Assessment of the abdomen
case study assignment , taking from ‘Jarvjs, carolyn: physical examination and health assessment’
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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