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  • Lesson 9 Abbreviations

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    Vital signs including blood pressure, pulse, respiratory rate, oxygen saturation, BMI are recorded. General physical exam notes the patient appears healthy with no distress. Psych exam finds the patient alert and oriented with normal mood, memory and affect. Head, eyes, ears, nose, mouth and throat exams are normal. The neck, heart, lungs, abdomen, genitourinary and skin exams are also normal or negative. The musculoskeletal, neurological and cranial nerve exams have no abnormalities.

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    Abbreviations

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    Vital signs including blood pressure, pulse, respiratory rate, oxygen saturation, BMI are recorded. General physical exam notes the patient appears healthy with no distress. Psych exam finds the patient alert and oriented with normal mood, memory and affect. Head, eyes, ears, nose, mouth and throat exams are normal. The neck, heart, lungs, abdomen, genitourinary and skin exams are also normal or negative. The musculoskeletal, neurological and cranial nerve exams have no abnormalities.

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    8 views1 page

    Lesson 9 Abbreviations

    Uploaded by

    klinso
    Vital signs including blood pressure, pulse, respiratory rate, oxygen saturation, BMI are recorded. General physical exam notes the patient appears healthy with no distress. Psych exam finds the patient alert and oriented with normal mood, memory and affect. Head, eyes, ears, nose, mouth and throat exams are normal. The neck, heart, lungs, abdomen, genitourinary and skin exams are also normal or negative. The musculoskeletal, neurological and cranial nerve exams have no abnormalities.

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    Normal Physical Exam Template

    Vital Signs:
    BP: __ mmHg P: __ bpm 1. BP: blood pressure
    RR: __ per minute SpO2 __% on __ 2. P: pulse
    Temperature: __ oC BMI: __ 3. RR:
    Weight: __ kg Height: __ cm 4. SpO2: peripheral oxygen saturation
    5. BMI: body mass index
    General: Healthy appearing, well-developed, NAD. 6. NAD: no apparent distress
    Psych: Good judgment, AOx4. Normal memory, 7. AOx4: alert and oriented to person, place, time, situation
    mood, and affect 8. NC/AT: normocephalic, atraumatic
    HEENT 9. PERRLA: pupils equal, round, reactive to light & accommodation
    -Head: NC/AT. 10. EOMI: extraocular movements intact
    -Eyes: PERRLA, EOMI. No discharge or redness. 11. MMM: moist mucus membranes
    -Ears: Normal external ears, normal TMs. 12. RRR: regular rate and rhythm
    -Nose: Normal nares 13. m/r/g: murmurs, rubs, or gallops
    -Mouth and Throat: MMM. Normal gums, mucosa, 14. CTAB: clear to auscultation bilaterally
    palate. Good dentition. 15. w/r/r: wheezes, rales, or rhonchi
    NECK: Supple, with no masses. 16. NT/ND: non-tender, non-distended
    CV: RRR, no m/r/g. 17. NBS: normal bowel sounds
    LUNGS: CTAB, no w/r/r. 18. CN: cranial nerves
    ABD: Soft, NT/ND, NBS, no masses or organomegaly. 19. AC > BC: air conduction > bone conduction
    GU: Normal genitalia. 20. JVD: jugular venous distension
    SKIN: Warm & well perfused. No skin rashes or 21. AP: anteroposterior
    abnormal lesions. 22. TM: tympanic membranes
    MSK: Normal extremities & spine. No deformities. 23. ROM: range of motion
    Normal gait. No clubbing, cyanosis, or edema. 24. ICS: intercostal space
    NEURO: Normal muscle strength and tone. CN II to 25. GU: genitourinary
    XII intact. No focal deficits. 26. DTR: deep tendon reflexes

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