How to Decipher the Physical Examination Note

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

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