05 Dec CHAPTER 22 Abdomen 199 REGI0NAI WRITE-UP-ABD0 M El,l
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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