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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3067_Библиотеки_им_академика_М_И_Перельмана
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LR: light reflex
M/R/G: murmur/rubs/gallops
MMM: moist mucous
membranes
MS: mental status
NAD: no acute distress
NC/AT: normocephalic/
atraumatic
nl: normal
NT/ND: nontender/
nondistended
PERRLA: pupils equal, round,
reactive to light, and
accommodation
PMI: point of maximum
impulse
POx: pulse oximetry
RA: room air
ROM: range of motion
RRR: regular rate and rhythm
S1, S2: 1st, 2nd heart sounds
TM: tympanic membrane
VS: vital signs
w/: with
w/o: without
W/R/R: wheezes/rales/ronchi
WD/WN: well developed, well
nourished
Breast
• Skin/nipples (−) lesions/discharge,
(−) masses on palpation, (+) fibrocystic
changes
Abdomen
• Soft, NT/ND; (−) HSM; (−) masses;
(−) bruits (note location); (+) BS; (−) CVA
tenderness
Genitourinary
• GU (male): nl circumcised
(uncircumcised); (−) rashes; (−) lesions;
(−) testicular masses; (−) inguinal hernia
• GU (female): nl external genitalia; cervix
nl; pap smear taken; bimanual nl;
(−) adnexal masses/enlargement
Rectal
• Good sphincter tone; prostate NT, not
enlarged; brown, heme (−) stool; (−)
polyps/masses; (−) hemorrhoids
(internal/external)
Extremities
• Warm w/ nl capillary refill; (−) C/C/E;
2+ radial; DP/PT pulses B/L
Musculoskeletal
• Comment on joints if pertinent
Neurologic
• MS: AO (×4); minicog normal
• CN: CN II–XII grossly intact
• Motor: 5/5 B/L upper and lower
extremities
• Sensory: grossly intact and equal to
light touch, pin prick, vibration
• Coordination: (−) Romberg; intact rapid
alternating movements; (−) tremor
• Gait: normal gait; intact heel, toe, heel
to toe
• Reflexes: 2+B/L symmetric
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REFERENCES
Bickley L, Szilagyi PG. Bates’ Guide to Physical Examination and History-Taking. 11th ed.
Philadelphia: Lippincott Williams & Wilkins; 2012.
Fortin AH, Dwamena F, Frankel R, Smith RC. Smith’s Patient-Centered Interviewing: An
Evidence-Based Method. 3rd ed. McGraw-Hill: New York; 2012.
Hansen JT. Netter’s Clinical Anatomy. 3rd ed. Philadelphia: Elsevier; 2014.
Marshall GB, Farnquist BA, MacGregor JH, Burrowes PW. Signs in thoracic imaging.
J Thorac Imaging. 2006;21(1):76–90.
Masterson T, Handler J, Tenner S, Rothenhaus T. The EKG Pocket Survival Guide. 1st ed.
Alexandria, VA: International Medical Publishing, Inc; 1993.
Maxwell RW. Maxwell Quick Medical Reference. 6th ed. Minneapolis, MN: Maxwell
Publishing Company; 2011. Available at: www.maxwellbook.com.
Netter FH, Hansen J, Benninger B, Brueckner-Collins J, Hoagland T, Tubbs RS, eds. Atlas of
Human Anatomy. 6th ed. Philadelphia: Elsevier; 2014.
Rosado-de-Christenson ML. Chest Overview; n.d. Available for subscription at https://
my.statdx.com/document/chest-overview/bf44c873-e33f-4e25-bea1-c60d07e63173.
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