosis
Polydipsia – excessive thirst
BA – Bronchial asthma
Orthopnea – shortness of breath that occur when lying flat
P/Hx – patient history
Dyspnea – difficulty in breathing
PE – Physical Examination
Melena – dark sticky feces containing partly digested blood
ER – Emergency Room
Hematochezia – passage of fresh blood through the anus
BP – Blood Pressure
Oliguria – production of abnormally small amount of urine
HR – Heart Rate
Hematuria – presence of blood in urine
RR – Respiratory Rate
Nocturia – excessive urinating at night
CLAD – Canine Leukocyte Adhesion Deficiency
Anorexia – obsessive desired to lose weight by refusing to eat
NVE – Natural Valve Endocarditis
Anicteric sclera – white part of eye is yellow
ECE – Extracapsular extent
Hyperosmolar state – complication of DM in which high blood sugar result is
CBS – Cerebral Brain Syndrome high osmolarity without significant ketoacidosis

AP – Angina Pectoris Azotemia – abnormal high levels of nitrogen containing compounds in blood

DHS – Dynamic Hip Screw Hemorrhagic cellulitis - The syndrome consists of an acute onset of extremely
painful erythema affecting dependent areas, followed by dermal hemorrhage
NRRR – Normal Rate, Regular Rhythm and sloughing of the overlying epidermis, and requiring both antibiotics and
systemic corticosteroids for complete resolution.
AB – Abdomen

ICSLAAL – Intercostal space left anterior axillary line

NABS – normoactive bowel sounds

PN – practical nurse

UELE – upper extremity left eye

NO – not observed

NIR – not insulin resistant

RODKA – rule-out ketoacidosis

CHF – Congestive Heart Failure

FC II prob 2 to IHD – Failure condition II secondary to Ischemic heart disease

RLL – right lower leg

O₂ support at 2-4 LPM via nc – Oxygen support at 2 to 4 liters per minute via
nasal cannula

NPO – nothing by mouth

IVF – Intravenous fluid