Vital Signs:

COMPLETE
PHYSICAL
T (temperature)
EXAM ABBREVIATIONS:
HR (pulse) RR (respiration rate) BP (systolic/diast
olic)General
SYSTEM
GEN:
SPO2
Physical
pulse
NAD,Exam
oxAAOX4,
Documentation
WDWN (AAM,Detailed
AAF, WM,Abbreviation
WF) No acuteExplanation
distress, alert, awake
, and
place,
American
White
HEENT:
eyes,
NCAT,
reactive
conjunctival
Normocephalic
extraocular
to
membrane
anicteric,
NECK:
Supple,
thyromegally
no
CV:
sustained,
Regular
murmurs/rubs/or
displaced
capillary
LUNGS:
nl
Clear
egophany,
ABD:
pitched
percussion,
CVA
Obese,
all
resonant
rebound
EXT:
hepatosplenomegaly
CN
neurologic
NEURO:
light
carotid
percussion
II-XII
cardiovascular
tenderness,
four
abdomen
extremities
oriented
Female)
ears,
MMM,
Supple,
to
time,
Head,
CTAB,
no
noto
rate
or
Male,
and
intact
auscultation
quadrants,
and
refill
no
pulsatile
intact,
EOMI,
no
jugular
bruit
tinkling
guarding,
nose,
light,
muscles
Soft,
percussion,
purpose,
injection
accommodation
HJR,
and
tactice
Obese,
atraumatic,
conjunctival
non
times
African
r/r/w,
and
JVD,
gallops,
PERRLA,
rhythm,
less
throat
CR
sustained,
ND/NT,
HSM
no
b/l
venous
RRR,
c/c/e
intact,
reactive
sounds,
masses,
no
4bilaterally,
<2secs
fremitus,
no
focal
Well
than
tocostovertebral
American
sclera
LAD,
pulsatile
high
S1S2nl,
egophany,
Soft,
b/l
S1
point
No
name,
mucous
distention,
developed
bilaterally,
2injection
rebound/guarding,
deficit
pupils
and
resonant
normal
pitched
cyanosis/clubbing/or
TMnon-distended/non-tender,
to
no
seconds
anicteric,
carotid
ofHepatojugular
normal
Female,
intact
light,
S2
membranes
masses,
m/r/g,
maximal
equally
are
no
bowel
Cranial
tactile
or
well
to
bruit,
no
rales/rhonchi/wheezes,
percussion
&bilateral
bilateral
normal,
tinkling
angle
White
intensity
lymphadenopathy,
PMI
+BS
sounds
nourished
moist,
round
Nerve
fremitus,
non
nl
tenderness,
Male,
Reflux,
nosounds,
x4,
normal
and
sclera
displaced/non
edema
II
tympanic
(African
non
through
reactive
high
innono XII
no intact, no focal
PSYCH:
Normal
SKIN
dysarthria
deficity
Intact,
psychiatric
affect,
rashes,
no hallucinations,
nl affect,
lesions,
hallucinations,
normal
errythema
speech,
Intact,
nlnospeech,
no rashes,

no lesions, no erryth
Tanya Oberoi Pandya D.O., M.B.A.
ema

Mmsk:
GU:
LAD,
varicocele,
Male:
masses
lymphadenopathy,
without
Pelvic:
epispadias
consistency
Bimanual:
discharge
bleeding,
RECTAL
stone,
No
normal
prostate
(lymphatic)
LYMPH:
nl
(musculoskeletal)
nodularity
LAD
rashes,
bright
ROM,
(genitourinary)
b/l
nosphincter
No
orext/int
hydrocele
testicles
rashes,
BRBPR,
walnut
tenderness
lymphadenopathy
lesions,
rashes,
No
no
red
joint
normal
sor
CMT
without
cervical
discharge,
hypospadias/epispadias
atrophy
blood
tone,
hemorrhoids,
hypertrophy,
size
swelling
nomelena,
bilateral
orno
nl
VB
bartholin
per
nl
Male:
penile
atrophy
inguinal
varicocele,
bartholin
without
inno
inguinal
or
motion
discharge
noor
rectum,
consistency
discharge,
masses
external
discharge,
testicles
rashes,
gland,
or
masses,
errythema
tenderness,
prostate
nodularity
hernia,
hernia,
gland,
discharge,
prostate
nomasses
noor
vaginal
melena,
normal
hypospadias
cervical
nl
sNormal
sphincter
penile
vaginal
walnut
internal
hydrocele
no
inguinal
tenderness
or
nocervical
inguinal
mucosa
no
hypertrophy,
inrange
vaginal
discharge,
shaft
os
size
mucosa
masses,
consistency
hemorrhoids,
sororofof
without
os
nlmotion,
normal
without
penilenoshaft
no
joints swelling or
Tanya
errythema
Oberoi Pandya D.O., M.B.A.

