Assessment Of The Abdomen

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?
  7. What medications are you taking?
  8. 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)