GEN
VSS, NAD
VSS - Vital Signs Stable
NAD - No Appreciable Disease
HEENT
PERRL, EOMI, TTP,
PERRL - Pupils Equal, Round, and Reactive to Light
EOMI - Extraocular Movements Intact
TTP - Tender To Palpation
CV
RRR, no M/G/R
RRR - Regular Rate and Rhythm
M/G/R - Murmur, Gallops, and Rubs
PULMONARY
CTAB
Clear To Auscultation Bilaterally
ABD
NABS
No Abnormal Bowel Sound
EXT
CCE
Clubbing, Cyanosis, and Edema
NEURO
A&O, DTR
A&O - Alert and Oriented to person, place and time
DTR - Deep Tendon Reflex