COMMON
CC
HPI
ROS
PMH
NKDA
CP
SOB
DOE
PND
If
JVD
HJR
LE
CTAB
RRR
S1S2
are
NSR
LVH
LAE
RAE
RAD
EKG:
Right
Left
Normal
LAD
EOMI
PERRL
CNII-XII
MMSE
No
Ctx
Fx
P.V.
P.R.
SBP
DBP
HR
RR
SPO2
BRBPR
DTR
ARF
CRI
CRF
FEN/GI
AAOX3
Nutrition/Gastroenterology
time,
NAD
MMM
ND/NT
BSx4
N,
S.Q.
PTCA
PCI
CAD
ICD
CABG
VB
FM
CMT
LMP
NSVD
PPROM
PROM
LTCS
VBAC
EBL
EGA
EDC
Tanya
Chief
Chest
talking
edema
c/c/e
r/r/w
m/r/g
T/A/D
Fracture
Heart
VRespiratory
Vaginal
Fetal
History
Review
Past
Shortness
Dyspnea
If
Jugular
Hepato-Jugular
Regular
normal
Lymphadenopathy
Contractions
Systolic
Diastolic
Deep
Acute
Chronic
No
Mucus
Percutaneous
Coronary
Implantable
Cervical
Last
Estimated
Expected
NoOberoi
Clear
nl
Axis
Atrial
Ventricular
Extra-ocular
Mini
Per
Pulse
Bowel
Nausea,
Subcutaneous
Percutaneous
Coronary
Normal
Premature
Low
Vaginal
Axis
Atrial
Pupils
Bright
Alert,
place)
Non
Preterm
ABREVIATIONS
talking
Sinus
Fluids,
Acute
known
S1
complaint
Medical
Pain
Lower
intact
No
Vagina
Rectum
Rate
Tendon
Movement
menstrual
Transverse
Deviation
Mental
Renal
Membranes
Distended/Non
ofSpontaneous
Upper
To
(first
in
Deviation
Oximetry
Sounds
Bleeding
ofPandya
on
Venous
cyanosis/clubbing/edema
Rales/rhonchi/wheezes
murmurs/rubs/gallops
Rate
Enlargement
Tobacco/Alcohol/IV
or
Renal
Enlargement
Rhythm
Equally
Blood
Red
awake,
Distress
Vomiting
Artery
motion
Birth
Gestational
Date
System
Drug
of
Auscultation
auscultation
Artery
Premature
Blood
Present
exertion
cardiac:
Extremity
function
Rate
Electrolytes,
Rupture
Cranial
Reflexes
Failure
Cardioverter
History
Breath
respiratory:
and
Hypertrophy
Status
Blood
Intervention
heart
muscles
Insufficiency
Failure
present
Transluminal
of
Allergies
Distention
Reflux
Pressure
period
After
ENCOUNTERED
Pressure
and
Moist
Disease
tenderness
Cesarean
Loss
D.O.,
Rhythm
Round
Bypass
Confinement
Illness
Per
of
Paroxysmal
sound)
Nerves
Exam
(depending
Oriented
Tender
Vaginal
Rupture
edema
Cesarean
Age
intact
in
Membranes
M.B.A.
Bilaterally
and
Rectum
Graft
and
all
Defibrillator
Section
Post
(cardiac)
and
Reactive
two
drug
Coronary
IN(babys
Delivery
of
4times
Section
PRACTICE:
Nocturnal
Nasal
S2
through
on
quadrants
Membranes
usecontext)
(second
3Angioplasty
todue
Drip
(to
light
twelve
Dyspnea
person,
date)
heartintact
sound)

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