Assessment Of The Abdomen

CHAPTER 22 Abdomen 199

REGI0NAI WRITE-UP-ABD0 M El,l

Patient

Date

Examiner

Aee Genderv Reason for visit I. Health History

1. Any change in appetite? Loss? 2. My difficulty swallowing? 3. Any foods you cannot tolerate? 4. Ary abdominal pain? 5. Any nausea or vomiting? 6. How often are bowel movements? 7 . My past history of GI disease? 8. What medications are you taking?

9. Tell me all food you ate in the last 24 hours, starting with: breakfast snack lunch snack

II. Physical Examination A. Inspection

Contour of abdomen General symmetry Skin color and condition Pulsation or movement Umbilicus

dinner snack

State of hydration and nutrition Person’s facial expression and position in bed

B. Auscultation Bowel sounds Note any vascular sounds.

C. Percussion Percuss in all four quadrants. If suspect ascites, test

D. Palpation Light palpation in all

for fluid wave and shifting dullness.

four quadrants Muscle wall ,,—, Tenderness Enlarged organs Masses

Deep palpation in all four quadrants Masses

Contour of liver Spleen Kidneys Aorta Rebound tenderness CVA tenderness

|arvis, Carolyn: PHYSICAL EXAMINATION AND HEALIH ASSESSMENT: Study Guide and Laboratory Manual, Eighth Edition. Copyright @ 2020,2016, 2012, 2008, 2004, 2000, 1996 by Elsevier Inc. All rights reserved.

200 UNIT III PhYsical Examination

REGIO]IAL WRITE.U P-ABDOM El{

Summarizeyour findings using the SOAP format.

Subjective (reason for seeking care, health history)

Objective (physical examination findings)

Assessment (assessment of health state or problem, diagnosis)

Plaq (diagnostic evaluation, follow-up care, teaching)

Jarvjs, carolyn: pHysICAL EXAMINATIoN AND HEAIIH AssEssMENT: study Guide and Laboratory Manual, Eighth Edition.

Copyright @ 2O2O,2016,zotz,2oo1,2Oo4,2000, 1996 by Elsevier Inc. All rights reserved.

Record findings on diagram.

 
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