You may see something like this when you view your physical examination notes
PHYSICAL EXAM
GEN- A+OX3, NAD, resting comfortably
HEENT– NCAT, PERLA, EOMI, anicteric, oropharynx moist –exudates
NECK- Supple, no JVD, -LAD
CVS- RRR, S1S2 -S3S4, 2/6 systolic LLSB, PMI non-displaced
PULM- Bilat equal BS, CTA, nl WOB
ABD/GI- nl BS, ND, NTTP, rectal s lesions, stool heme-
MSK- -CCE, full ROM all exts
NEURO- CN II-XII intact, motor 5/5 all exts, FNF nl, DTR’s 2+ symmetric
PSYCH– normal affect, denies SI/HI
This is incomprehensible to the uninitiated. Fortunately, Template generated and voice transcribed EMR notes eliminate much of the shorthand and use plain English. But hand-typed notes may still contain many abbreviations and acronyms with which you are probably not familiar.
Below is a system-by-system list of the most common abbreviations you will encounter when trying to read your physical exam notes.
First, here are some general notation pointers.
- N before an abbreviation generally indicates negative, not present or normal
- c/w= consistent with, nl=normal, wnl=within normal limits, s=without, c=with, bl=bilateral
- s/p: Status Post: After, in the past. For example CHEST- “S/P CABG” indicates the person has a scar from previous coronary bypass surgery, regardless of how long ago this occured.
- Grading scales: a finding may come with a grading scale such as “3/5.” These are standardized ways of describing the intensity or severity of a finding. Most of these are on a 3-5 or 6 rank scale, with higher numbers indicating a stronger finding. Thus 0/5 indicates complete absence of the finding. For example the motor strength of a paralyzed limb on a scale of 0-5 is 0/5, whereas 5/5 indicates full normal strength.
Scroll over the text to see its meaning
CONSTITUTIONAL (GENERAL APPEARANCE)
- NAD diaphoretic, toxic, WD, WN, cachectic,
- AOX3
- AA(m/f), W(m/f)
HEENT (Head, Eyes, Ears, Nose, Throat)
- General Inspection: Normocephalic, atraumatic, NCAT
- Conjunctiva: scleral icterus, icteric, anicteric, injected, conjunctival d/c, SCH
- Eyes: EOMI, PERLA, OD/OS, proptosis,
- Throat/mouth- mmm, erythema, exudate, PTA
- Nose: Rhinorrhea
- Ears: AD/AS/AU, TM
NECK
- JVD, HJR, TMG,LAD
CARDIOVASCULAR
- Heart sounds: RRR, +S1S2, -S3S4, no Rub, no Murmur, no Gallop (-RMG), 2/6 systolic
- Other: PMI, CR
PULMONARY
- BS, rhonchi, rales, crackles, no r/r/w or no cwr, CTA, WOB
ABDOMEN
- BS nl x 4, TTP/NTTP, ND s/nt/nd HSM, guarding, rebound tenderness, LLQ/RLQ/RUQ/LUQ
- BRBPR, stool heme +/-, FOBT, AAA, MS
SKIN
- ecchymoses, SQ, FB, MP
MUSCULOSKELETAL
- MSK, ROM, -c/c/e, CVAT , effusion, BKA/AKA, OA, LE/UE, TTP, STS
NEURO
- CN CNII-XII intact, Motor 5/5 all ext’s, FNF, A+O X 3, DTR’s 2+
GU Female Pelvic
- CMT, VB, VD/DC PR/PV
Psychiatric
SI, HI, TW/TI/TB
Don’t see what you are looking for? Ask us!
You may see something like this when you view your physical examination notes
PHYSICAL EXAM
GEN- A+OX3, NAD, resting comfortably
HEENT– NCAT, PERLA, EOMI, anicteric, oropharynx moist –exudates
NECK- Supple, no JVD, -LAD
CVS- RRR, S1S2 -S3S4, 2/6 systolic LLSB, PMI non-displaced
PULM- Bilat equal BS, CTA, nl WOB
ABD/GI- nl BS, ND, NTTP, rectal s lesions, stool heme-
MSK- -CCE, full ROM all exts
NEURO- CN II-XII intact, motor 5/5 all exts, FNF nl, DTR’s 2+ symmetric
PSYCH- normal affect, denies SI/HI
This is incomprehensible to the uninitiated. Fortunately, Template generated and voice transcribed EMR notes eliminate much of the shorthand and use plain English. But hand-typed notes may still contain many abbreviations and acronyms with which you are probably not familiar.
Below is a system-by-system list of the most common abbreviations you will encounter when trying to read your physical exam notes.
First, here are some general notation pointers.
- N before an abbreviation generally indicates negative, not present or normal
- c/w= consistent with, nl=normal, wnl=within normal limits, s=without, c=with, bl=bilateral
- s/p: Status Post: After, in the past. For example CHEST- “S/P CABG” indicates the person has a scar from previous coronary bypass surgery, regardless of how long ago this occured.
- Grading scales: a finding may come with a grading scale such as “3/5.” These are standardized ways of describing the intensity or severity of a finding. Most of these are on a 3-5 or 6 rank scale, with higher numbers indicating a stronger finding. Thus 0/5 indicates complete absence of the finding. For example the motor strength of a paralyzed limb on a scale of 0-5 is 0/5, whereas 5/5 indicates full normal strength.
Constitutional (general appearance)
- NAD (No Acute Distress)
- Diaphoretic (sweaty)
- Toxic (appearing critically ill)
- WD, WN (Well Developed, Well-Nourished
- Cachectic (waisted, emaciated)
- AOX3 (Alert and Oriented to person, place, time)
- AA(m/f), W(M/F) (African American, White Male/Female)
HEENT (Head, Eyes, Ears, Nose, Throat)
- Normocephalic; the head appears normal
- Atraumatic; no evidence of trauma to the head,
- NCAT; NormoCephalic ATraumatic
- Conjunctiva: scleral icterus, icteric, anicteric, injected, conjunctival d/c, SCH
- Eyes: EOMI, PERLA, OD/OS, proptosis,
- Throat/mouth- mmm, erythema, exudate, PTA
- Nose: Rhinorrhea
- Ears: AD/AS/AU, TM
NECK
- JVD, HJR, TMG,LAD
CARDIOVASCULAR
- Heart sounds: RRR, +S1S2, -S3S4, no Rub, no Murmur, no Gallop (-RMG), 2/6 systolic
- Other: PMI, CR
PULMONARY
- BS, rhonchi, rales, crackles, no r/r/w or no cwr, CTA, WOB
ABDOMEN
- BS nl x 4, TTP/NTTP, ND s/nt/nd HSM, guarding, rebound tenderness, LLQ/RLQ/RUQ/LUQ
- BRBPR, stool heme +/-, FOBT, AAA, MS
SKIN
- ecchymoses, SQ, FB, MP
MUSCULOSKELETAL
- MSK, ROM, -c/c/e, CVAT , effusion, BKA/AKA, OA, LE/UE, TTP, STS
NEURO
- CN CNII-XII intact, Motor 5/5 all ext’s, FNF, A+O X 3, DTR’s 2+
GU Female Pelvic
- CMT, VB, VD/DC PR/PV
Psychiatric
- SI, HI, TW/TI/TB
Don’t see what you are looking for? Ask us!